Eye involvement in primary central nervous system lymphoma

Comparison of various treatment modalities in patients with primary vitreoretinal lymphoma: A systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis investigated different treatment modalities' effect on the risk of central nervous system lymphoma progression, ocular disease relapse, systemic lymphoma development and overall survival in primary vitreoretinal lymphoma patients.

METHODS

PubMed, EMBASE, Scopus and the Cochrane Library of clinical trials were searched from inception to April 21, 2024. Cohort, cross-sectional and case series studies were included. Methodological quality was assessed using the NIH quality assessment tools. Heterogeneity between studies was assessed using Chi square test and I2 statistic. Outcomes were pooled as odds ratios (OR) using fixed-effects models. Risk of publication bias was assessed using a funnel plot.

RESULTS

Included were 28 studies with 476 participants. Ocular treatments included intravitreal methotrexate and/or rituximab injections and ocular radiotherapy. Systemic treatments included intravenous and/or intrathecal chemotherapy, whole-brain radiotherapy and autologous stem cell transplantation. Ocular treatment alone, as compared to systemic or combined treatment, resulted in significantly lower risk of central nervous system lymphoma development (OR = 0.54, p = 0.02) and in no significant difference in the risk for progression to systemic disease (OR = 0.38, p = 0.30) or in overall survival. Significantly lower risk of ocular relapse was found in patients receiving ocular or combined therapy as compared to systemic therapy alone (OR = 0.26, p = 0.001). A subgroup analysis, comparing ocular treatment alone and combined treatment, found no significant difference regarding the risk of central nervous system or systemic lymphoma progression, ocular disease relapse and overall survival.

CONCLUSIONS

No benefit was observed for the addition of systemic therapy to ocular treatment in patients with primary vitreoretinal lymphoma.

A CASE OF EPSTEIN-BARR VIRUS-ASSOCIATED PRIMARY VITREORETINAL LYMPHOMA IN AN IMMUNOSUPPRESSED PATIENT

PURPOSE

To describe a rare case of Epstein-Barr virus (EBV)-positive primary vitreoretinal lymphoma in an immunosuppressed patient.

METHODS

Observational case report.

RESULTS

A 64-year-old man under immunosuppressive therapy for rheumatic arthritis was referred for 2 months of blurred vision and decreased visual acuity in the right eye. Only mutton-fat keratic precipitates and mild vitreous opacity were found in the right eye without (sub)retinal or sub-retinal pigment epithelial lesions. Vitreous biopsy and systemic workup suggested the diagnosis of primary vitreoretinal lymphoma of diffuse large B-cell lymphoma subform. Neoplastic cells stained positive for EBV antigens, EBV-encoded small RNA, and Epstein-Barr nuclear antigen 2, consistent with EBV-positive diffuse large B-cell lymphoma. Intravitreal methotrexate was effective in improving ocular symptoms.

CONCLUSION

The case provided evidence on the association of EBV infection with primary vitreoretinal lymphoma.

Isolated Third Cranial Nerve Palsy As the Initial Presentation of Primary Central Nervous System Lymphoma: A Rare Case

This is an unusual case of primary central nervous system lymphoma (PCNSL) with isolated third cranial nerve palsy as the initial manifestation. Neurolymphomatosis (NL) is a rare manifestation of PCNSL. While NL is a rare manifestation of PCNSL, primary vitreoretinal lymphoma (PVRL) can be the presenting feature or a later-involved manifestation. We present an unusual case of PCNSL with the isolated third cranial nerve palsy as the initial manifestation, which mimics the surgical third cranial nerve palsy. The patient developed PVRL subsequently and succumbed to the disease not long after the presentation.

Primary Cerebral Lymphoma With Isolated Vitreoretinal and Cerebral Recurrences Without Meningeosis: A Case Report

Primary central nervous system lymphoma (PCNSL) is a diffuse, large B-cell lymphoma affecting the brain, spinal cord, leptomeninges, or eyes. A patient with a recurrence of a previous PCNSL manifesting as an isolated vitreoretinal disease without central nervous system (CNS) involvement and a second cerebral recurrence without vitreoretinal involvement has not yet been reported. The patient is an 86-year-old man with PCNSL of the left cerebellum diagnosed at the age of 82 years and treated with suboccipital trepanation and resection of the lesion followed by chemotherapy. At the age of 84, he suffered a first recurrence, which manifested as vitreoretinal lymphoma on the right and later also on the left eye, without CNS involvement. The recurrence was treated by vitrectomy on both sides. At the age of 86, the patient suffered a second recurrence, which manifested as infratentorial lesions treated by radiotherapy. He was discharged with dexamethasone, entecavir, valacyclovir, amphotericin-B, candesartan, tramadol, trazodone, and pantoprazole. This case demonstrates that PCNSL can recur with isolated secondary ophthalmologic lymphoma and a second time with isolated cerebral lymphoma. Although glucocorticoids, chemotherapy, and radiotherapy can be highly effective, the long-term outcomes of patients with PCNSL are not as favorable.

Vitreoretinal large B- cell lymphoma (VR- LBCL): Clinical and pathological features and treatment outcomes

CONTEXT

Vitreoretinal large B- cell lymphoma (VR- LBCL) is a type of non- Hodgkin lymphoma confined to the eye and central nervous system (CNS). The clinical manifestations of intraocular lymphoma can precede, occur simultaneously with, or follow disease at CNS sites. It differs from other forms of extra-nodal lymphoma; in that it does not involve systemic sites other than CNS.

OBJECTIVES

To analyse the clinical and pathological features, and treatment outcomes of a cohort of patients diagnosed with vitreoretinal lymphoma (VRL) in Royal Victoria Eye and Ear Hospital, Ireland between 2010 and 2024.

