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Romano A, De Giorgi S, Romano A, Moltoni G, Ascolese AM, Stoppacciaro A, Bozzao A. "Vanishing" glioblastoma: A case report and review of the literature. Radiol Case Rep 2024; 19:3276-3282. [PMID: 38812592 PMCID: PMC11133505 DOI: 10.1016/j.radcr.2024.04.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/11/2024] [Accepted: 04/15/2024] [Indexed: 05/31/2024] Open
Abstract
Contrast enhancement resolution induced by corticosteroids is a phenomenon primarily associated with primary central nervous system lymphoma, while malignant brain gliomas usually maintain a consistent radiological appearance during systemic steroid treatment. Although rare, a few primary and metastatic intracranial lesions have shown similar radiographic changes following corticosteroid therapy. In the case of glioblastomas, corticosteroid therapy is commonly used to alleviate pressure effects from peritumoral edema, but its impact on contrast enhancement is not well-established. A few reported cases in the literature describe reduced contrast enhancement in glioblastomas after corticosteroid treatment. We present a case of corticosteroid-induced regression on imaging of glioblastoma evaluated at our institutionwith the intention to explore the pathogenesis of this response and discuss the therapeutic and prognostic implications of this discovery.
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Affiliation(s)
- Allegra Romano
- Neuroradiology Unit, Sant'Andrea Hospital, Department of Neuroscience, Mental Health and Sense Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Sara De Giorgi
- Neuroradiology Unit, Sant'Andrea Hospital, Department of Neuroscience, Mental Health and Sense Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Andrea Romano
- Neuroradiology Unit, Sant'Andrea Hospital, Department of Neuroscience, Mental Health and Sense Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Giulia Moltoni
- Neuroradiology Unit, Sant'Andrea Hospital, Department of Neuroscience, Mental Health and Sense Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | | | - Antonella Stoppacciaro
- Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Alessandro Bozzao
- Neuroradiology Unit, Sant'Andrea Hospital, Department of Neuroscience, Mental Health and Sense Organs (NESMOS), Sapienza University of Rome, Rome, Italy
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2
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Reinecke R, Jahnke K, Foltyn-Dumitru M, Lachner K, Armbrust M, Weber KJ, Zeiner PS, Czabanka M, Brunnberg U, Hartmann S, Steinbach JP, Ronellenfitsch MW. Intrathecal IgM synthesis as a diagnostic marker in patients with suspected CNS lymphoma. J Neurochem 2024; 168:1157-1167. [PMID: 38332527 DOI: 10.1111/jnc.16069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 01/19/2024] [Accepted: 01/23/2024] [Indexed: 02/10/2024]
Abstract
For CNS lymphomas (CNSL), there is a high need for minimally invasive and easily obtainable diagnostic markers. Intrathecal IgM synthesis can easily be determined in routine CSF diagnostics. The aim of this study was to systematically investigate the diagnostic potential of intrathecal IgM synthesis in primary and secondary CNSL (PCNSL and SCNSL). In this retrospective study, patients with a biopsy-proven diagnosis of PCNSL or SCNSL were compared with patients with other neurological diseases in whom CNSL was initially the primary radiological differential diagnosis based on MRI. Sensitivity and specificity of intrathecal IgM synthesis were calculated using receiver operating characteristic curves. Seventy patients with CNSL were included (49 PCNSL and 21 SCNSL) and compared to 70 control patients. The sensitivity and specificity for the diagnosis of CNSL were 49% and 87%, respectively, for the entire patient population and 66% and 91% after selection for cases with tumor access to the CSF system and isolated intrathecal IgM synthesis. In cases with MRI-based radiological suspicion of CNSL, intrathecal IgM synthesis has good specificity but limited sensitivity. Because of its low-threshold availability, analysis of intrathecal IgM synthesis has the potential to lead to higher diagnostic accuracy, especially in resource-limited settings, and deserves further study.
