High-dose methotrexate with or without whole brain radiotherapy for primary CNS lymphoma (G-PCNSL-SG-1): a phase 3, randomised, non-inferiority trial

Role of Radiotherapy in PCNSL within the Current Therapeutic Landscape: a Comprehensive Review

OPINION STATEMENT

The therapeutic landscape for primary central nervous system lymphoma (PCNSL) continues to evolve, raising critical questions about the optimal integration of whole-brain radiotherapy (WBRT) to improve patient outcomes. Historically, WBRT has been a cornerstone in PCNSL management, offering effective disease control and relapse prevention. However, the use of high-dose WBRT (HD-WBRT) (≥ 36 Gy), while efficacious, has been associated with significant neurotoxicity, particularly in elderly patients, which has curtailed its long-term applicability. In recent years, high-dose chemotherapy combined with autologous stem cell transplantation (HDT-ASCT) has emerged as a consolidative treatment option, demonstrating efficacy comparable to WBRT, especially in younger patients and those with better performance status, thereby reshaping the therapeutic paradigm. As the therapeutic paradigm shifts, efforts to explore advances in WBRT techniques, such as dose reduction (23.4 Gy) and hyperfractionated protocols, have been aimed at mitigating neurotoxicity while maintaining therapeutic efficacy. These innovations make WBRT a viable option for carefully selected patient populations. Furthermore, this review explores emerging strategies, including localized radiotherapy, novel therapeutic combinations, and individualized treatment paradigms, while identifying key directions for future research to optimize outcomes for PCNSL patients.

Primary Diffuse Large B-Cell Lymphoma of the Central Nervous System-Outcomes in Finland: A Nationwide Population-Based Study

Primary central nervous system lymphoma (PCNSL) is a rare and aggressive malignancy commonly presenting with a rapid disease course and poor prognosis. Recent clinical trials have indicated improved treatment outcomes in a highly selected patient population. However, real-world data focusing on long-term, population-based outcomes remain largely unexplored. We analyzed trends in relative survival (RS) in patients diagnosed with PCNSL in Finland from 1995 to 2018. We identified 718 PCNSL patients from the comprehensive Finnish Cancer Registry (FCR) (51% males, median age 67.8 years). For the entire cohort, 5-year overall survival (OS) and RS rates were 21% and 22%, respectively. The 2-year RS was 39% for patients younger than 75 years and 14% for older patients. A gradual increase in the 2-year RS rate was observed over successive chronological diagnostic periods. Age above 75 years at diagnosis (HR 3.65, 95% CI: 2.73-4.89) and diagnosis during a calendar period of 1995-2006 (HR 1.30, 95% CI: 1.10-1.53) were associated with a significantly increased risk of death. An increase in the number of patients diagnosed with PCNSL during the study period was confirmed, and the prognosis of patients diagnosed after the age of 75 years continues to be dismal.

Efficacy and safety of the R2-MTX regimen in primary central nervous system lymphoma (PCNSL): a single-center retrospective analysis

PURPOSE

Primary central nervous system lymphoma (PCNSL) has a poor prognosis, mainly because of the significant challenges with the efficacy and tolerability of induction chemotherapy. This retrospective study aimed to evaluate the efficacy and safety of the R2-MTX regimen in PCNSL patients.

METHODS

We conducted a retrospective analysis of 39 PCNSL patients treated with the R2-MTX regimen, focusing on treatment outcomes and adverse events (AEs).

RESULTS

The overall response rate (ORR) was 72.2%, with a complete response (CR) rate of 69.4% and a partial response (PR) rate of 2.8%. With a median follow-up of 37.2 months (interquartile range [IQR] 24.2-47.5), the estimated 2-year progression-free survival (PFS) and overall survival (OS) rates were 54.9% (95% CI, 37.2-69.5%) and 78.5% (95% CI, 59.8-89.2%), respectively. The most common grade 3 or 4 AEs included neutropenia (33.3%), leukopenia (13.9%), anemia (2.8%), and thrombocytopenia (2.8%). Consolidation or maintenance therapy was associated with prolonged survival in PCNSL patients (2-year OS rates 100% vs. 42.9%, P = 0.067). Survival analysis revealed that clinicopathological factors, such as double-expressor lymphoma (DEL), ECOG PS ≥ 2, and high-risk classification based on the Memorial Sloan Kettering Cancer Center model (MSKCC), predicted poor survival.

CONCLUSIONS

Our results underscore the therapeutic potential of the R2-MTX regimen in managing newly diagnosed PCNSL patients. Further prospective studies with larger patient cohorts are imperative to solidify these preliminary findings.

High-Dose Methotrexate, Ibrutinib, and Temozolomide in the Treatment of Newly Diagnosed Primary CNS Lymphoma: A Multicenter, Prospective Phase II Study

SIGNIFICANCE

We report promising efficacy and good tolerability of Bruton tyrosine kinase (BTK) inhibitor ibrutinib in treatment of newly diagnosed PCNSL. Additionally, we explored the contribution of ctDNA profiling to predictive potential in this prospective study. The consistency of ctDNA clearance from CSF/plasma was associated with more sustained treatment response and survival.

Consolidation Regimen and Cerebral Atrophy in Patients With Primary Central Nervous System Lymphoma

PURPOSE

In primary central nervous system lymphoma (PCNSL), the extent to which post-methotrexate consolidation contributes to neurotoxicity is unclear. Concerns for neurotoxicity from standard dose whole-brain radiation therapy (WBRT) have led to declining use. Cerebral atrophy is an established surrogate for neurotoxicity; however, the relative extent to which modern consolidation (ie, reduced-dose [RD-]WBRT ≤24 Gy, autologous hematopoietic cell transplant) contributes to cerebral atrophy is unclear.

METHODS AND MATERIALS

Patients with PCNSL from 2000-2020 who achieved a complete response to consolidation following methotrexate-based induction were included. Inclusion criteria were preconsolidation magnetic resonance imaging (baseline) and ≥1 magnetic resonance imaging showing sustained remission at 1, 3, 5, or 10 years. An expert neuroradiologist longitudinally measured parenchymal volume loss via ventricular volumetric change. Linear mixed-effects models were performed to estimate absolute and annual volumetric change rates.

RESULTS

Of 139 patients (median follow-up, 4.5 years), most were Memorial Sloan Kettering Cancer Center (MSK) recursive partitioning analysis (RPA) class 2 (age ≤50 years, Karnofsky performance score (KPS) ≥70). Consolidation therapies included nonmyeloablative chemotherapy (n = 57; 41%), high-dose myeloablative chemotherapy with autologous hematopoietic cell transplant (n = 50; 36%), and RD-WBRT (n = 28; 20%). A higher MSK RPA class was associated with greater baseline ventricular volume (P < .001). Overall adjusted annual ventricular volume change rates were greater than those published in healthy controls (4.3% vs 1.8%) and generally increased by age/decade at diagnosis: 40 to 49-year-olds 1.8% (95% CI, -1.4% to 5.0%), 50 to 59-year-olds 3.1% (95% CI, 0.7%-5.5%), 60 to 69-year-olds 4.8% (95% CI, 2.4%-7.3%), 70 to 79-year-olds 7.2% (95% CI, 4.3%-10.2%), and 80 to 89-year-olds 4.2% (95% CI, -1.1% to 9.6%). There were no significant associations between consolidation strategy and ventricular volume change rates accounting for age, KPS, gender, baseline ventricular volume, or interaction between age and consolidation.

CONCLUSIONS

These findings demonstrate accelerated cerebral atrophy in PCNSL after consolidation compared with healthy adults. However, atrophy did not differ by consolidation strategy. These long-term results suggest acceptable neurotoxicity following RD-WBRT.

Age-related differences in primary central nervous system lymphomas based on the SEER database

Objective

The aim of this study was to compare prognostic factors and survival outcomes in patients with primary central nervous system lymphoma (PCNSL).

Methods

The Surveillance, Epidemiology, and End Results (SEER) database was queried for patients diagnosed with PCNSL between 2000 and 2019.

Results

Between 2000 and 2019, a total of 5,812 patients were diagnosed with PCNSL, of whom 2,175 (37%) were ≤ 60 years old and 3,637 (63%) were >60 years old. The younger patients had a higher rate of being diagnosed with stage I-II, a higher rate of receiving chemotherapy and radiotherapy, a similar rate of receiving surgery, and a longer survival time. The most common histological subtype among PCNSL patients was diffuse large B-cell lymphoma (PCNS-DLBCL). Younger PCNS-DLBCL patients who received surgery and chemotherapy exhibited significantly improved overall survival (OS) and disease-specific mortality (DSM) and that African American patients were associated with poorer OS and DSM. Older patients receiving surgery, chemotherapy, and radiotherapy exhibited significantly improved OS and DSM, male and higher Ann Arbor stage were associated with poorer OS and DSM. We created a nomogram for PCNS-DLBCL to predict OS, with a C-index of 0.6749 in the younger cohort and 0.6676 in the older cohort. In the combined therapy analysis, chemotherapy combined with surgical resection had better OS and DSM in all patients.