METHOD

Retrospective review of medical records and pathology specimens of patients with ocular involvement in VR- LBCL over 14-year period and a review of the literature.

RESULTS

Eight patients were included. All of them underwent pars plana vitrectomy and were confirmed to have VR- LBCL. The median age at diagnosis was 71 years. Three were men and five were women. Six had bilateral disease and two unilateral. Four of four patients had MYD88 L265P mutation present. Four patients showed a high interleukin-10 (IL-10) to interleukins-6 (IL-6) ratio in keeping with the diagnosis of VRL. Three patients had primary CNS lymphoma with subsequent eye involvement, despite systemic chemotherapy treatment. Of the five patients who presented with ocular lymphoma, two patients had CNS involvement after primary vitreoretinal lymphoma was diagnosed. Of those, one was initially treated with local intravitreal chemotherapy. Three patients had no CNS recurrence. At the time of this study, seven patients of eight are alive, four are disease free and two are on a first- line local chemotherapy treatment. One underwent treatment for CNS relapse. One patient died of the disease before commencing targeted therapy.

CONCLUSION

This case series demonstrated excellent treatment outcomes for seven patients, alive at the time of the study. Both local radiotherapy and intravitreal chemotherapy achieved good ocular control with acceptable side effects and no significant difference in visual outcome. VRL is a difficult diagnosis and vitreous cytology should be prioritised in cases of vitritis unresponsive to treatment. Analysis of MYD88 L265P mutation and IL- 10: IL- 6 ratio >1 are useful adjuncts in the diagnosis of VR- LBCL, particularly in cases where limited vitreous material makes cytological evaluation challenging.

Lymphoma involvement of the eyelid and eye

Lymphomas of the eye and ocular adnexa are rare lymphoproliferative diseases of the ocular and ocular adnexal tissue. The incidence of these diseases has been rapidly increasing over the past few decades. The exact pathogenesis remains unknown, but it is postulated to be multifactorial and includes genetic aberrations, epigenetic and environmental factors, infectious agents, and chronic antigenic stimulation. The majority of ocular and ocular adnexal lymphomas are of B-cell origin, except for eyelid lymphomas, which are more often of T-cell type. Lymphoproliferative diseases of ocular and ocular adnexal structures are either primary, when they arise in the eye, orbit, lacrimal gland, eyelid, and/or conjunctiva, or secondary extranodal manifestation of systemic lymphoma. Diagnosis is challenging and requires a multidisciplinary approach involving ophthalmologists, dermatologists, oncologists, and radiation oncologists.

A comprehensive overview of diagnosis, imaging and treatment of vitreoretinal lymphoma

Vitreoretinal lymphoma (VRL) is a rare B-cell intraocular neoplasia characterized by poor long-term prognosis and lack of effective therapies. It mainly involves the vitreous humor, the retina, and the retinal pigment epithelium (RPE), although anterior segment involvement can occur. VRL is classified as a lymphoma of immune privileged sites, along with testis lymphoma and primary central nervous system lymphoma (PCNSL). VRL and PCNSL are strictly connected indeed: 80% of VRL develop PCNSL, while 20% of patients with PCNSL present VRL during natural history of lymphoma. Due to the lack of worldwide consensus about diagnosis, therapy, and follow-up timing, VRL represents one of the most challenging ocular affections.VRL commonly masquerades as a posterior uveitis, and misdiagnosis often occurs because of partial response to topical steroids. Gold standard for diagnosis is cytological analysis of vitreous humor. However, this technique lacks sensitivity and supplemental molecular analyses can improve the diagnostic process. Multimodal imaging allows ophthalmologists to empower their clinical suspicion and a comprehensive examination can highlight typical features of VRL and justify further invasive procedures.There is no consensus about VRL therapy, and none of the therapeutical scheme has demonstrated to prevent cerebral involvement and improve patient's overall survival. Intravitreal injections of chemotherapeutics drugs, ocular radiation therapy and systemic chemotherapy can be considered in the treatment of VRL. Once cerebral involvement occurs, systemic chemotherapy must be included in the treatment as a life-saving therapy. Further multicentric studies are required to find out the best treatment of patients with VRL.

Prognosis, Risk Factors, and Clinical Features of Intraocular Recurrence in Primary Vitreoretinal Lymphoma

PURPOSE

To investigate the clinical features, risk factors, and prognosis of the intraocular recurrence in primary vitreoretinal lymphoma (PVRL).

DESIGN

Retrospective case-control study.

PARTICIPANTS

Ninety-seven eyes of 51 patients diagnosed with PVRL between December 2011 and January 2021 were enrolled in this study. Fourteen patients among them had experienced intraocular recurrence.

METHODS

Data on demographic and ophthalmic characteristics, results of diagnostic tests, treatments, and prognosis of intraocular recurrence and nonrecurrence for PVRL patients were collected and compared. Multivariate logistic regression was used to identify independent risk factors. Receiver operating characteristic curves were used to determine the cutoff values.

MAIN OUTCOME MEASURES

Clinical features and risk factors.