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Affiliation(s)
- Raphael Reinecke
- Dr. Senckenberg Institute of Neurooncology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- University Cancer Center (UCT), Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
| | - Kolja Jahnke
- Department of Neurology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
| | - Martha Foltyn-Dumitru
- Dr. Senckenberg Institute of Neurooncology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Karsten Lachner
- Institute of Neuroradiology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
| | - Moritz Armbrust
- Neurological Institute (Edinger Institute), Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
| | - Katharina J Weber
- University Cancer Center (UCT), Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- Neurological Institute (Edinger Institute), Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- German Cancer Consortium (DKTK), partner site Frankfurt/Mainz, a partnership between DKFZ and University Hospital Frankfurt, Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Pia S Zeiner
- Dr. Senckenberg Institute of Neurooncology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- University Cancer Center (UCT), Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- German Cancer Consortium (DKTK), partner site Frankfurt/Mainz, a partnership between DKFZ and University Hospital Frankfurt, Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Marcus Czabanka
- Department of Neurosurgery, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
| | - Uta Brunnberg
- University Cancer Center (UCT), Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- Department of Medicine, Hematology and Oncology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
| | - Sylvia Hartmann
- Dr. Senckenberg Institute of Pathology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
| | - Joachim P Steinbach
- Department of Neurology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- University Cancer Center (UCT), Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- German Cancer Consortium (DKTK), partner site Frankfurt/Mainz, a partnership between DKFZ and University Hospital Frankfurt, Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Michael W Ronellenfitsch
- Dr. Senckenberg Institute of Neurooncology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- University Cancer Center (UCT), Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- German Cancer Consortium (DKTK), partner site Frankfurt/Mainz, a partnership between DKFZ and University Hospital Frankfurt, Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), Goethe University Frankfurt, Frankfurt am Main, Germany
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3
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Duan L, He Y, Guo W, Du Y, Yin S, Yang S, Dong G, Li W, Chen F. Machine learning-based pathomics signature of histology slides as a novel prognostic indicator in primary central nervous system lymphoma. J Neurooncol 2024; 168:283-298. [PMID: 38557926 PMCID: PMC11147825 DOI: 10.1007/s11060-024-04665-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 03/26/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE To develop and validate a pathomics signature for predicting the outcomes of Primary Central Nervous System Lymphoma (PCNSL). METHODS In this study, 132 whole-slide images (WSIs) of 114 patients with PCNSL were enrolled. Quantitative features of hematoxylin and eosin (H&E) stained slides were extracted using CellProfiler. A pathomics signature was established and validated. Cox regression analysis, receiver operating characteristic (ROC) curves, Calibration, decision curve analysis (DCA), and net reclassification improvement (NRI) were performed to assess the significance and performance. RESULTS In total, 802 features were extracted using a fully automated pipeline. Six machine-learning classifiers demonstrated high accuracy in distinguishing malignant neoplasms. The pathomics signature remained a significant factor of overall survival (OS) and progression-free survival (PFS) in the training cohort (OS: HR 7.423, p < 0.001; PFS: HR 2.143, p = 0.022) and independent validation cohort (OS: HR 4.204, p = 0.017; PFS: HR 3.243, p = 0.005). A significantly lower response rate to initial treatment was found in high Path-score group (19/35, 54.29%) as compared to patients in the low Path-score group (16/70, 22.86%; p < 0.001). The DCA and NRI analyses confirmed that the nomogram showed incremental performance compared with existing models. The ROC curve demonstrated a relatively sensitive and specific profile for the nomogram (1-, 2-, and 3-year AUC = 0.862, 0.932, and 0.927, respectively). CONCLUSION As a novel, non-invasive, and convenient approach, the newly developed pathomics signature is a powerful predictor of OS and PFS in PCNSL and might be a potential predictive indicator for therapeutic response.