Conclusions

The two age-stratified cohorts significantly differed in terms of OS and independent influences on OS and DSM. Our constructed nomogram exhibited high accuracy in predicting OS in PCNS-DLBCL patients.

New recommendations for reversal of high-dose methotrexate cytotoxicity with folinic acid

PURPOSE

Folinic acid (FA) rescue protocols to counter the adverse effects of high-dose methotrexate (HDMTX) vary widely, and the risk of over-rescue and potential adverse effects of excessive FA (e.g., hypercalcemia) are under-recognized issues when providing augmented rescue in cases of delayed methotrexate elimination (DME). This opinion summary defines over-rescue, describes its potential adverse impacts, highlights the risk of hypercalcemia associated with excessive FA dosing in patients with acute kidney injury (AKI) from HDMTX, and provides recommendations to improve safety and efficacy of FA rescue in patients receiving HDMTX.

METHODS

A multidisciplinary panel of experts with clinical experience in HDMTX treatment convened in three roundtable meetings to coalesce expert opinion and best published evidence on the pharmacology and clinical effects and interactions of FA and HDMTX.

RESULTS

The type of FA (calcium folinate, calcium levofolinate, sodium levofolinate), dose, and frequency of FA administration may be factors for over-rescue and the development of hypercalcemia due to their respective pharmacokinetic characteristics, especially in cases of DME requiring augmented FA rescue.

CONCLUSION

Clinicians are reminded of the possibility of over-rescue with FA and its impact on subsequent HDMTX courses, types of FA available and their durations of action, and avoid providing too frequent doses. In the setting of AKI and DME requiring high doses of FA, use of sodium levofolinate or calcium levofolinate may be considered to reduce the risk of hypercalcemia associated with calcium folinate.

Comparison of outcomes in postinduction strategies for primary central nervous system lymphoma: a Mayo Clinic experience

ABSTRACT

Primary central nervous system lymphoma (PCNSL) is a rare form of non-Hodgkin lymphoma involving the brain, cerebrospinal fluid, or retina/vitreous without systemic involvement. Induction with high-dose methotrexate (HD-MTX) followed by consolidation with autologous stem cell transplant (auto-SCT) has become the standard treatment paradigm for most patients. However, limited data are available regarding the efficacy of a maintenance approach with HD-MTX. Herein, we retrospectively reviewed the characteristics and outcomes of 148 patients diagnosed with PCNSL between October 2010 and June 2022, who underwent HD-MTX-based induction therapy followed by either auto-SCT consolidation (n = 70) or HD-MTX maintenance therapy (n = 37). At a median follow-up time of 4.5 years, the progression-free survival (PFS) was 8.3 years and the overall survival (OS) was not reached. Compared to patients who underwent auto-SCT, patients who received maintenance HD-MTX had a higher median age at diagnosis of 72 vs 62 years and a trend toward higher proportion of patients being Eastern Cooperative Oncology Group 2 or higher (41% vs 29%). At 5-years postinduction treatment initiation, the PFS rates in the auto-SCT cohort and HD-MTX maintenance cohort were 74.6% and 72.6%, respectively, and the OS rates were 76.0% and 82.4%, respectively. Overall, there was no significant difference in PFS or OS based on postinduction management strategy. Our data suggest that maintenance HD-MTX may be a reasonable, time-limited treatment strategy for patients with PCNSL responding to initial induction therapy.

Impact of Systemic and Radiation Therapy on Survival of Primary Central Nervous System Lymphoma

Introduction: Treatment for primary central nervous system lymphoma (PCNSL) includes high-dose methotrexate (HD-MTX)-based systemic therapy. Multiple regimens exist with no clear standard of care. We evaluated the impact of different therapies on PCNSL outcomes at a single institution. Materials and Methods: A total of 95 consecutive patients with PCNSL from 2002 to 2021 were retrospectively reviewed. The overall survival (OS) and progression-free survival (PFS) were estimated by the Kaplan-Meier method. The log-rank test and univariate and multivariable Cox regression analysis were used to evaluate the relationship between clinicopathologic and treatment variables with outcomes. Results: Among the 62 patients treated with definitive systemic therapy, the median age was 58; 71% had a Karnofsky performance status > 70, 49% had a single lesion, 31% received HD-MTX alone, and 61% had HD-MTX + rituximab. The two-year OS and PFS were 64% (95% CI: 49.8-75.0%) and 49% (95% CI: 35.0-60.9%), respectively. On multivariable analysis, the completion of > six cycles of HD-MTX (HR 0.40; 95% CI: 0.21-0.76; p = 0.01) was associated with superior OS, while the use of rituximab was associated with inferior OS (HR 2.82; 95% CI: 1.37-5.83; p = 0.01). There were no significant associations between the OS and PFS with temozolomide, the extent of surgical resection, radiation, or the size or number of initial lesions (all p > 0.05). Discussion: Innovation is needed to improve the outcomes for patients with PCNSL.

Treatment-related leukoencephalopathy in adults with central nervous system lymphoma: a retrospective analysis of 126 patients

Neurotoxicity associated with high-dose chemotherapy and whole brain radiotherapy (WBRT) is one of major complications for patients with central nervous system lymphoma (CNSL). Here we determined the incidence and risk factors of treatment-related leukoencephalopathy (tLE) in a clinical setting. We retrospectively reviewed clinical and radiological findings of 126 patients with  (CNSL) treated with high-dose methotrexate with or without intrathecal methotrexate administration (IT MTX) and response-adapted WBRT. During the whole observation period with a median of 38.7 months, tLE was found in 33 patients, most of them asymptomatic, with the median time to development 3.0 months, and the cumulative incidence reaching 29.2% (95% confidence interval, 20.6-38.2%) two years post chemotherapy. By multivariable analysis, IT MTX was identified as the only one significant risk factor (hazard ratio, 4.50; P < 0.001), and the number of IT MTX was associated with the increased incidence and severity of tLE. These findings highlight the frequent neurological complications associated with CNS-directed therapy and confirm the neurotoxicity of IT MTX.

High-dose methotrexate-based chemotherapy for induction remission of newly diagnosed primary CNS lymphoma: A systematic review and meta-analysis

BACKGROUND

This study aimed to comprehensively assess the optimal regimen for high-dose methotrexate (HD-MTX) in treating primary central nervous system lymphoma (PCNSL).

METHODS

We have searched 8 databases, including PubMed, EMBASE, Cochrane Library, WOS, Epistemonikos, CNKI, WAN-FANG Database, and CBM, and were selected for the clinical trials about PCNSL. A total of 37 studies were included in our analysis, consisting of 6 randomized controlled trials and 31 single-arm clinical studies.

RESULTS

After analyzing the data from 37 clinical studies, we found that the pooled overall response rate (ORR) for low-dose (<3 g/m2), medium-dose (3-5 g/m2), and high-dose (>5 g/m2) methotrexate (MTX) were 0.78, 0.80, and 0.80, respectively. The pooled 2-year overall survival (OS) for low-dose, medium-dose, and high-dose MTX were 52%, 60%, and 71%, respectively. The ORR, complete response (CR), and 2-year OS of patients who received <5 cycles of MTX were 79%, 41%, and 59%, respectively, whereas those for PCNSL patients who received >5 cycles of MTX were 81%, 54%, and 64%, respectively. The pooled ORR for MTX, dual therapy, triplet therapy, tetrad therapy, and multiple therapy were 71%, 70%, 81%, 85%, and 80%, respectively. The pooled 2-year OS for different numbers of medication combinations were 59%, 52%, 66%, 63%, and 60%, respectively. The addition of cytarabine to MTX-based chemotherapy resulted in higher CR, although no statistically significant difference was observed in OS. Adding rituximab to the treatment regimen improved patients' progression-free survival without affecting treatment response or OS.

CONCLUSION

Based on the findings of this study, the treatment strategies of MTX are associated with the prognosis and efficacy response of PCNSL patients. The results suggested that the current recommended HD-MTX dosage of 3.5 g/m2 is sufficient for PCNSL to have a favorable treatment response and prognosis. When the number of MTX treatment cycles increases, the therapeutic effect and prognosis of PCNSL patients are improved. The patients treated with MTX-based triplet combination regimens have a better ORR and CR. Although HD-MTX is generally well tolerated, it is necessary to be cautious about the use of multiple therapy that includes cytarabine to prevent potential acute toxicity.