RESULTS

Fourteen (19 eyes) of 51 PVRL patients had intraocular recurrences, resulting in a recurrence rate of 27.5% over a mean follow-up period of 42.5 months. No difference was observed in central nervous system lymphoma (CNSL) relapse rate (54.3% vs. 64.3%, P = 0.52) or median time to CNSL (36.5 months; 95% confidence interval [CI], 24.6-48.3 vs. 37.3 months; 95% CI, 24.8-49.8; P = 0.78) between intraocular nonrecurrence and intraocular recurrence groups. Furthermore, there were no statistically significant differences in the survival outcomes, such as mortality (28.6% vs. 29.7%, P = 1.00) and median overall survival (70.8 months; 95% CI, 54.0-87.7 vs. 59.2 months; 95% CI, 44.8-73.6; P = 0.30), between these 2 groups. Younger onset age (odds ratio [OR] 0.90; 95% CI, 0.84-0.98; P = 0.010), isolated PVRL (OR, 35.3; 95% CI, 2.08-600.0; P = 0.014), and no history of intravitreal chemotherapy (OR, 7.72; 95% CI, 1.37-43.6; P = 0.021) were identified as independent risk factors for intraocular recurrences. Of the patients with intraocular recurrence, 23.6% were asymptomatic and were diagnosed during routine follow-up. The rate of interleukin-10 (IL-10)/interleukin-6 > 1 was significantly lower than that at diagnosis (43.8% vs. 92.3%, P = 0.008). However, the rate of IL-10 ≥ 50 pg/mL was high (81.3%) and not significantly different from that at diagnosis (92.3%, P = 0.61).

CONCLUSIONS

This study did not identify an impact of intraocular recurrence on CNS manifestations or survival outcomes in patients with PVRL. Younger patients have a higher risk of intraocular recurrence, and combined systemic and intravitreal chemotherapy may reduce intraocular recurrence. Regular ophthalmic follow-up and IL-10 testing are recommended to detect intraocular recurrence.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

AN UNUSUAL CASE OF PRIMARY VITREORETINAL LYMPHOMA: A TRANSFORMED LYMPHOMA

PURPOSE

To report a case of primary vitreoretinal lymphoma (VRL) presenting as diffuse large b-cell lymphoma 19 years after initial systemic follicular lymphoma.

METHOD

A case report.

RESULTS

An 81-year-old male patient presented with a 1-month history of floaters and blurry vision in the left eye. He had a history of follicular non-Hodgkin lymphoma treated with systemic chemotherapy in 2002 and prostate cancer treated surgically in 2004. Ophthalmic examination revealed vitritis, retinal whitening, perivascular sheathing, and a vascularized cream-colored retinal mass in the superonasal periphery of the left eye. Diagnostic vitrectomy with retina and vitreous biopsies demonstrated diffuse large b-cell lymphoma. Positron emission tomography/computed tomography confirmed the isolated lesion in the left eye without systemic involvement. Treatment with systemic and intraocular chemotherapy was planned.

CONCLUSION

To the best of our knowledge, this is the first reported case of primary vitreoretinal lymphoma of diffuse large b-cell lymphoma transformed from follicular lymphoma. Intravitreal and systemic chemotherapy, including rituximab, should be considered in the management of patients with transformed vitreoretinal lymphoma.

Presentation, Diagnostic Testing and Initial Treatment of Vitreoretinal Lymphoma

PURPOSE

Vitreoretinal lymphoma is a malignancy with high mortality. Incidence is rare, and there is a lack of medical evidence to direct management. This work describes presentation, diagnostic testing, and first treatment approaches in a recently diagnosed and treated patient cohort.

DESIGN

Clinical registry-based observational study.

SUBJECTS

Forty-eight women and 32 men (age range, 32-91 years; median age, 64 years) diagnosed with vitreoretinal lymphoma.

METHODS

An international network of ophthalmologists reported clinical features and management of patients presenting with vitreoretinal lymphoma between January 1, 2020 and December 31, 2022 via an electronic platform.

MAIN OUTCOME MEASURES

Visual acuity at presentation (logarithm of the minimum angle of resolution [logMAR]); basis for diagnosis; first treatment.

RESULTS

Vitreoretinal lymphoma was bilateral at presentation in 65% of patients (n = 52) and an initial site of lymphoma in 78% (n = 62). Of 127 eyes with lymphoma at presentation, vitreous was involved in 89% (n = 113) and was the only involved eye tissue in 40% (n = 51), and retina was involved in 46% (n = 59) and was the only involved eye tissue in 9% (n = 11). Median logMAR visual acuity of the worse-seeing eye was 0.50. The lymphoma was diagnosed from ocular specimens in 80% of patients (64/80), usually vitreous (57/64 patients [89%]), and on other clinical information in 20% of patients (16/80). Cellular studies were performed on ocular specimens from 59 of 64 patients (92%), most often cytology. Tumor gene analysis was used in 21 of 64 patients (33%), and cytokine assays were used in 13 of 64 patients (20%). For 76 patients (95%), treatment was initiated within 6 months of diagnosis and included ocular (38/76 [48%]), extraocular (17/76 [21%]), and ocular plus extraocular (21/76 [26%]) approaches. Intravitreal methotrexate was the most common ocular treatment (83/87 eyes [95%]).

CONCLUSIONS

Using data collected from 80 patients diagnosed with vitreoretinal lymphoma since 2020, we show that visual impairment is common, and that management often involves diagnosis by cellular tests and treatment with intravitreal chemotherapy.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Uveitis masquerade syndromes: An approach to diagnosis

Uveitis masquerade syndromes are a diverse group of clinical entities which mimic conventional immune-mediated uveitis due to the presence of inflammatory signs but are resistant to anti-inflammatory therapy. Misdiagnosis hinders appropriate management in these conditions and may result in poor outcomes. This review discusses commonly encountered neoplastic and non-neoplastic disease processes that masquerade as intraocular inflammation with a focus on relevant clinical features and adjunctive investigations that are helpful in reaching a correct diagnosis.