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Affiliation(s)
- Ling Duan
- Department of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, No.119 West Nansihuan Road, Beijing, 100070, China
| | - Yongqi He
- Department of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, No.119 West Nansihuan Road, Beijing, 100070, China
| | - Wenhui Guo
- Department of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, No.119 West Nansihuan Road, Beijing, 100070, China
| | - Yanru Du
- Department of Pathology, Beijing Tiantan Hospital, Capital Medical University, No.119 West Nansihuan Road, Beijing, 100070, China
| | - Shuo Yin
- Department of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, No.119 West Nansihuan Road, Beijing, 100070, China
| | - Shoubo Yang
- Department of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, No.119 West Nansihuan Road, Beijing, 100070, China
| | - Gehong Dong
- Department of Pathology, Beijing Tiantan Hospital, Capital Medical University, No.119 West Nansihuan Road, Beijing, 100070, China.
| | - Wenbin Li
- Department of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, No.119 West Nansihuan Road, Beijing, 100070, China.
| | - Feng Chen
- Department of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, No.119 West Nansihuan Road, Beijing, 100070, China.
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4
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Hernández RF, Rodriguez JEM, Trecu MSG, Tariq Bhatti M. Not everything is ischemic optic neuropathy. Surv Ophthalmol 2024:S0039-6257(24)00054-7. [PMID: 38796109 DOI: 10.1016/j.survophthal.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 05/20/2024] [Accepted: 05/20/2024] [Indexed: 05/28/2024]
Abstract
A 71-year-old woman developed sudden, painful, decreased vision in the left eye accompanied by progressive instability. Initial examination revealed left optic disc edema, and macular optical coherence tomography confirmed the presence of intraretinal and subretinal fluid, as well as hyperreflective material under the retinal pigment epithelium. Subsequent investigations, including brain magnetic resonance imaging and a comprehensive serological analysis, ruled out infectious and autoimmune causes, further complicating the diagnostic picture. The patient's vision in both eyes continued to deteriorate, prompting empirical corticosteroid treatment. While the vision improved, the case took an unexpected turn with worsening neurological symptoms. Ultimately a brain biopsy was consistent with diffuse large B-cell lymphoma.
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Affiliation(s)
| | | | | | - M Tariq Bhatti
- The Permanente Medical Group. Department of Ophthalmology, Kaiser Permanente-Northern California. Roseville, California USA
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5
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Bai SJ, He JX, Zheng YJ, Geng Y, Gao YN, Zhang CX, Wang YR, Qin LY, Wang WJ, Yang LH. Clinical characteristics and prognosis of patients with newly diagnosed primary central nervous system lymphoma: a multicentre retrospective analysis. Ann Hematol 2024:10.1007/s00277-024-05797-7. [PMID: 38761184 DOI: 10.1007/s00277-024-05797-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 05/09/2024] [Indexed: 05/20/2024]
Abstract
Bruton's tyrosine kinase inhibitors (BTKi) exhibit superior efficacy in relapsed/refractory primary central nervous system lymphoma (PCNSL), but few studies have evaluated patients with newly diagnosed PCNSL, and even fewer studies have evaluated differences in efficacy between treatment with BTKi and traditional chemotherapy. This study retrospectively analyzed the clinical characteristics of 86 patients with PCNSL and identified predictors of poor prognosis for overall survival (OS). After excluding patients who only received palliative care, 82 patients were evaluated for efficacy and survival. According to the induction regimen, patients were divided into the traditional chemotherapy, BTKi combination therapy, and radiotherapy groups; the objective response rates (ORR) of the three groups were 71.4%, 96.2%, and 71.4% (P = 0.037), respectively. Both median progression-free survival and median duration of remission showed statistically significant differences (P = 0.019 and P = 0.030, respectively). The median OS of the BTKi-containing therapy group was also longer than that of the traditional chemotherapy group (not reached versus 47.8 (32.5-63.1) months, P = 0.038).Seventy-one patients who achieved an ORR were further analyzed, and achieved an ORR after four cycles of treatment and maintenance therapy had prolonged OS (P = 0.003 and P = 0.043, respectively). In conclusion, survival, and prognosis of patients with newly diagnosed PCNSL are influenced by the treatment regimen, with the BTKi-containing regimen showing great potential.