Association between surgery and increased survival in primary central nervous system lymphoma: a retrospective cohort study

This study investigated the effect of surgery on the prognosis of patients with primary central nervous system lymphoma (PCNSL) using data from the surveillance, epidemiology, and end results (SEER) database. A cohort of 5932 patients was analyzed, with 1466 undergoing surgical intervention (780 subtotal resection (STR), 686 gross total resection (GTR)) and 4466 receiving no surgery or biopsy only. The median age of the study population was 61.5 years. The median survival was 24.0 months for STR, 30.0 months for GTR, and 18.0 months for non-surgical patients (P < 0.001). Multivariate Cox regression analyses showed that the adjusted hazard ratio (HR) for STR was 0.77 (95% CI 0.70-0.85, P < 0.001) for overall survival (OS) and 0.74 (95% CI 0.66-0.83, P < 0.001) for cancer-specific survival (CSS). For GTR, the adjusted HR was 0.73 (95% CI 0.65-0.80, P < 0.001) for OS and 0.73 (95% CI 0.65-0.82, P < 0.001) for CSS. These results remained robust even after subgroup analyses, sensitivity analyses and propensity score matching (PSM). No significant interactions were observed in any subgroup. These findings indicate that surgery may improve the survival of patients with PCNSL, though further research is needed to confirm these findings. A key limitation is the inability to stratify patients by performance status and lesion number, critical for assessing resective surgery suitability.

High-dose MTX-based polychemotherapy for primary CNS lymphoma in younger patients: Long-term efficacy of the modified Bonn protocol

Background

Polychemotherapy based on high-dose methotrexate (HD-MTX) is the standard therapy for newly diagnosed younger patients (<65 years) with primary CNS lymphoma (PCNSL). In the modified Bonn protocol, consolidation therapy consists of intraventricular chemotherapy that is added to the continuation of HD-MTX-based chemotherapy. This study investigates the efficacy and toxicity of the modified Bonn protocol in first-line therapy of young patients with PCNSL.

Methods

All consecutive immunocompetent patients aged <65 years who were newly diagnosed with PCNSL from 2012 to 2021 and started first-line therapy with the modified Bonn protocol at the Neurooncology Center Bonn were included in this retrospective analysis. Treatment comprised 3 courses of rituximab/HD-MTX/IFO followed by consolidation therapy with 2 courses of HD-AraC and 2 courses of HD-MTX/IFO, including intrathecal MTX and intrathecal AraC. Progression-free and overall survival were evaluated.

Results

Forty-three patients were included. Thirty-seven patients (86%) reached intrathecal consolidation therapy. Grade 3/4 toxicity was observed in 58.1%. The median PFS was 102.8 months; 5-year OS rate was 76% (median not reached). Eighteen patients developing refractory/relapsed PCNSL received second-line therapy using the modified Freiburg protocol (AraC/TT +/- HD-MTX/rituximab followed by BCNU/TT-based HD-ASCT). A second relapse was observed in 11/18 patients (median follow-up of 17 months (IQR 5-43.7 months)).

Conclusions

First-line treatment of PCNSL with the modified Bonn protocol is highly effective. The outcome compares well with other seemingly more toxic PCNSL protocols for younger patients. In patients with disease recurrence, second-line therapy according to the modified Freiburg protocol appears to be effective.

Clinicopathological risk factors for prognosis and therapeutic response of primary central nervous system lymphoma in China: a single-center retrospective analysis of 118 cases

To investigate the prognostic significance of clinicopathological factors in patients with primary central nervous system lymphoma (PCNSL) in a single center. Patients newly diagnosed with PCNSL at our center were recruited between January 2019 and March 2023. Baseline demographic and clinicopathological data were collected retrospectively. The Kaplan-Meier method and Cox regression analysis were performed for survival analyses. A total of 118 patients were enrolled. The median age was 64 (IQR, 54-68). The median progression-free survival (PFS) and overall survival (OS) were 12.70 (95%CI, 9.73-23.30) months and 36.87 (95%CI, 25.57-NR) months, respectively. KPS < 70 and ECOG ≥ 3 were significantly associated with worse PFS and OS. High International Extranodal Lymphoma Study Group (IELSG) score (IELSG 4-5) and high-risk Memorial Sloan-Kettering Cancer Center (MSKCC) score were also adverse factors for PFS and OS. BTK inhibitors (BTKi) therapy (HR 0.39, 95% CI, 0.18-0.86, p = 0.020) and consolidation therapy (HR 0.19, 95% CI, 0.06-0.64, p = 0.007) were confirmed as independent favorable factors for OS. A high NK lymphocyte proportion was associated with worse OS (p = 0.008). Patients in the high NK lymphocyte group experienced a higher rate of primary tumor resistance (57.14%) than the low NK lymphocyte group (33.33%). KPS < 70, ECOG ≥ 3, IELSG 4-5, and high-risk MSKCC score are adverse factors for PFS and OS. Importantly, BTKi therapy and consolidation therapy are independent favorable factors for OS. Peripheral lymphocyte immunophenotyping could be a potential predictive indicator for prognosis and therapeutic response in PCNSL.

Lack of Apparent Neurotoxicity in Older Patients with Primary Central Nervous System Lymphoma Receiving Long-term Tirabrutinib: Report of 2 Cases

Older patients represent a unique and vulnerable subgroup, requiring careful consideration when determining treatment options. Treatment-related leukoencephalopathy is commonly observed in older patients months to years after receiving radiotherapy and/or methotrexate for primary central nervous system lymphoma (PCNSL). Tirabrutinib is an orally available, highly selective, and potent second-generation Bruton's tyrosine kinase inhibitor (BTKi) approved for treating recurrent/refractory PCNSL in Japan. However, limited studies evaluate the imaging findings in patients receiving tirabrutinib. In this study, we reported 2 cases of older patients with PCNSL who did not develop treatment-related neurotoxicity or leukoencephalopathy after long-term administration of tirabrutinib.

Evolving consolidation patterns and outcomes for a large cohort of patients with primary CNS lymphoma

ABSTRACT

Consolidation for primary central nervous system lymphoma (PCNSL) after induction chemoimmunotherapy include whole-brain radiotherapy (WBRT; ≤24 Gy reduced-dose [RD], >24 Gy standard-dose) and cytarabine, nonmyeloablative chemotherapy (NMC), or autologous hematopoietic cell transplantation (AHCT). Comparative outcomes are lacking. Outcomes from 1983-2020 were stratified by decade and Memorial Sloan Kettering Cancer Center recursive partitioning analysis (RPA) class. Clinicodemographic associations were analyzed by multinomial logistic regression. Progression-free survival (PFS) and overall survival (OS) were analyzed by proportional hazards. Of 559 patients, 385 (69%) were consolidated. Median follow-up and OS were 7.4 and 5.7 years, respectively. WBRT use declined (61% (1990s) vs 12% (2010s)), whereas AHCT (4% (1990s) vs 32% (2010s)) and NMC (27% (1990s) vs 52% (2010s)) rose. Compared with RPA 1, RPA 2 was more likely to receive NMC. Those with partial response to induction were less likely to receive AHCT (odds ratio, 0.36; P = .02). Among 351 with complete response to consolidation, only receipt of rituximab, methotrexate, procarbazine, and vincristine induction was associated with improved PFS (hazard ratio, 0.5; P = .006). Among RPA 1, median PFS and OS were not reached for AHCT or RD-WBRT, vs 2.5 and 13.0 years, respectively, after NMC. Among RPA class 3, median PFS and OS after RD-WBRT were 4.6 and 10 years, vs 1.7 and 4.4 years after NMC. No significant adjusted survival differences were seen across consolidation strategies. NMC is increasingly used in lieu of RD-WBRT despite a trend toward less favorable PFS. RD-WBRT can be considered in patients ineligible for AHCT.

Prognostic factors and surgical approaches in the analysis of primary central nervous system diffuse large B-cell lymphoma: a large population-based cohort study and external validation

Introduction

This study aims to investigate prognostic indicators and assess surgical interventions' impact on Primary central nervous system lymphoma-diffuse large B-cell lymphoma (PCNS-DLBCL) patients.

Methods

A comprehensive examination was performed on a group of 3,962 cases in the Surveillance, Epidemiology, and End Results (SEER) database, as well as 27 cases of PCNS-DLBCL from the First Affiliated Hospital of Wenzhou Medical University. The application of both univariate and multivariate Cox regression analyses facilitated the identification of significant risk factors associated with PCNS-DLBCL. Developing and verifying nomograms, the reliability of the nomogram was evaluated by C-index, ROC curve, calibration curve and decision curve analysis. Finally, by using Kaplan-Meier (KM) curves to assess the survival rates for PCNS-DLBCL patients.