Primary central nervous system lymphoma

Primary central nervous system lymphoma (PCNSL) is a diffuse large B cell lymphoma in which the brain, spinal cord, leptomeninges and/or eyes are exclusive sites of disease. Pathophysiology is incompletely understood, although a central role seems to comprise immunoglobulins binding to self-proteins expressed in the central nervous system (CNS) and alterations of genes involved in B cell receptor, Toll-like receptor and NF-κB signalling. Other factors such as T cells, macrophages or microglia, endothelial cells, chemokines, and interleukins, probably also have important roles. Clinical presentation varies depending on the involved regions of the CNS. Standard of care includes methotrexate-based polychemotherapy followed by age-tailored thiotepa-based conditioned autologous stem cell transplantation and, in patients unsuitable for such treatment, consolidation with whole-brain radiotherapy or single-drug maintenance. Personalized treatment, primary radiotherapy and only supportive care should be considered in unfit, frail patients. Despite available treatments, 15-25% of patients do not respond to chemotherapy and 25-50% relapse after initial response. Relapse rates are higher in older patients, although the prognosis of patients experiencing relapse is poor independent of age. Further research is needed to identify diagnostic biomarkers, treatments with higher efficacy and less neurotoxicity, strategies to improve the penetration of drugs into the CNS, and roles of other therapies such as immunotherapies and adoptive cell therapies.

Clinical features predictive of vision loss in patients with vitreoretinal lymphoma: a single tertiary center experience

To clarify the long-term visual prognosis and prognostic factors for vision loss in patients with vitreoretinal lymphoma (VRL). This retrospective longitudinal study included 64 consecutive patients with VRL. We analyzed the best-corrected visual acuity (BCVA), optical coherence tomography findings, and clinical features at every visit. Significant vision loss was defined as a final BCVA ≥ 0.5 logMAR. Predictors of significant vision loss following treatment were evaluated using univariate and multivariate linear regression analyses. We included 113 eyes of 64 patients (mean age, 64.2 ± 10.9 years), and 49 patients (76.6%) showed bilateral ocular involvement. The mean follow-up duration was 35.4 ± 25.8 months. At diagnosis, 36 (56.3%), 17 (26.6%), and 11 (17.2%) patients had primary, secondary, and concurrent VRL, respectively. All eyes received intraocular methotrexate injections (mean, 17.1 ± 5.5 injections). The mean BCVA improved from 0.44 ± 0.28 at diagnosis to 0.33 ± 0.29 1 month after treatment initiation. Vision improved significantly after treatment (final mean BCVA, 0.24 ± 0.21). Univariate and multivariate analyses showed that baseline BCVA and retinal/subretinal infiltration were significantly correlated with vision loss. In this study, a good visual outcome was maintained for > 35 months in patients with VRL. Baseline BCVA and retinal/subretinal infiltration were significant predictors of vision loss after treatment for VRL.

UTILITY OF EN FACE OPTICAL COHERENCE TOMOGRAPHY IN INTRAOCULAR LYMPHOMA

PURPOSE

To report the en face optical coherence tomography (OCT) features of intraocular lymphoma.

METHODS

Retrospective, observational case report.

RESULTS

A 59-year-old man, a known case of primary testicular carcinoma, complained of right eye blurred vision since 1 week. He had previously undergone systemic intravenous chemotherapy (R-CHOP regimen), orchiectomy, and external beam radiotherapy for the primary malignancy. His right eye vision was 20/30, 6/6 reduced Snellen. The right eye anterior segment examination was normal. Fundus examination showed vitreous cells 1+ and a large, bumpy, subretinal dull-yellow lesion sparing the fovea with multiple discrete yellow retinal lesions at the posterior pole. Magnetic resonance imaging of the brain was normal. Multimodal imaging was used to document the clinical features. On the en face OCT, multiple hyperreflective lesions were identified on the superficial, deep, and outer retinal slabs of the scan corresponding to the vertical hyperreflective lesions extending from the retinal nerve fiber layer to the retinal pigment epithelium. The subretinal pigment epithelium lesion can be well delineated in the choriocapillaris segment. He was treated with multiple injections of intravitreal methotrexate 400 μg/0.1 mL along with systemic chemotherapy in conjunction with the oncologist. At the 6-month follow-up, fundus lesions had regressed. In addition, resolution of the lesions was noted on the OCT and en face OCT scans.

CONCLUSION

En face OCT imaging can be considered for monitoring the therapeutic efficacy after intravitreal chemotherapy in intraocular lymphoma.

Survival and Recurrence in Vitreoretinal Lymphoma Simulating Uveitis at Presentation: The Possible Role of Combined Chemotherapy

PURPOSE

To investigate the role of combined systemic and local chemotherapy in improving the survival of patients with vitreoretinal lymphoma (VRL).

METHODS

Patients with VRL consecutively seen from 2006 to 2020 were retrospectively reviewed; data on the presence and time of central nervous system (CNS) involvement and treatment regimen (systemic, local or combined chemotherapy) were collected. Overall survival (OS) and progression-free survival (PFS) were calculated for each group.

RESULTS

Forty-three eyes of 22 subjects with histology-proven VRL were included. Mean time of survival was 64.8 months (SE±10.8). Twelve patients (57%) presented CNS involvement, which was significantly associated with progression (r = 0.48, P = .03) and death (r = 0.56, P = .009). The isolated primary VRL group had a 5-year OS of 80%. Combined systemic and local chemotherapy reduced the risk of death by 82% (hazard ratio 0.18[0.04- 0.85]) in the entire cohort.

CONCLUSION

Combined systemic and local chemotherapy significantly improved OS but not PFS of patients affected by VRL.