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Affiliation(s)
- Si-Jun Bai
- Department of Hematology, Second Hospital of Shanxi Medical University, No.382 Wuyi Road, Xinghualing District, Taiyuan, Shanxi, 030000, China
- Department of Hematology, Shanxi Provincial People's Hospital, Taiyuan, 030000, China
| | - Jian-Xia He
- Department of Hematology, Shanxi Provincial People's Hospital, Taiyuan, 030000, China
| | - Yuan-Jun Zheng
- Department of Hematology, First Hospital of Shanxi Medical University, Taiyuan, 030000, China
| | - Ye Geng
- Department of Hematology, Shanxi Provincial People's Hospital, Taiyuan, 030000, China
| | - Yi-Nan Gao
- Department of Hematology, Shanxi Provincial People's Hospital, Taiyuan, 030000, China
| | - Cai-Xia Zhang
- Department of Hematology, Shanxi Provincial People's Hospital, Taiyuan, 030000, China
| | - Ya-Ru Wang
- Department of Hematology, Shanxi Provincial People's Hospital, Taiyuan, 030000, China
| | - Li-Yuan Qin
- Department of Hematology, Shanxi Provincial People's Hospital, Taiyuan, 030000, China
| | - Wen-Jun Wang
- Department of Hematology, Shanxi Provincial People's Hospital, Taiyuan, 030000, China
| | - Lin-Hua Yang
- Department of Hematology, Second Hospital of Shanxi Medical University, No.382 Wuyi Road, Xinghualing District, Taiyuan, Shanxi, 030000, China.
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6
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Cherng HJJ, Herrera A. Circulating Tumor DNA in Diffuse Large B-Cell Lymphoma: from Bench to Bedside? Curr Treat Options Oncol 2024; 25:659-678. [PMID: 38656685 DOI: 10.1007/s11864-024-01201-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2024] [Indexed: 04/26/2024]
Abstract
OPINION STATEMENT Diffuse large B-cell lymphoma (DLBCL) is a curable disease with variable outcomes due to underlying heterogeneous clinical and molecular features-features that are insufficiently characterized with our current tools. Due to these limitations, treatment largely remains a "one-size-fits-all" approach. Circulating tumor DNA (ctDNA) is a novel biomarker in cancers that is increasingly utilized for risk stratification and response assessment. ctDNA is readily detectable from the plasma of patients with DLBCL but has not yet been incorporated into clinical care to guide treatment. Here, we describe how ctDNA sequencing represents a promising technology in development to personalize the care of patients with DLBCL. We will review the different types of ctDNA assays being studied and the rapidly growing body of evidence supporting the utility of ctDNA in different treatment settings in DLBCL. Risk stratification by estimation of tumor burden and liquid genotyping, molecular response assessment during treatment, and monitoring for measurable residual disease (MRD) to identify therapy resistance and predict clinical relapse are all potential applications of ctDNA. It is time for clinical trials in DLBCL to utilize ctDNA as an integral biomarker for patient selection, response-adapted designs, and surrogate endpoints. As more ctDNA assays become commercially available for routine use, clinicians should consider liquid biopsy when treatment response is equivocal on imaging. Incorporating MRD may also guide decision-making if patients experience severe treatment toxicities. Though important barriers remain, we believe that ctDNA will soon be ready to transition from bench to bedside to individualize treatment for our patients with DLBCL.
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MESH Headings
- Lymphoma, Large B-Cell, Diffuse/therapy
- Lymphoma, Large B-Cell, Diffuse/diagnosis
- Lymphoma, Large B-Cell, Diffuse/blood
- Lymphoma, Large B-Cell, Diffuse/genetics
- Humans
- Circulating Tumor DNA/blood
- Biomarkers, Tumor/blood
- Liquid Biopsy/methods
- Disease Management
- Translational Research, Biomedical
- Precision Medicine/methods
- Prognosis
- Clinical Decision-Making
- Disease Susceptibility
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Affiliation(s)
- Hua-Jay J Cherng
- Lymphoma Service, Division of Hematology & Oncology, Columbia University Irving Medical Center, 177 Fort Washington Avenue, 6GN-Rm 435, New York, NY, 10032, USA.