Results

Age, gender, marital status, tumor location, HIV infection status, chemotherapy, and surgical scopes emerged as independent prognostic factors for overall survival (OS) in multivariate Cox regression analysis, whereas gender did not demonstrate significance as a factor for cancer-specific survival (CSS). The C-index, calibration curves, ROC curves, and DCA curves demonstrating strong reliability and practicality. KM analysis revealed significantly improved OS and CSS in patients who underwent surgical resection compared to those who received no surgery/biopsy, especially receiving subtotal resection (STR). In addition, among patients receiving chemotherapy, both STR and gross total resection (GTR) improved survival time compared to chemotherapy alone, particularly with STR. In the non-chemotherapy group, GTR potentially improved CSS, there was no notable disparity in OS between patients who underwent surgery and those who did not or received biopsy.

Conclusion

This study analyzed prognostic factors in PCNS-DLBCL patients, resulting in nomograms predicting 1-, 3-, and 5-year OS and CSS, which showed preferable performance. Combining different resection scopes with chemotherapy improved survival compared to chemotherapy alone, advocating for integrated treatment strategies. Surgery alone is not recommended based on our findings.

Advances in Primary Central Nervous System Lymphoma

PURPOSE OF REVIEW

Optimal initial management can have a significant impact in long-term outcome in primary CNS lymphoma. This article reviews recent advances and the state of the field.

RECENT FINDINGS

Genomic analysis of CSF cell-free DNA has emerged as a new diagnostic tool for PCNSL. Treatment options have likewise evolved, with mature data from first-line chemotherapy-based prospective trials disclosing excellent results in younger (< 60-65) patients, with a cure achieved in a majority. However, results in older patients remain dismal, with several new salvage options under investigation including BTK pathway-targeted therapies, and CAR-T cell treatments. Meanwhile, low-dose radiation has emerged as an additional alternative for consolidation therapy. For younger PCNSL patients, the goal of treatment is now a cure, with the next frontier being the development of therapies affording optimized neurocognitive outcome and lower toxicity. Treatment for older patients remains however an unmet need, with several promising clinical trials ongoing.

The risk of venous thromboembolism in primary central nervous system lymphoma: a systematic review and meta-analysis

Primary central nervous system lymphoma (PCNSL) is a rare extranodal lymphoma localized to the central nervous system. Small single-center studies have suggested that patients with PCNSL may be at high risk of venous thromboembolism (VTE). This systematic review aimed to estimate the risk of VTE in patients with PCNSL. A systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. MEDLINE, Embase, and CINAHL were searched from 1990 to 2022. Prospective and retrospective observational studies as well as clinical trials were included. The primary efficacy outcome was VTE, and the primary safety outcome was major bleeding as defined by the individual studies. After screening 883 studies, 46 studies (3688 patients) with PCNSL were included. Mean age was 62.4 years. Five studies explored the use of thromboprophylaxis (acetyl salicylic acid or anticoagulation [n = 1]) and low-molecular-weight heparin (n = 4). Overall, 420 patients developed VTE (11.4%), including 17 fatal events (4% of all VTE). Two studies that reported on VTE prophylaxis representing 77 patients identified 8 breakthrough VTE events (10.4%). Most studies (n = 34; 74.5%) did not report major bleeding complications. Among studies reporting on bleeding, 174 major bleeding (7.4%) events were reported out of 2361 patients, 3 of which were attributed to thromboprophylaxis. Patients with PCNSL seem to be at high risk of both VTE and bleeding complications. Future clinical trials in this population should routinely collect data on incidence of VTE and bleeding to help clinicians assess the risk-to-benefit ratio of thromboprophylaxis in this high-risk patient population.

Sequential high-dose methotrexate and cytarabine administration improves outcomes in real-world patients with primary central nervous system lymphoma: A report from the Australasian Lymphoma Alliance

Background

Despite recent advances, optimal therapeutic approaches applicable to subpopulations with primary central nervous system (CNS) lymphoma outside of clinical trials remain to be determined.

Methods

We performed a retrospective study of immunocompetent, adult patients with histologically confirmed diffuse large B-cell lymphoma of the CNS (PCNSL). 190/204 (93%) patients (median age: 65) received one of five high-dose methotrexate (HD-MTX) containing chemotherapy regimens: MPV/Ara-C (HD-MTX, procarbazine, and vincristine, followed by cytarabine [Ara-C]) (n = 94, 50%), MATRix (HD-MTX, Ara-C, thiotepa, and rituximab) (n = 19, 10%), HD-MTX/Ara-C (n = 31, 16%), HD-MTX monotherapy (n = 35, 18%) and MBVP (HD-MTX, carmustine, teniposide, prednisolone) (n = 11, 6%).

Results

Cumulative median HD-MTX and Ara-C doses were 17 g/m2 (range: 1-64 g/m2) and 12 g/m2 (0-32 g/m2) respectively. Using 14 g/m2 as the reference dose, the median HD-MTX relative dose intensity (HD-MTX-RDI) was 1.25 (0.27-4.57) with 84% receiving > 0.75. The overall response rate (ORR) was 72% (complete response: 50%) after completing HD-MTX. At a median follow-up of 3.41 years (0.06-9.42), progression-free survival (PFS) and overall survival (OS) were different between chemotherapy cohorts, with the best outcomes achieved in the MPV/Ara-C cohort (2-year PFS 74%, 2-year OS 82%; p = 0.0001 and p = 0.0024 respectively). On multivariate analysis, MPV/Ara-C administration and HD-MTX-RDI > 0.75 were associated with longer PFS and OS.

Conclusion

Sequential, response-adapted approaches can improve outcomes, even in older patients who are ineligible for a high-intensity concurrent chemotherapy approach and do not undergo traditional consolidative strategies.

Interim FDG-PET improves treatment failure prediction in primary central nervous system lymphoma: An LOC network prospective multicentric study

BACKGROUND

The purpose of our study was to assess the predictive and prognostic role of 2-18F-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography (PET)/MRI during high-dose methotrexate-based chemotherapy (HD-MBC) in de novo primary central nervous system lymphoma (PCNSL) patients aged 60 and above.

METHODS

This prospective multicentric ancillary study included 65 immunocompetent patients who received induction HD-MBC as part of the BLOCAGE01 phase III trial. FDG-PET/MRI were acquired at baseline, post 2 cycles (PET/MRI2), and posttreatment (PET/MRI3). FDG-PET response was dichotomized with "positive" indicating persistent tumor uptake higher than the contralateral mirroring brain region. Performances of FDG-PET and International PCNSL Collaborative Group criteria in predicting induction response, progression-free survival (PFS), and overall survival (OS) were compared.

RESULTS

Of the 48 PET2 scans performed, 9 were positive and aligned with a partial response (PR) on MRI2. Among these, 8 (89%) progressed by the end of the induction phase. In contrast, 35/39 (90%) of PET2-negative patients achieved complete response (CR). Among the 18 discordant responses at interim (PETCR/MRIPR), 83% ultimately achieved CR. Eighty-seven percent of the PET2-negative patients were disease free at 6 months versus 11% of the PET2-positive patients (P < .001). The MRI2 response did not significantly differentiate patients based on their PFS, regardless of whether they were in CR or PR. Both PET2 and MRI2 independently predicted OS in multivariate analysis, with PET2 showing a stronger association.

CONCLUSIONS

Our study highlights the potential of interim FDG-PET for early management of PCNSL patients. Response-driven treatment based on PET2 may guide future clinical trials.

TRIAL

LOCALYZE, NCT03582254, ancillary of phase III clinical trial BLOCAGE01, NCT02313389 (Registered July 10, 2018-retrospectively registered) https://clinicaltrials.gov/ct2/show/NCT03582254?term=LOCALYZE&draw=2&rank=1.

Patterns of Treatment Failure in Primary Central Nervous System Lymphoma

OBJECTIVES

Progression of PCNSL remains a challenge with salvage therapies, including the risk of substantial morbidity and mortality. We report patterns of first tumor progression to inform opportunities for improvement.

METHODS

This is an institutional retrospective review from 2002 to 2021 of 95 consecutive patients with pathologically confirmed PCNSL, of whom 29 experienced progressive disease. Kaplan-Meier method, log-rank test, and Cox proportional hazard models are used to characterize associations of patient, tumor, and treatment variables with LC, PFS, and patterns of first failure.