Logistic regression models of cytokines in differentiating vitreoretinal lymphoma from uveitis

Background

Vitreoretinal lymphoma (VRL) can commonly masquerade as chronic idiopathic uveitis due to its nonspecific clinical presentation. Thus, its early diagnosis is difficult. In this study, new logistic regression models were used to classify VRL and uveitis. Additionally, the diagnostic performance of interleukin (IL)‐10, the IL‐10/IL‐6, and the Interleukin Score for IntraOcular Lymphoma Diagnosis (ISOLD) are evaluated.

Methods

Sixty‐nine aqueous humors (AH) (46 VRL, 23 uveitis) and 65 vitreous humors (VH) (49 VRL, 16 uveitis) were collected from a single‐center retrospective cohort. Logistic regression models were conducted based on IL‐6 and IL‐10. The cut‐off values, area under the receiver operating characteristic curve (ROC) curve (AUC), sensitivity and specificity of IL‐10, the IL‐10/IL‐6, the ISOLD, and the models were calculated from the ROC. Furthermore, Spearman's rank correlation analysis was performed to determine cytokine levels in VH and AH.

Results

We redefined the cut‐off values of IL‐10, the IL‐10/IL‐6, the ISOLD, and the logistic regression models. In AH, the AUC values of IL‐10, ISOLD, IL10/IL6, and the model were 0.91, 0.953, 0.952, and 0.967. In VH, they were 0.93, 0.95, 0.954, and 0.954, respectively. IL‐6 (r = 0.7844) and IL‐10 (r = 0.8506) in AH and VH showed a strong correlation.

Conclusions

IL‐6 and IL‐10 levels were introduced into new logistic regression models. The diagnostic efficacy of the models improved compared to the indicators mentioned above among Chinese patients. Additionally, the models could predict the probability of VRL more accurately. A strong correlation of cytokine levels showed the great potential of AH as prioritized auxiliary diagnostic for VRL.

The International Vitreoretinal B-Cell Lymphoma Registry: a protocol paper

INTRODUCTION

Vitreoretinal lymphoma is a rare ocular cancer with high morbidity and mortality despite treatment. Diagnosis by cytopathology is often delayed, and various molecular and image-based investigations have been developed. Diverse treatments are used, but there is a limited medical evidence to differentiate their effectiveness. We designed an international registry that would collect diagnostic, treatment and outcomes data, to establish new evidence for the management of this cancer.

METHODS AND ANALYSIS

The International Vitreoretinal B-Cell Lymphoma Registry will accrue data retrospectively for individuals aged 18 years or older, diagnosed with new or recurrent vitreoretinal B-cell lymphoma on or after 1 January 2020. A steering committee of subspecialised ophthalmologists identified 20 key clinical data items that describe patient demographics, tissue involvements, diagnostic testing, ocular and systemic treatments and treatment complications, and visual acuity and survival outcomes. Customised software was designed to permit collection of these data across a single baseline and multiple follow-up forms. The platform collects data without identifiers and at 3 month reporting intervals. Outcomes of the project will include: (1) descriptions of clinical presentations, and diagnostic and therapeutic preferences; (2) associations between clinical presentations, and diagnostics and treatments, and between diagnostics and treatments (assessed by ORs with 95% CIs); and (3) estimations of rates of vision loss, and progression-free and overall survival (assessed by Kaplan-Meier estimates).

ETHICS AND DISSEMINATION

The registry has received Australia-wide approval by a national human research ethics committee. Sites located outside Australia are required to seek local human research ethics review. Results generated through the registry will be disseminated primarily by peer-reviewed publications that are expected to inform clinical practice, as well as educational materials.

Accuracy and safety of 101 consecutives neurosurgical procedures for newly diagnosed central nervous system lymphomas: a single-institution experience

INTRODUCTION

Brain surgery is required to ascertain the diagnosis of central nervous system lymphoma. We assessed the diagnostic yield and safety of the surgical procedures, the predictors of postoperative morbidity, and of overall survival.

METHODS

Observational single-institution retrospective cohort study (1992-2020) of 101 consecutive adult patients who underwent stereotactic biopsy, open biopsy, or resection for a newly diagnosed central nervous system lymphoma.

RESULTS

The diagnostic yield was 100% despite preoperative steroid administration in 48/101 cases (47.5%). A preoperative Karnofsky Performance Status score less than 70 (p = 0.006) was an independent predictor of a new postoperative focal neurological deficit (7/101 cases, 6.9%). A previous history of hematological malignancy (p = 0.049), age 65 years or more (p = 0.031), and new postoperative neurological deficit (p < 0.001) were independent predictors of a Karnofsky Performance Status score decrease 20 points or more postoperatively (13/101 cases, 12.9%). A previous history of hematological malignancy (p = 0.034), and preoperative Karnofsky Performance Status score less than 70 (p = 0.024) were independent predictors of postoperative hemorrhage (13/101 cases, 12.9%). A preoperative Karnofsky Performance Status score less than 70 (p = 0.019), and a previous history of hematological malignancy (p = 0.014) were independent predictors of death during hospital stay (8/101 cases, 7.9%). In the 82 immunocompetent patients harboring a primary central nervous system lymphoma, age 65 years or more (p = 0.044), and time to hematological treatment more than 21 days (p = 0.008), were independent predictors of a shorter overall survival. A dedicated hematological treatment (p < 0.001) was an independent predictor of a longer overall survival.

CONCLUSION

Brain biopsy is feasible with low morbidity for central nervous system lymphomas. Postoperatively, patients should be promptly referred for hematological treatment initiation.