| | - Alex Herrera
- Division of Lymphoma, Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
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7
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von Roemeling C, Ferreri AJM, Soussain C, Tun HW, Grommes C. Targets and treatments in primary CNS lymphoma. Leuk Lymphoma 2024:1-13. [PMID: 38659230 DOI: 10.1080/10428194.2024.2342560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 04/08/2024] [Indexed: 04/26/2024]
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare and highly aggressive lymphoma entirely localized in the central nervous system or vitreoretinal space. PCNSL generally initially responds to methotrexate-containing chemotherapy regimens, but progressive or relapsing disease is common, and the prognosis is poor for relapsed or refractory (R/R) patients. PCNSL is often characterized by activation of nuclear factor kappa B (NF-κB) due to mutations in the B-cell receptor (BCR) or toll-like receptor (TLR) pathways, as well as immune evasion. Targeted treatments that inhibit key PCNSL mechanisms and pathways are being evaluated; inhibition of Bruton's tyrosine kinase (BTK) downstream of BCR activation has demonstrated promising results in treating R/R disease. This review will summarize the evidence and potential for targeted therapeutic agents to improve treatment outcomes in PCNSL. This includes immunotherapeutic and immunomodulatory approaches and inhibitors of the key pathways driving PCNSL, such as aberrant BCR and TLR signaling.
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Affiliation(s)
- Christina von Roemeling
- Preston A. Wells Center for Brain Tumor Therapy, Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Andrés J M Ferreri
- Department of Onco-Hematology, University Vita-Salute San Raffaele, Milano, Italy
- Department of Onco-Hematology, Lymphoma Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Carole Soussain
- Institut Curie, Service d'Hématologie, site de Saint-Cloud, France
- INSERM U932, Institut Curie, PSL Research University, Paris, France
| | - Han W Tun
- Department of Hematology, Mayo Clinic, Jacksonville, Florida, USA
| | - Christian Grommes
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Neurology, Weill Cornell Medical College, New York, New York, USA
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8
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Wu YX, Guo L, Guo H. Primary central-nervous-system lymphoma in the right lateral ventricle and the fourth ventricle: A case report. Asian J Surg 2024; 47:1696-1698. [PMID: 38160138 DOI: 10.1016/j.asjsur.2023.12.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 12/08/2023] [Indexed: 01/03/2024] Open
Affiliation(s)
- Yu-Xian Wu
- Department of Cardiology, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, 650101, PR China.
| | - Li Guo
- Department of Radiology, Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, 650101, PR China.
| | - Hao Guo
- Department of Cardiology, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, 650101, PR China.
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9
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Phillips EH, Cwynarski K. Extending potentially curative options for older patients with PCNSL. Lancet Haematol 2024; 11:e171-e173. [PMID: 38301671 DOI: 10.1016/s2352-3026(24)00004-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 01/11/2024] [Indexed: 02/03/2024]
Affiliation(s)
- Elizabeth H Phillips
- Division of Cancer Sciences, University of Manchester, Manchester, UK; The Christie Hospital, Manchester M204BX, UK.