RESULTS

Most patients were below 65 years old (62%) with KPS >70 (64%) and negative CSF cytology (70%). In 70 patients with MRIs, the median tumor volume was 12.6 mL (range: 0.5 to 67.8 mL). After a median follow-up of 11 months, 1-year PFS was 48% and 1-year LC was 80%. Of the 29 patients with progression, 24% were distant only, 17% were distant and local, and 59% were local only. On MVA, LC was associated with age (HR: 1.08/y, P =0.02), KPS (HR: 0.10, P =0.02), completion of >6 cycles of HD-MTX (HR: 0.10, P <0.01), and use of intrathecal chemotherapy (HR: 0.03, P <0.01). On UVA, local only first failure trended to be increased with >14 mL tumors (OR: 5.06, P =0.08) with 1-year LC 83% (<14 mL) versus 64% (>14mL). There were no significant associations with LC and WBRT ( P =0.37), Rituximab ( P =0.12), or attempted gross total resection ( P =0.72).

CONCLUSIONS

Our findings reaffirm the importance of systemic and intrathecal therapies for local control in PCNSL. However, bulky tumors trend to fail locally, warranting further investigation about the role of local therapies or systemic therapy intensification.

Diagnostics and treatment delay in primary central nervous system lymphoma: What the neurosurgeon should know

PURPOSE

The gold standard for diagnostics in primary central nervous system lymphoma (PCNSL) is histopathological diagnosis after stereotactic biopsy. Yet, PCNSL has a multidisciplinary diagnostic work up, which associated with diagnostic delay and could result in treatment delay. This article offers recommendations to neurosurgeons involved in clinical decision-making regarding (novel) diagnostics and care for patients with PCNSL with the aim to improve uniformity and timeliness of the diagnostic process for patients with PCNSL.

METHODS

We present a mini review to discuss the role of stereotactic biopsy in the context of novel developments in diagnostics for PCNSL, as well as the role for cytoreductive surgery.

RESULTS

Cerebrospinal fluid-based diagnostics are supplementary and cannot replace stereotactic biopsy-based diagnostics.

CONCLUSION

Histopathological diagnosis after stereotactic biopsy of the brain remains the gold standard for diagnosis. Additional diagnostics should not be a cause of diagnostic delay. There is currently no sufficient evidence supporting cytoreductive surgery in PCNSL, with recent studies showing contradictive data and suboptimal study designs.

Prolonged remission with ibrutinib maintenance therapy following radiation in a patient with relapsed primary CNS lymphoma

Background: Treatment for refractory or relapsed primary CNS lymphoma (r/r PCNSL) is challenging. Salvage whole-brain radiation therapy (WBRT) is an option but has a short duration of disease control, so additional treatment modalities are warranted. Case: A 75-year-old female with r/r PCNSL who had multiple progressions after multiple lines of treatment underwent salvage WBRT. The patient received ibrutinib, a Bruton's tyrosine kinase inhibitor, as maintenance therapy for 18 months following WBRT with the intention of increasing survival duration after salvage WBRT. She survived 81 months from diagnosis, including 57 months after completion of WBRT. Conclusion: This case presentation describes the experience of using ibrutinib as maintenance therapy in treating r/r PCNSL after salvage WBRT.

Primary central nervous system lymphomas: EHA-ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up

This EHA-ESMO Clinical Practice Guideline provides key recommendations for managing primary DLBCL of the CNS.The guideline covers clinical, imaging and pathological diagnosis, staging and risk assessment, treatment and follow-up.Algorithms for first-line and salvage treatments are provided.The author group encompasses a multidisciplinary group of experts from different institutions and countries in Europe.Recommendations are based on available scientific data and the authors' collective expert opinion.

Genetic polymorphisms and clinical parameters associated with renal toxicity in Thai hematologic malignancy patients receiving high dose methotrexate

High-dose methotrexate (HD-MTX) is a widely used chemotherapy regimen for hematologic malignancies such as lymphomas and acute lymphoblastic leukemia, but its use can lead to adverse effects, including acute kidney injury (AKI), impaired liver function, and mucositis, causing extended hospital stays and delayed subsequent chemotherapy. Our study aimed to investigate the predictive factors for renal toxicities associated with HD-MTX in Thai patients undergoing treatment for hematologic malignancies. We enrolled 80 patients who underwent MTX-containing regimens, analyzing 132 chemotherapy cycles. The most common disease was primary central nervous system lymphoma (33%). Genetic polymorphisms were examined using the MassARRAY® system, identifying 42 polymorphisms in 25 genes. Serum creatinine and MTX levels were measured 24 and 48 h after MTX administration. For the primary outcome, we found that the allele A of MTRR rs1801394 was significantly related to renal toxicity (odds ratio 2.084 (1.001-4.301), p-value 0.047). Patients who exceeded the MTX threshold levels at 24 h after the dose had a significantly higher risk of renal toxicity (OR (95%CI) = 6.818 (2.350-19.782), p < 0.001). Multivariate logistic regression analysis with a generalized estimated equation revealed hypertension and age as independent predictors of increased MTX levels at 24 h after the given dose.

High-dose methotrexate and zanubrutinib combination therapy for primary central nervous system lymphoma

In this editorial I comment on the article, published in the current issue of the World Journal of Clinical Oncology. Primary central nervous system lymphoma (PCNSL) is a disease of elderly and immunocompromised patients. The authors reported clinical results of 19 patients with PCNSL treated with zanubrutinib/high dose methotrexate (HD-MTX) until disease progression. They demonstrated that the combination of zanubrutinib with HD-MTX led to a marked clinical response and tolerability among these patients. They also observed that cerebrospinal fluid liquid biopsy to detect circulating tumor DNA may be a good option for evaluating treatment response and tumor burden in patients with PCNSL. PCNSL is a challenging disease for treatment as these patients present with different neurological states and comorbidities. Treatment has evolved over the years from whole brain radiotherapy to HD-MTX followed by autologous stem cell transplant. Gradually, treatment of patients with PCNSL is going to become individualized.

All-cause and tumor-specific mortality trends in elderly primary central nervous system lymphoma (PCNSL) patients: a surveillance, epidemiology, and end results (SEER) analysis

BACKGROUND

Recent primary central nervous system lymphoma (PCNSL) literature indicates that younger patients benefit from improved survival; however, this benefit is not shared by those 70+ years of age. The purpose of this study was to examine mortality trends in PCNSL patients 70+ years of age to better understand why improved prognosis has not yet reached this rapidly growing population subset.

METHODS

Two thousand seventy-five cases (1973-2012, age at diagnosis 70+ years) within the Surveillance, Epidemiology, and End Results (SEER) database were included in Kaplan-Meier and multivariate Cox Regression analyses. Variables include age at diagnosis, decade of diagnosis (1=1973-1982, 2=1983-1992, 3=1993-2002, 4=2003-2012), sex, race and surgery.

RESULTS

Before stratification, both univariate and multivariate analyses agreed that patients aged 70-74 years at diagnosis lived the longest, while those 85+ years lived the shortest (median±SD; 6.0±0.5 months vs. 2.0±0.2 months, respectively, P<0.0005); women lived longer than men (5.0±0.3 months vs. 4.0±0.3 months, respectively, P=0.01); patients who received surgery (6.0±0.5 months) lived longer than those who did not (contraindicated=1.0±0.5 months, P<0.0005; not performed=4.0±0.3 months, P<0.0005). Univariate analysis showed decade 4 lived longer than only decade 3 (4.0±0.3 vs. 4.0±0.5, respectively, P=0.008), while multivariate analysis showed decade 4 lived longer than both 2 (5.0±0.8 months, P=0.03) and 3 (P<0.0005). Following stratification, decade and sex no longer influenced survival. Race did not influence survival.

CONCLUSIONS

Minimal clinically meaningful improvements in elderly PCNSL patient all-cause and tumor-specific mortality have been made since 1973, while the best predictors of longevity include younger age and surgery.

The association between graded prognostic assessment and the prognosis of brain metastases after whole brain radiotherapy: a meta-analysis

Introduction

This meta-analysis aims to provide evidence-based medical evidence for formulating rational treatment strategies and evaluating the prognosis of brain metastasis (BM) patients by assessing the effectiveness of the graded prognostic assessment (GPA) model in predicting the survival prognosis of patients with BM after whole-brain radiotherapy (WBRT).

Methods

A comprehensive search was conducted in multiple databases, including the China Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), PubMed, Wanfang database, Cochrane Library, Web of Science, and Embase. Cohort studies that met the inclusion and exclusion criteria were selected. The quality of the included literature was evaluated using the Newcastle-Ottawa Scale, and all statistical analyses were performed with R version 4.2.2. The effect size (ES) was measured by the hazard ratio (HR) of overall survival (OS). The OS rates at 3, 6, 12, and 24 months of patients with BM were compared between those with GPAs of 1.5-2.5, 3.0, and 3.5-4.0 and those with GPAs of 0-1 after WBRT.