Primary central nervous system lymphoma: Inter-compartmental progression

There is limited understanding of the inter-compartmental progression and treatment outcomes of primary central nervous system lymphoma (PCNSL). In this multicenter retrospective cohort study on 234 patients with PCNSL (median age: 62.5 years [18-92]; median follow-up 35 months [0.1-237.0]) from 2000 till 2018 were divided into group 1 (ocular, 44 patients): 1A and 1B without and with CNS progression and group 2 (CNS, 190 patients): 2A and 2B without and with ocular progression, respectively. In group 1 (44 patients), 33 patients received local treatment, and 11 patients received systemic treatment. In group 2 (15 patients), six patients received combination treatment, while seven patients received only systemic treatment. A complete response was observed in 19 (43%) and 91 (48%) patients in groups 1 and 2, respectively. The 2-year progression-free survival (PFS) was 35% (95% CI: 0.23, 0.54) and 56% (95% CI: 0.49, 0.63) for groups 1 and 2, respectively (p < 0.0001). Age < 60 years was significantly associated with longer PFS (median PFS 48 vs. 24 months, p = 0.01). The overall survival (OS) at 2-year was similar among groups 1 and 2 (83% and 67%), respectively (p = 0.06). Thus, Initial compartment of involvement does not influence local response rate or OS.

Optical Coherence Tomography Benefits the Diagnosis and Follow-Up of Primary Central Nervous System Lymphoma with Intraocular Involvement

Purpose

To describe the characteristic manifestations of vitreoretinal lymphoma (VRL) with optical coherence tomography (OCT) and monitor their outcomes after treatmEnt.

Patients and Methods

Patients with primary central nervous system lymphoma (PCNSL) and intraocular involvement were assigned to the VRL group. OCT manifestations were analyzed and changes in abnormalities were recorded after intravitreal methotrexate injections. OCT manifestations of PCNSL patients without intraocular involvement were analyzed as well (non-VRL group).

Results

There were 48 eyes with high-quality OCT records in the VRL group, of which 19 had abnormal manifestations. The most frequent abnormality was outer retina (OR) fuzzy borders (14 of 19, 73.7%). Other abnormalities included: focal subretinal deposits (8 of 19, 42.1%), hyperreflective subretinal dots (2 of 19, 10.5%), pigment epithelium detachment (PED) (5 of 19, 26.3%), preretinal deposits (5 of 19, 26.3%), epiretinal membrane (3 of 19, 15.8%), cystoid macular edema (3 of 19, 15.8%), subretinal fluid (3 of 19, 15.8%), outer retina atrophy (2 of 19, 10.5%), unilateral optic papilledema (2 of 19, 10.5%), retinal thickening (1 of 19, 5.3%), and subretinal fibrosis (1 of 19, 5.3%). Nine eyes with retinal abnormalities were receiving regular intravitreal methotrexate. The retinal structure of seven eyes (only outer retina involved) returned to almost normal on OCT images. The remaining two eyes (with severe retinal vasculitis) showed little improvement after treatment.

Conclusion

OCT is helpful for the diagnosis of PCNSL with intraocular involvement and long-term follow-up of the disease.

Summary Statement

The characteristic manifestations of vitreoretinal lymphoma (VRL) with optical coherence tomography (OCT) were described and their outcomes after treatment were monitored. These findings suggested that OCT is helpful for the diagnosis of PCNSL with intraocular involvement and long-term follow-up of the disease.

Clinical Outcomes in Vitrectomized versus Non-vitrectomized Eyes in Patients with Primary Vitreoretinal Lymphoma

AIM

To evaluate if there is a difference in the clinical course of primary vitreoretinal lymphoma (PVRL) in vitrectomized versus non-vitrectomized eyes.

METHODS

Observational multicenter retrospective case series of patients diagnosed with PVRL between 2007 and 2019, at three tertiary centers. The main outcomes were relapse rates, inflammatory parameters, and best-corrected visual acuities (BCVA). Statistical methods used were an adjusted generalized estimating equation model, and a proportional Cox model.

RESULTS

Eighty patients (150 eyes) were followed for a median of 1.7 years. At presentation, there were no clinical differences between the groups. The relapse rate was 0.091/eye-year (EY) for vitrectomized eyes and 0.087/EY for non-vitrectomized eyes (p = .35). Vitrectomized eyes had better BCVA than non-vitrectomized eyes (p < .001).

CONCLUSIONS

Vitrectomy had no effect on the relapse rate in eyes with PVRL. However, the decrease in vitreous cell and debris led to vitrectomized eyes having better visual acuity than non-vitrectomized eyes.

Comprehensive Laboratory Diagnostic Workup for Patients with Suspected Intraocular Lymphoma including Flow Cytometry, Molecular Genetics and Cytopathology

Background: Intraocular lymphoma (IOL) presents a real challenge in daily diagnostics. Cyto- and/or histopathology of vitreous body represent the diagnostic cornerstones. Yet, false negative results remain common. Therefore, we analyzed the diagnostic significance of flow cytometry (FC) within the workup algorithm of IOL and compared its sensitivity with the results obtained from routine cytopathology and molecular genetics; Methods: Seven patients undergoing vitrectomy due to suspected IOL were investigated by FC and parallel cytopathology and, if available, digital droplet PCR (ddPCR) for MYD88 L265P; Results: Four out of seven patients were finally diagnosed with IOL. Among the IOL patients, cytopathology confirmed the presence of lymphoma cells in only two cases. In contrast, FC was positive for IOL in all four cases, and FC additionally confirmed the lack of IOL in the remaining patients. In IOL patients diagnosed by FC and with available ddPCR, the diagnosis of IOL was confirmed by the presence of the MYD88 L265P mutation in all three patients; Conclusions: The combination with FC was superior to cytopathology alone in the diagnostic work-up of IOL, and it showed an excellent correlation with ddPCR results. A comprehensive diagnostic panel consisting of cytopathology, FC and molecular genetics should be considered for the work-up of suspected IOL.