| | - Kate Cwynarski
- Haematology Department, University College London Hospital, London, UK
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10
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Winter JN, Ferreri AJM. Predicting outcomes in CNS lymphoma with ctDNA. Blood 2024; 143:478-480. [PMID: 38329774 DOI: 10.1182/blood.2023023008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024] Open
Affiliation(s)
| | - Andres J M Ferreri
- Istituto di Ricerca e Cura a Carattere Scientifico Ospedale San Raffaele
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11
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Heger JM, Mattlener J, Schneider J, Gödel P, Sieg N, Ullrich F, Lewis R, Bucaciuc-Mracica T, Schwarz RF, Rueß D, Ruge MI, Montesinos-Rongen M, Deckert M, Blau T, Kutsch N, Balke-Want H, Weiss J, Becker K, Reinhardt HC, Hallek M, Borchmann P, von Tresckow B, Borchmann S. Entirely noninvasive outcome prediction in central nervous system lymphomas using circulating tumor DNA. Blood 2024; 143:522-534. [PMID: 37946299 DOI: 10.1182/blood.2023022020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/19/2023] [Accepted: 10/19/2023] [Indexed: 11/12/2023] Open
Abstract
ABSTRACT State-of-the-art response assessment of central nervous system lymphoma (CNSL) by magnetic resonance imaging is challenging and an insufficient predictor of treatment outcomes. Accordingly, the development of novel risk stratification strategies in CNSL is a high unmet medical need. We applied ultrasensitive circulating tumor DNA (ctDNA) sequencing to 146 plasma and cerebrospinal fluid (CSF) samples from 67 patients, aiming to develop an entirely noninvasive dynamic risk model considering clinical and molecular features of CNSL. Our ultrasensitive method allowed for the detection of CNSL-derived mutations in plasma ctDNA with high concordance to CSF and tumor tissue. Undetectable plasma ctDNA at baseline was associated with favorable outcomes. We tracked tumor-specific mutations in plasma-derived ctDNA over time and developed a novel CNSL biomarker based on this information: peripheral residual disease (PRD). Persistence of PRD after treatment was highly predictive of relapse. Integrating established baseline clinical risk factors with assessment of radiographic response and PRD during treatment resulted in the development and independent validation of a novel tool for risk stratification: molecular prognostic index for CNSL (MOP-C). MOP-C proved to be highly predictive of outcomes in patients with CNSL (failure-free survival hazard ratio per risk group of 6.60; 95% confidence interval, 3.12-13.97; P < .0001) and is publicly available at www.mop-c.com. Our results highlight the role of ctDNA sequencing in CNSL. MOP-C has the potential to improve the current standard of clinical risk stratification and radiographic response assessment in patients with CNSL, ultimately paving the way toward individualized treatment.
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Affiliation(s)
- Jan-Michel Heger
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
- Cancer Center Cologne Essen (CCCE), Cologne, Germany
- Cologne Lymphoma Working Group, Cologne, Germany
| | - Julia Mattlener
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
- Cancer Center Cologne Essen (CCCE), Cologne, Germany
- German Hodgkin Study Group, Cologne, Germany
| | - Jessica Schneider
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
- Cancer Center Cologne Essen (CCCE), Cologne, Germany
| | - Philipp Gödel
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
- Cologne Lymphoma Working Group, Cologne, Germany
| | - Noëlle Sieg
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
- Cancer Center Cologne Essen (CCCE), Cologne, Germany
- Cologne Lymphoma Working Group, Cologne, Germany
| | - Fabian Ullrich
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center and German Cancer Consortium (Deutsches Konsortium für Translationale Krebsforschung partner site Essen), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- CCCE, Essen, Germany
| | - Richard Lewis
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
- Cancer Center Cologne Essen (CCCE), Cologne, Germany
- Cologne Lymphoma Working Group, Cologne, Germany
| | - Teodora Bucaciuc-Mracica
- Institute for Computational Cancer Biology, Center for Integrated Oncology, Cancer Research Center Cologne Essen, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Roland F Schwarz
- Institute for Computational Cancer Biology, Center for Integrated Oncology, Cancer Research Center Cologne Essen, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Berlin Institute for the Foundations of Learning and Data, Berlin, Germany
| | - Daniel Rueß
- Department of Stereotaxy and Functional Neurosurgery, Center of Neurosurgery, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Maximilian I Ruge
- Department of Stereotaxy and Functional Neurosurgery, Center of Neurosurgery, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Manuel Montesinos-Rongen
- Institute of Neuropathology, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
| | - Martina Deckert
- Institute of Neuropathology, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