Results

A total of 1,797 participants who underwent WBRT were included in this study. The meta-analysis revealed a significant association between GPA and OS rates after WBRT: compared with BM patients with GPA of 0-1, 3-month OS rates after WBRT were significantly higher in BM patients with GPA of 1.5-2.5 (HR = 0.48; 95% CI: 0.40-0.59), GPA of 3 (HR = 0.38; 95% CI: 0.25-0.57), and GPA of 3.5-4 (HR = 0.28; 95% CI: 0.15-0.52); 6-month OS rates after WBRT were significantly higher in BM patients with GPA of 1.5-2.5 (HR = 0.48; 95% CI: 0.41-0.56), GPA of 3 (HR = 0.33; 95% CI: 0.24-0.45), and GPA of 3.5-4 (HR = 0.24; 95% CI: 0.16-0.35); 12-month OS rates after WBRT were significantly higher in BM patients with GPA of 1.5-2.5 (HR = 0.49; 95% CI: 0.41-0.58), GPA of 3 (HR = 0.48; 95% CI: 0.32-0.73), and GPA of 3.5-4 (HR = 0.31; 95% CI: 0.12-0.79); and 24-month OS rates after WBRT were significantly higher in BM patients with GPA of 1.5-2.5 (HR = 0.49; 95% CI: 0.42-0.58), GPA of 3 (HR = 0.49; 95% CI: 0.32-0.74), and GPA of 3.5-4 (HR = 0.38; 95% CI: 0.15-0.94).

Conclusion

BM patients with higher GPAs generally exhibited better prognoses and survival outcomes after WBRT compared to those with lower GPAs.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42023422914.

Three-year follow-up analysis of phase 1/2 study on tirabrutinib in patients with relapsed or refractory primary central nervous system lymphoma

Background

The ONO-4059-02 phase 1/2 study showed favorable efficacy and acceptable safety profile of tirabrutinib, a second-generation Bruton's tyrosine kinase inhibitor, for relapsed/refractory primary central nervous system lymphoma (PCNSL). Here, we report the long-term efficacy and safety after a 3-year follow-up.

Methods

Eligible patients were aged ≥ 20 years with histologically diagnosed PCNSL and KPS of ≥ 70. Patients received oral tirabrutinib once daily at 320 or 480 mg, or 480 mg under fasted conditions.

Results

Between October 19, 2017, and June 13, 2019, 44 patients were enrolled: 33 and 9 had relapsed and refractory, respectively. The 320, 480, and 480 mg fasted groups included 20, 7, and 17 patients, respectively. The median follow-up was 37.1 months. The overall response rate was 63.6% (95% CI: 47.8-77.6) with complete response (CR), unconfirmed CR, and partial response in 9, 7, and 12 patients, respectively. The median duration of response (DOR) was 9.2 months, with a DOR rate of 19.8%; the median progression-free survival (PFS) and median overall survival (OS) were 2.9 months and not reached, respectively, with PFS and OS rates of 13.9% and 56.7%, respectively. Adverse events occurred in 38 patients (86.4%): grade ≥ 3 in 23 (52.3%) including 1 patient with grade 5 events. KPS and quality of life (QoL) scores were well maintained among patients receiving long-term treatment.

Conclusions

The results demonstrated the long-term clinical benefit of tirabrutinib, with deep and durable response in a subset of patients and acceptable safety profile, while KPS and QoL scores were maintained.

Novel approaches to treatment of leptomeningeal metastases

PURPOSE OF REVIEW

The incidence of leptomeningeal metastases is increasing in the setting of improved survival from systemic cancers. In more recent years, our understanding of leptomeningeal metastasis pathogenesis, how to diagnose and treat has been evolving.

RECENT FINDINGS

Diagnosing leptomeningeal metastasis has been challenging due to the limitations of cytology and neuroimaging; However, newer techniques detecting circulating tumor cells (CTCs) or circulating tumor DNA (ctDNA) have shown potential advantage with diagnosis, quantification and detection of oncogenic mutations. The use of small molecule inhibitors and immunotherapy has shown some promise in specific leptomeningeal metastasis subtypes.

SUMMARY

These new discoveries have improved clinical trials' ability to assess treatment response and thereby more optimally compare different treatments. Furthermore, they have helped the individual clinician better diagnose, monitor the disease and provide novel therapies.

Is reduced-dose whole-brain radiotherapy also feasible in primary CNS lymphoma for curative or salvage purpose?

PURPOSE

Recently, reduced-dose whole-brain radiotherapy (WBRT) has been used to treat primary central nervous system lymphoma (PCNSL). However, whether reduced-dose WBRT is also an acceptable option for curative or salvage purposes has not yet been reported. We analyzed the clinical outcomes of patients with PCNSL who received radiotherapy for curative or salvage purposes and compared the clinical outcomes according to the WBRT dose.

METHODS

A total of 66 patients were divided into two groups: those treated with 30 Gy (2 Gy per fraction) or less WBRT (low-dose WBRT, n = 34) and those treated with more than 30 Gy WBRT (high-dose WBRT, n = 32). The median WBRT dose was 25.2 and 49.6 Gy in low-dose and high-dose WBRT groups, respectively. The median total radiotherapy dose, including the boost dose, was 50 Gy (range, 36.0-55.8 Gy).

RESULTS

The 3-year overall survival and progression-free survival were 77.8% and 29.8%, respectively. Intracranial relapse occurred in 31 patients (47.0%) at a median of 27 months after RT. Overall survival and progression-free survival did not differ between the two groups. The 3-year intracranial disease control rate did not differ between the two groups (35.2% vs. 41.6%, p = 0.300). Grade 3 or higher neurological toxicities were observed in six patients, of whom five were in the high-dose WBRT group.

CONCLUSION

Reduced-dose WBRT in curative and salvage treatments for PCNSL had no significant negative effect on the intracranial disease control rate or survival. Therefore, without impaired efficacy, use of reduced-dose WBRT appears promising for reduction of neurotoxicity.

Prognostic model and treatment choices for patients with primary intracranial central nervous system lymphoma: A population-based study

BACKGROUND

Primary central nervous system lymphoma (PCNSL) is a non-Hodgkin lymphoma that occurs in the CNS. With the advancement of medical care, its prognosis and treatment have also undergone tremendous changes. This study aimed to construct a prognostic model and compare the effects of different treatments for intracranial PCNSL.

METHODS

Cases diagnosed as PCNSL between 2004 and 2015 were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. Data were analyzed using Kaplan-Meier method and Cox regression analysis. Nomogram was built and validated using the R program.

RESULTS

A total of 2861 PCNSL patients were included in the analysis. Age, year of diagnosis, surgery and chemotherapy were independent predictors for both overall survival (OS) and cancer-specific survival (CSS). A nomogram was established to predict 3-, 5- and 10-year OS and CSS for patients. Receiver operating characteristic (ROC) curves and decision curve analysis (DCA) showed the nomogram had good predictive performance and clinical application value. We also revealed that gross total resection had significantly better OS and CSS than biopsy alone (P < 0.001). Patients who received only chemotherapy had the best prognosis and did not benefit from additional radiotherapy.

CONCLUSION

We developed a nomogram to predict patient survival rates based on independent predictors. It is an effective tool to help clinicians make survival predictions. Our results showed that patients can benefit from gross total resection of tumor, if it is feasible, and chemotherapy. The role of radiotherapy remained to be further assessed.

Impact of Thiotepa-Based Autologous Hematopoietic Cell Transplantation in Primary Central Nervous System Lymphoma in First Complete Remission: A University of California Hematologic Malignancies Consortium Retrospective Analysis

BACKGROUND

The choice between nonmyeloablative chemotherapy (NMA-C) or autologous hematopoietic cell transplantation (autoHCT) as consolidation in primary central nervous system lymphoma (PCNSL), and timing of autoHCT differs among centers. We aimed to clarify these points.

METHODS

We retrospectively analyzed PCNSL adult patients who received consolidation in CR1 or underwent autoHCT during their treatment course. Cohort A included those who underwent autoHCT in CR1, cohort B included those who underwent NMA-C in CR1, and cohort C included patients who underwent autoHCT in CR2+. We compared cohorts A and B, and cohorts A and C. The primary endpoint was overall survival (OS), and secondary endpoints were progression-free survival (PFS), treatment-related mortality (TRM) and cumulative incidence of relapse (CIR).