Primary central nervous system lymphoma in the United States, 1975–2017

Background:

Primary central nervous system lymphoma (PCNSL) has received more attention because of an inferior prognosis. Less is known about the incidence rate, histological type, and survival rate of PCNSL, especially in the 2010s.

Methods:

Data of PCNSL from the Surveillance, Epidemiology, and End Results (SEER) registry database (SEER 9 registries and SEER 18 registries) were used. Incidence was estimated by age, gender, race, site, and histological type. Trends were analyzed using joinpoint regression and described as annual percent change (APC) and average annual percent change (AAPC). Five-year overall survival estimates were compared using log-rank tests.

Results:

Most PCNSL occurred in the brain, followed by the spinal cord. The most frequent histological type of PCNSL was diffuse large B-cell lymphoma, followed by marginal zone lymphoma. Incidence rate increased from 0.1/100,000 to 0.5/100,000 with an AAPC of 5.3% from 1975 to 2017. Incidence rates varied greatly between the younger and older age population. The 5-year overall survival rates in SEER 9 registries and SEER 18 registries were 30.5% and 37.4%, respectively. Even though the 5-year overall survival rate significantly increased from 27.9% for the 1975–1979 time period to 44.8% for the 2010–2017 time period, survival benefit could not be expected for patients ⩾60 years. The 5-year survival rate for elderly patients was about 30% in the 2010s.

Conclusion:

With aging, the incidence of PCNSL in the elderly is increased. Over the past decade, no advances have been made in the treatment of elderly PCNSL. Prospective trials with PCNSL are warranted to improve the survival of elderly patients.

Comparative Molecular Analysis of Primary Central Nervous System Lymphomas and Matched Vitreoretinal Lymphomas by Vitreous Liquid Biopsy

Primary Central Nervous System Lymphoma (PCNSL) is a lymphoid malignancy of the brain that occurs in ~1500 patients per year in the US. PCNSL can spread to the vitreous and retina, where it is known as vitreoretinal lymphoma (VRL). While confirmatory testing for diagnosis is dependent on invasive brain tissue or cerebrospinal fluid sampling, the ability to access the vitreous as a proximal biofluid for liquid biopsy to diagnose PCNSL is an attractive prospect given ease of access and minimization of risks and complications from other biopsy strategies. However, the extent to which VRL, previously considered genetically identical to PCNSL, resembles PCNSL in the same individual with respect to genetic alterations, diagnostic strategies, and precision-medicine based approaches has hitherto not been explored. Furthermore, the degree of intra-patient tumor genomic heterogeneity between the brain and vitreous sites has not been studied. In this work, we report on targeted DNA next-generation sequencing (NGS) of matched brain and vitreous samples in two patients who each harbored VRL and PCSNL. Our strategy showed enhanced sensitivity for molecular diagnosis confirmation over current clinically used vitreous liquid biopsy methods. We observed a clonal relationship between the eye and brain samples in both patients, which carried clonal CDKN2A deep deletions, a highly recurrent alteration in VRL patients, as well as MYD88 p.L265P activating mutation in one patient. Several subclonal alterations, however, in the genes SETD2, BRCA2, TERT, and broad chromosomal regions showed heterogeneity between the brain and the eyes, between the two eyes, and among different regions of the PCNSL brain lesion. Taken together, our data show that NGS of vitreous liquid biopsies in PCNSL patients with VRL highlights shared and distinct genetic alterations that suggest a common origin for these lymphomas, but with additional site-specific alterations. Liquid biopsy of VRL accurately replicates the findings for PCNSL truncal (tumor-initiating) genomic alterations; it can also nominate precision medicine interventions and shows intra-patient heterogeneity in subclonal alterations. To the best of our knowledge, this study represents the first interrogation of genetic underpinnings of PCNSL with matched VRL samples. Our findings support continued investigation into the utility of vitreous liquid biopsy in precision diagnosis and treatment of PCNSL/VRL.

Vitreoretinal Lymphoma

Vitreoretinal lymphoma (VRL) is a rare variant of primary central nervous system lymphoma (PCNSL), mostly of diffuse large B cell lymphoma, which affects the retina and/or the vitreous with or without optic nerve involvement. The disease course is aggressive. Up to 90% of the patients develop central nervous system lymphoma within one year. The diagnosis of VRL is challenging due to nonspecific chronic and relapsing uveitis and is made by anterior chamber tab or vitreous aspirate biopsy. There is no established treatment protocol for VRL patients with bilateral involvement without CNS involvement. There are suggestions to use only intravitreal chemotherapy with methotrexate and/or rituximab. Alternatively, systemic high-dose MTX treatment or external beam radiotherapy is used. Further studies are needed to prove and confirm the prophylactic systemic therapy in preventing CNS involvement in limited VRL.

Efficacy and safety of intravitreal methotrexate for vitreo-retinal lymphoma - 20 years of experience

Vitreo-retinal lymphoma (VRL) is the most common intraocular lymphoma and is highly associated with central nervous system (CNS) lymphoma (CNSL), both posing a therapeutic challenge. We investigated patients' characteristics, efficacy and safety of intravitreal methotrexate (MTX) injections and their outcomes over 20 years. The records of 129 patients diagnosed between 1997 and 2018 were retrospectively reviewed. Lymphoma involved both the CNS and vitreo-retina (49%), solely the CNS (37%) or solely the vitreo-retina (14%). In all, 45·5% of the patients with CNSL either presented with VRL or developed it after a mean (±SE) of 85·7 (7·3) months. In all, 66·0% of the patients diagnosed with VRL either presented with CNSL or developed it after a mean (±SE) 42·6 (7·6) months. The 81 patients with VRL (134 eyes) received a mean (±SD) of 19 (7) injections; however, only 5 (4) injections were needed to reach complete remission. Local recurrence occurred in two of the 81 patients. Overall, 80·2% of eyes had an initial moderate-severe visual loss, and >50% of them improved. Reversible keratopathy was the most prevalent side-effect. A total of 18·5% developed intraocular pressure (IOP) elevation due to angle neovascularisation after 16 injections, which could be reversed with prompt intravitreal injection of bevacizumab. Intravitreal MTX injections are a safe and effective treatment for VRL. Fewer injections (15) may offer similar results with fewer side-effects.