| | - Tobias Blau
- Institute of Neuropathology, University of Duisburg-Essen, University Hospital Essen, Essen, Germany
| | - Nadine Kutsch
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
- Cancer Center Cologne Essen (CCCE), Cologne, Germany
- Cologne Lymphoma Working Group, Cologne, Germany
| | - Hyatt Balke-Want
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
- Cancer Center Cologne Essen (CCCE), Cologne, Germany
- Cologne Lymphoma Working Group, Cologne, Germany
- Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA
| | - Jonathan Weiss
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
| | - Kerstin Becker
- West German Genome Center, University of Cologne, Cologne, Germany
| | - H Christian Reinhardt
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center and German Cancer Consortium (Deutsches Konsortium für Translationale Krebsforschung partner site Essen), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- CCCE, Essen, Germany
| | - Michael Hallek
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
- Cancer Center Cologne Essen (CCCE), Cologne, Germany
| | - Peter Borchmann
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
- German Hodgkin Study Group, Cologne, Germany
| | | | - Sven Borchmann
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
- Cancer Center Cologne Essen (CCCE), Cologne, Germany
- Cologne Lymphoma Working Group, Cologne, Germany
- German Hodgkin Study Group, Cologne, Germany
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12
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Wang X, Zhao L, Wang S, Zhao X, Chen L, Sun X, Liu Y, Liu J, Sun S. Utility of contrast-enhanced MRI radiomics features combined with clinical indicators for predicting induction chemotherapy response in primary central nervous system lymphoma. J Neurooncol 2024; 166:451-460. [PMID: 38308802 DOI: 10.1007/s11060-023-04554-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 12/23/2023] [Indexed: 02/05/2024]
Abstract
PURPOSE To assess the utility of combining contrast-enhanced magnetic resonance imaging (CE-MRI) radiomics features with clinical variables in predicting the response to induction chemotherapy (IC) for primary central nervous system lymphoma (PCNSL). METHODS A total of 131 patients with PCNSL (101 in the training set and 30 in the testing set) who had undergone contrast-enhanced MRI scans were retrospectively analyzed. Pyradiomics was utilized to extract radiomics features, and the clinical variables of the patients were gathered. Radiomics prediction models were developed using different combinations of feature selection methods and machine learning models, and the best combination was ultimately chosen. We screened clinical variables associated with treatment outcomes and developed clinical prediction models. The predictive performance of radiomics model, clinical model, and combined model, which integrates the best radiomics model and clinical characteristics, was independently assessed and compared using Receiver Operating Characteristic (ROC) curves. RESULTS In total, we extracted 1598 features. The best radiomics model we selected as the best utilized T-test and Recursive Feature Elimination (RFE) for feature selection and logistic regression for model building. Serum Interleukin 2 Receptor (IL-2R) and Eastern Cooperative Oncology Group (ECOG) Score were utilized to develop a clinical predictive model for assessing the response to induction chemotherapy. The results of the testing set revealed that the combined prediction model (radiomics and IL-2R) achieved the highest area under the ROC curve at 0.868 (0.683, 0.967), followed by the radiomics model at 0.857 (0.681, 0.957), and the clinical prediction model (IL-2R and ECOG) at 0.618 (0.413, 0.797). The combined model was significantly more accurate than the clinical model, with an AUC of 0.868 compared to 0.618 (P < 0.05). While the radiomics model had slightly better predictive power than the clinical model, this difference was not statistically significant (AUC, 0.857 vs. 0.618, P > 0.05). CONCLUSIONS Our prediction model, which combines radiomics signatures from CE-MRI with serum IL-2R, can effectively stratify patients with PCNSL before high-dose methotrexate (HD-MTX) -based chemotherapy.
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Affiliation(s)
- Xiaochen Wang
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neuroradiology, Beijing Neurosurgical Institute, Beijing, China
| | - Litao Zhao
- School of Engineering Medicine, Beihang University, Beijing, China
- Key Laboratory of Big Data-Based Precision Medicine (Beihang University), Ministry of Industry and Information Technology of China, Beijing, China
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Sihui Wang
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuening Zhao
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lingxu Chen
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuefei Sun
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuanbo Liu
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jiangang Liu
- School of Engineering Medicine, Beihang University, Beijing, China.