RESULTS

36 patients were included in cohort A, 30 in cohort B, and 14 in cohort C. The 5-year OS for cohorts A vs B and vs C were 90.7% vs 62.8% (P = .045) and vs 77.9% (P = .32), respectively. The 5-year PFS from diagnosis for cohorts A vs B was 87.8% vs 37.3% (P < .001). The 5-year PFS from autoHCT for cohorts A vs C was 87.6% vs 58.4% (P = .023). The 5-year TRM and CIR in cohorts A vs B was 9.4% vs 9.5% (P = .674), and 2.9% vs 53.2% (P < .001), respectively. The 5-year TRM and CIR in cohorts A vs C from the time of autoHCT was 9.5% vs 22.1% (P = .188), and 2.9% vs 19.5% (P = .104), respectively.

CONCLUSION

Despite the limitations, thiotepa-based autoHCT in CR1 appears to improve outcomes in eligible patients with PCNSL.

Immunochemotherapy or chemotherapy alone in primary central nervous system lymphoma: a National Cancer Database analysis

Debate remains over the role of rituximab, a large molecule with reduced central nervous system (CNS) penetration, in therapy for primary CNS lymphoma (PCNSL). Since 2013, the National Cancer Database has distinguished between chemotherapy and immunotherapy for frontline treatment. In this setting, rituximab would be the only standard frontline immunotherapy. We examined factors associated with the receipt of immunotherapy using a multivariate regression model for relative risk, with a random intercept to account for the hospital-specific treatment selection process. Patients were matched using a 1:1 propensity score to limit possible confounders, and overall survival (OS) was compared in the matched cohort. We identified 4691 patients with PCNSL diagnosed between 2013 and 2018. The use of immunotherapy has increased from 45% in 2013 to 76% in 2018. Immunotherapy use was associated with sociodemographic variables and local (hospital level) preference rather than clinical factors. The main factors associated with reduced use of immunotherapy included male sex, Black race or Hispanic ethnicity (compared with White non-Hispanic), HIV+ status, treatment in a lower-volume hospital, and earlier year of diagnosis. We matched 2830 patients for the survival analysis. Receipt of immunotherapy was associated with a significantly better OS (hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.67-0.83). There was heterogeneity according to age, because the advantage of immunotherapy was more pronounced for patients aged ≤75 years (HR, 0.71; 95% CI, 0.63-0.80) than for those older than 75 years (HR, 0.87; 95% CI, 0.70-1.08). Overall, our findings support the current trend toward rituximab use, although a nuanced approach should be adopted when treating older patients.

Fractionated Stereotactic Radiation for Central Nervous System Lymphoma: Retrospective Analysis of Initial Cases

Primary central nervous system lymphoma (PCNSL) is primarily treated with combination chemotherapy, while whole-brain radiotherapy (WBRT) can be used as consolidative treatment or as a salvage option for central nervous system (CNS) relapse. We investigated whether fractionated stereotactic radiosurgery (fSRS) could replace WBRT in cases where patients had poor performance status or minimal disease at the time of consolidation, to spare patients the adverse effects of WBRT. We retrospectively identified 10 patients who completed 14 courses of fSRS for PCNSL or for CNS relapse of systemic lymphoma. Of 14 fSRS treatments, there were 10 distant brain recurrences among 6 patients, occurring on average 13.6 months after fSRS. A total of 4 of the 10 recurrences were treated with further fSRS, and 4 were treated with WBRT. There was one late in-field recurrence after both fSRS and WBRT, which occurred 27 months after fSRS. The median survival after fSRS was 36 months, and side effects after fSRS were minimal. This case series represents a potential treatment option for patients with CNS lymphoma, for whom WBRT is indicated but where the toxic effects of this treatment would be prohibitive.

Primary central nervous system lymphoma (PCNSL) in older patients

INTRODUCTION

Primary central nervous system lymphoma (PCNSL) is a rare, chemo and radio-sensitive tumor limited to the central nervous system. The incidence of PCSNL increases notably in the elderly population which represented approximately half of the patients. The limit of 'elderly' population remained debated and nonuniform, including 60 years as a cutoff for brain radiotherapy, 65 years for autologous stem-cell transplantation, and 70 years for the last clinical trials. Current therapeutic options include first line treatment based on high-dose methotrexate based polychemotherapy, consolidation chemotherapy, and adapted autologous stem cell transplantation for highly selected patients. At relapse, single agent targeted therapies or salvage chemotherapy followed by intensive consolidation are promising therapeutic options. Nevertheless, improving management of elderly patients is an urgent medical need that currently remains unresolved.

OBJECTIVE

We will focus on elderly patients with PCNSL and their specificities including clinical presentations, available therapeutic options and adaptations to be made.

CONCLUSION

To improve survival, it will be necessary to personalized and adapt the treatments, to each patient and his comorbidities, to increase their effectiveness and limit their toxicity in this frail population. Finally, inclusion of these patients in clinical trials is one of the major challenges to significantly change PCNSL elderly patient prognosis.

First-line induction chemotherapy with high-dose methotrexate versus teniposide in patients with newly diagnosed primary central nervous system lymphoma: a retrospective, multicenter cohort study

BACKGROUND

This study aimed to compare the efficacy and safety of high-dose methotrexate (HD-MTX) versus teniposide (TEN) in patients with newly diagnosed immunocompetent primary central nervous system lymphomas (PCNSLs).

METHODS

The study included immunocompetent, adult patients with newly diagnosed PCNSL at 22 centers in China from 2007 to 2016. The patients received HD-MTX or TEN as first-line induction therapy. The objective response rate, progression-free survival, and overall survival were analyzed for each patient cohort.

RESULTS

A total of 96 patients were eligible: 62 received HD-MTX, while 34 received teniposide. The overall response rate was 73.2% and 72.7% in the MTX and the TEN cohorts, respectively (P = 0.627). The median progression-free survival was 28.4 months [95% confidence interval (CI): 13.7-51.2] in the MTX cohort and 24.3 months (95% CI: 16.6-32.1) in the TEN cohort (P = 0.75). The median overall survival was 31 months (95% CI: 26.8-35.2) in the MTX cohort and 32 months (95% CI: 27.6-36.4) in the TEN cohort (P = 0.77). The incidence of any grade of coagulopathy/deep-vein thrombosis and gastrointestinal disorders was significantly higher in the MTX cohort than in the TEN cohort; no significant difference was found in the incidence of other adverse events between the two cohorts.

CONCLUSIONS

This was the first multicenter study using TEN as the main agent compared with HD-MTX in newly diagnosed primary CNS lymphoma. The TEN-based regimen was non-inferior to the HD-MTX-based regimen with similar overall responses.

CLASSIFICATION OF EVIDENCE

This study provided Class III evidence that the teniposide-based regimen was non-inferior to high-dose methotrexate - based regimen with similar overall responses and long-time survival in immunocompetent patients with PCNSL.

Primary Central Nervous System Lymphoma Presenting as Isolated Multiple Cranial Neuropathies: An Extremely Rare Case

Primary central nervous system lymphoma (PCNSL) is an uncommon malignancy of B-cell origin that typically involves the brain, eyes, and spinal cord without systemic spread. PCNSL typically involves the cerebral hemispheres, basal ganglia, or periventricular region. Isolated leptomeningeal PCNSL without any evidence of parenchymal involvement is very rare. We present a very unusual case of PCNSL presenting as persistent bilateral Bell's palsy and trigeminal neuralgia with magnetic resonance imaging (MRI) brain showing significantly hypertrophied enhancing bilateral facial and trigeminal nerves.

Radiotherapy for newly diagnosed primary central nervous system lymphoma: role and perspective

Whole brain radiotherapy (WBRT) has long been a key treatment of newly diagnosed primary central nervous system lymphoma (PCNSL). In the 1990s, the addition of high dose Methotrexate-based induction chemotherapy (HD MTX-based CT) has enabled a drastic improvement in PCNSL patients outcome. However, combined treatment has led to radiation-induced delayed neurotoxicity, especially in older patients. Alternative treatment strategies have been assessed to improve the efficacy and neurotoxicity ratio. Nowadays, in the elderly patients WBRT is widely omitted or deferred, and in younger patients WBRT is challenged by high dose chemotherapy with autologous stem cell transplant (HCT-ASCT) for consolidation treatment after HD MTX-based CT. In this setting, this review is addressed to clinicians with the aim to summarize the role of WBRT in the treatment of newly diagnosed PCNSL and its perspectives.

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.