Primary central nervous system lymphoma - ocular variant: an interdisciplinary review on management

Primary central nervous system lymphoma-ophthalmic variant (PCNSL-O) is an ocular subset of PCNSL predominantly involving subretinal pigment epithelium space, retina, and vitreous. The ophthalmic manifestations can precede, occur simultaneously, or follow other compartments of the CNS. Clinical trials have resulted in a significantly improved outcome in PCNSL patients over the past 2 decades, with a higher proportion of patients receiving frontline high dose methotrexate-based polychemotherapy regimens with curative intent; however, the current management of PCNSL-O remains controversial owing to lack of prospective data. The goals of PCNSL-O treatment are both to achieve local (ocular) control and to prevent tumor-specific mortality from further CNS involvement. Despite achieving high rates of ocular control with intravitreal agents like methotrexate and rituximab, the overall survival is poor, as 65-85% of patients eventually succumb to CNS disease. Few studies define the role of systemic chemotherapy with/without local treatment as a first line induction treatment for PCNSL-O considering limiting factors such as ocular penetration of systemically administered drugs and treatment related neurotoxicity. Also, the role of adjuvant treatment for PCNSL-O to prevent CNS progression and to improve overall survival is unknown. In this systematic review of the literature, we analyze treatment outcomes of various regimens (local, systemic, and combination) in terms of local control, CNS progression, and overall survival.

Changing Incidence and Survival of Primary Central Nervous System Lymphoma in Australia: A 33-Year National Population-Based Study

Simple Summary

In Australia, all cancers are recorded in the Australian Cancer Database. We used pathological and anatomical classification codes to identify cases of brain lymphoma—termed primary central nervous system lymphoma or PCNSL—that had occurred in Australia during the past four decades. This allowed us to calculate the incidence of PCNSL, as well as the overall survival after diagnosis with this lymphoma. PCNSL is rare, recently affecting approximately 4 per one million adult Australians per year. However, the number of people diagnosed with this cancer is increasing. Survival of people diagnosed with PCNSL has been improving, but is still low, with only 33% of people alive at 5 years after receiving this diagnosis. As the first survey of the incidence of PCSNL in Australia and the survival of Australians diagnosed with this rare cancer, our research supports current efforts to understand risk factors and improve outcomes.

Abstract

Primary central nervous system lymphoma (PCNSL) is a rare brain cancer that remains challenging to study. Epidemiology of PCNSL in the Australian population, which is racially and ethnically diverse, has not been examined previously. Using ICD-O-3.1 Morphology and Topography Codes to identify cases, we analyzed complete datasets from the comprehensive Australian Cancer Database (1982–2014, adults aged ≥ 20 years) to establish incidence rates and trends of PCNSL, and to define survival outcomes of individuals diagnosed with PCNSL, including the predominant diffuse large B-cell lymphoma (DLBCL) type. Age-standardized incidence of PCNSL increased by an average annual 6.8% percent over the study period, with current incidence of 0.43 (95% confidence interval, 0.41–0.46) per 100,000 person-years, in comparison to 21.89 (21.41–22.38) per 100,000 person-years for non-CNS lymphoma. Increase in incidence was characterized by an acute rise between 1996 and 1999, was more pronounced with increasing age, and was driven by increasing incidence of DLBCL. Overall survival for persons diagnosed with PCNSL improved significantly across the study period, with 5-year survival probability increasing from 0.21 (95% confidence interval, 0.16–0.26) to 0.33 (0.30–0.36), and median survival increasing from 318 to 600 days, between 1982–1999 and 2000–2014. Increase in survival was significantly higher for persons with DLBCL versus non-DLBCL PCNSL, but substantially lower than that for persons with non-CNS lymphoma, who had a 5-year survival probability of 0.62 (0.62–0.62) and a median survival of 3388 days in 2000–2014. This study links increasing incidence of PCNSL in Australia to increasing incidence of DLCBL, including in younger adults, and highlights the improving, but low, survival outcome of this cancer.

Floral Pattern of Keratic Precipitates in Vitreoretinal Lymphoma on In Vivo Confocal Microscopy

PURPOSE

To describe the morphological patterns of keratic precipitates (KPs) in vitreoretinal lymphoma (VRL) using in vivo confocal microscopy (IVCM).

METHODS

Six eyes of three biopsy-proven VRL patients were included. KPs were identified and analyzed on IVCM.

RESULTS

On examination, pigmented KPs in four eyes, white central KPs in two eyes and anterior chamber cells with flare in six eyes and pseudo hypopyon in one eye were identified. A typical floral pattern of KPs on IVCM was noted in all eyes. Three eyes each showed the complete and incomplete floral patterns, respectively. Resolution of KPs on IVCM was noted after chemotherapy.

CONCLUSION

In addition to the routinely used clinical and imaging markers like the visual acuity, presence of lymphomatous cells in the vitreous and optical coherence tomography findings, the presence and appearance of KPs on IVCM can also be considered as a useful, diagnostic and treatment monitoring marker in VRL.