Clinicopathological analysis and specific discriminating markers of interleukin detection in cerebrospinal fluid with primary central nervous system lymphoma: results from a retrospective study

Primary central nervous system lymphoma (PCNSL) is special extranodal malignant non-Hodgkin lymphomas. This study analyzed clinical features and prognostic factors of PCNSL and evaluated the difference of interleukin (IL) concentrations in cerebrospinal fluid (CSF) between PCNSL and systemic non-Hodgkin lymphoma (sNHL). Patients consecutive newly diagnosed with PCNSL were recruited, the demographic and clinicopathological data were retrospectively analyzed, and the potential prognostic factors for overall survival (OS) were identified with survival analysis. 27 patients with PCNSL and 21 patients with sNHL collected CSF IL-5, IL-6, and IL-10 concentrations at diagnosis. The difference in interleukin (IL) concentrations in two diseases was analyzed to evaluate the value of IL concentrations. A total of 64 patients with PCNSL were enrolled, the median age was 54.50 years (range 16-85 years); male: female ratio was 1.91. Headache was the most common complaint symptom involved in 42.19% (27/64) of patients. Diffuse large B-cell lymphoma (DLBCL) accounted for 89.06% (57/64) of patients; other uncommon types accounted for 3.13% (2/64). In prognostic analysis, multiple lesions and Ki67 ≥ 75% expression exhibited a worse prognosis(P = 0.041), and patients with autologous hematopoietic stem cell transplantation (auto-HSCT) treatment presented superior OS (P < 0.05). In multivariate analysis, BCL2 expression was revealed as an unfavorable prognostic marker, and auto-HSCT was revealed as a favorable prognostic marker. CSF IL-10 concentration in patients with PCNSL was significantly higher than sNHL (P = 0.000) and excluded other histopathology of NHL; IL-10 value was still significantly different between DLBCL of PCNSL and sDLBCL (P = 0.003). In ROC curve analysis, the cutoff value of IL-10 was 0.43 pg/mL for the diagnosis value of PCNSL, sensitivity was 96.3%, specificity was 66.67%, and AUC was 0.84 (0.71-0.96). Although IL-6 concentration did not differ in the two groups, IL-10/IL-6 ratio was meaningful, with a cutoff value of 0.21, sensitivity of 81.48%, specificity of 80.95%, and AUC of 0.83 (0.71-0.95). This study highlights the characteristics of patients with PCNSL, potential prognostic makers also have been explained. CSF interleukin (IL) concentrations revealed IL-10 levels, and IL-10/IL-6 ratio may represent a useful biomarker in the differential diagnosis of PCNSL and sNHL.

Challenges in the management of primary central nervous system lymphoma

Primary central nervous system lymphoma (PCNSL) is a rare extranodal non-Hodgkin lymphoma. Stereotactic biopsy remains the gold standard for the pathological diagnosis of PCNSL. However, certain new auxiliary diagnostic methods are considered to have good application prospects; these include cytokine and tumor circulating DNA, among others. Although new drugs such as immunomodulators, immune checkpoint inhibitors, chimeric antigen receptor T-cells, and Bruton tyrosine kinase inhibitors have brought hope owing to their improved efficacy, the high recurrence rate and subsequent high mortality remain barriers to long-term survival. Increasing emphasis is therefore being placed on consolidation treatments. Consolidation treatment strategies include whole brain radiotherapy, autologous hematopoietic stem cell transplantation, and non-myeloablative chemotherapy. As studies directly comparing the effectiveness and safety of different consolidation treatment schemes are lacking, the optimal consolidation strategy remains uncertain. This article will review the diagnosis and treatment of PCNSL, focusing on the progress in research pertaining to consolidation therapy.

Recent advances in the diagnosis and the treatment of primary CNS lymphoma

This review focuses on the recent progress in the management of primary central nervous system lymphoma (PCNSL). Multiomic analyses allowed to better understand the tumorigenesis of PCNSL and to establish a molecular classification with prognostic value that will optimize patient management and guide future targeted approaches. Cooperative clinical trials have demonstrated the feasibility and efficacy, in selected fit patients, of high-dose chemotherapy with autologous stem cell transplantation as post-induction consolidation, that will progressively replace whole brain radiotherapy associated with a much higher risk of delayed neurotoxicity. Several novel treatments have shown efficacy and overall good tolerance in PCNSL patients, such as Bruton's tyrosine kinase (BTK) inhibitors, imids, immune checkpoint inhibitors and chimeric antigen receptor T-cells (CAR-T). This opens promising therapeutic perspectives to improve the current standard treatment, especially for elderly and unfit patients who represent a growing population.

Reciprocal expression of the immune response genes CXCR3 and IFI44L as module hubs are associated with patient survivals in primary central nervous system lymphoma

PURPOSE

Here, we investigated expression modules reflecting the reciprocal expression of the cancer microenvironment and immune response-related genes associated with poor prognosis in primary central nervous system lymphoma (PCNSL).

METHODS

Weighted gene coexpression network analysis revealed representative modules, including neurogenesis, immune response, anti-virus, microenvironment, gene expression and translation, extracellular matrix, morphogenesis, and cell adhesion in the transcriptome data of 31 PCNSL samples. RESULTS : Gene expression networks were also reflected by protein-protein interaction networks. In particular, some of the hub genes were highly expressed in patients with PCNSL with prognoses as follows: AQP4, SLC1A3, GFAP, CXCL9, CXCL10, GBP2, IFI6, OAS2, IFIT3, DCN, LRP1, and LUM with good prognosis; and STAT1, IFITM3, GZMB, ISG15, LY6E, TGFB1, PLAUR, MMP4, FTH1, PLAU, CSF3R, FGR, POSTN, CCR7, TAS1R3, small ribosomal subunit genes, and collagen type 1/3/4/6 genes with poor prognosis. Furthermore, prognosis prediction formulae were constructed using the Cox proportional-hazards regression model, which demonstrated that the IP-10 receptor gene CXCR3 and type I interferon-induced protein gene IFI44L could predict patient survival in PCNSL.

CONCLUSION

These results indicate that the differential expression and balance of immune response and microenvironment genes may be required for PCNSL tumor growth or prognosis prediction, which would help understanding the mechanism of tumorigenesis and potential therapeutic targets in PCNSL.

Is CD19-directed chimeric antigen receptor T cell therapy a smart strategy to combat central nervous system lymphoma?

Primary central nervous system lymphoma (PCNSL) is a rare form and aggressive type of diffuse large B-cell lymphoma (DLBCL) that occurs in both immunocompetent and immunocompromised adults. While adding rituximab to chemotherapeutic regimens resulted in dramatic improvement in both progression-free survival and overall survival in patients with non-central nervous system (CNS) DLBCL, the outcomes of PCNSL are generally poor due to the immune-privileged tumor microenvironment or suboptimal delivery of systemic agents into tumor tissues. Therefore, more effective therapy for PCNSL generally requires systemic therapy with sufficient CNS penetration, including high-dose intravenous methotrexate with rituximab or high-dose chemotherapy followed by autologous stem cell transplantation. However, overall survival is usually inferior in comparison to non-CNS lymphomas, and treatment options are limited for elderly patients or patients with relapsed/refractory disease. Chimeric antigen receptor T (CAR-T) cell therapy has emerged as a cutting-edge cancer therapy, which led to recent FDA approvals for patients with B-cell malignancies and multiple myeloma. Although CAR-T cell therapy in patients with PCNSL demonstrated promising results without significant toxicities in some small cohorts, most cases of PCNSL are excluded from the pivotal CAR-T cell trials due to the concerns of neurotoxicity after CAR-T cell infusion. In this review, we will provide an overview of PCNSL and highlight current approaches, resistance mechanisms, and future perspectives of CAR-T cell therapy in patients with PCNSL.

European Association of Neuro-Oncology (EANO) guidelines for treatment of primary central nervous system lymphoma (PCNSL)

The management of primary central nervous system (PCNSL) is one of the most controversial topics in neuro-oncology because of the complexity of the disease and the limited number of controlled studies available. In 2021, given recent advances and the publication of practice-changing randomized trials, the European Association of Neuro-Oncology (EANO) created a multidisciplinary task force to update the previously published evidence-based guidelines for immunocompetent adult patients with PCNSL and added a section on immunosuppressed patients. The guideline provides consensus considerations and recommendations for the treatment of PCNSL, including intraocular manifestations and specific management of the elderly. The main changes from the previous guideline include strengthened evidence for the consolidation with ASCT in first-line treatment, prospectively assessed chemotherapy combinations for both young and elderly patients, clarification of the role of rituximab even though the data remain inconclusive, of the role of new agents, and the incorporation of immunosuppressed patients and primary ocular lymphoma. The guideline should aid the clinicians in everyday practice and decision making and serve as a basis for future research in the field.