- Key Laboratory of Big Data-Based Precision Medicine (Beihang University), Ministry of Industry and Information Technology of China, Beijing, China.
- Beijing Engineering Research Center of Cardiovascular Wisdom Diagnosis and Treatment, Beijing, China.
| | - Shengjun Sun
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- Department of Neuroradiology, Beijing Neurosurgical Institute, Beijing, China.
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13
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Seidel S, Kaulen L, von Baumgarten L. [New treatment strategies for primary lymphoma of the central nervous system]. DER NERVENARZT 2024; 95:117-124. [PMID: 37910181 DOI: 10.1007/s00115-023-01561-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/21/2023] [Indexed: 11/03/2023]
Abstract
Primary central nervous system lymphomas (PCNSL) are rare highly aggressive diffuse large B cell non-Hodgkin lymphomas confined to the brain, meninges, the spinal cord and the eyes. Although the implementation of high-dose methotrexate-based chemotherapy has significantly improved the prognosis of PCNSL during the last decades, about one third of patients show refractory disease and about half of the patients eventually relapse after having achieved complete response. This highlights the need for novel treatment strategies. The most promising progress has been made in the field of molecular targeted therapy that interferes with the oncogenic signaling pathways of PCNSL. These include inhibitors of Bruton tyrosine kinase and inhibitors of the PI3K/mTOR signaling pathway. In addition, the thalidomide analogues lenalidomide and pomalidomide, which belong to the class of immunomodulators, show efficacy in the treatment of PCNSL. As immune evasion appears to play a relevant pathogenetic role in PCNSL, immunotherapies in the treatment of PCNSL are the subject of intensive research. Promising initial clinical data are available for both immune checkpoint inhibitors and cellular immunotherapy with chimeric antigen receptor (CAR) T cells. Before the widespread clinical application of these novel therapies, the efficacy needs to be confirmed in larger prospective studies. Despite high response rates, targeted therapies and immunotherapy often fail to achieve lasting tumor control. Therefore, novel approaches are currently being investigated in combination protocols.
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Affiliation(s)
- Sabine Seidel
- Neurologische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Deutschland
| | - Leon Kaulen
- Neurologische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
- Klinische Kooperationseinheit Neuro-Onkologie, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Deutschland
| | - Louisa von Baumgarten
- Neurochirurgische Klinik, Ludwig Maximilians Universitätsklinikum München, München, Deutschland.
- Neuroonkologisches Zentrum der Neurochirurgische Klinik, Ludwig Maximilians Universitätsklinikum München, Marchioninistr. 15, 81377, München, Deutschland.
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14
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Wang L, Fan Y, Chen B, Zhang J, Yang L, Qiu X, Jiang H, Li J, Xiao X, Huang L, Xu Y. Case report: Successful treatment of a patient with relapsed/refractory primary central nervous system lymphoma with thiotepa-based induction, autologous stem cell transplantation and maintenance. Front Oncol 2024; 13:1333761. [PMID: 38348121 PMCID: PMC10859448 DOI: 10.3389/fonc.2023.1333761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/31/2023] [Indexed: 02/15/2024] Open
Abstract
Despite significant improvements in prognosis, a subset of patients with primary central nervous system lymphoma (PCNSL) remains at high risk for relapse. The treatment of relapsed and refractory (R/R) PCNSL remains a major clinical challenge. Herein, we present a 24-year-old patient with PCNSL who relapsed 4 years after initial diagnosis and subsequently became refractory to high-dose methotrexate (HD-MTX), temozolomide, whole brain radiation therapy (WBRT), ibrutinib, and lenalidomide. She received thiotepa with anti-programmed cell death protein 1 (PD-1) antibody and achieved partial remission and then underwent autologous stem cell transplantation (ASCT) with thiotepa-based conditioning. Post-transplant maintenance with thiotepa and anti-PD-1 at 3-month intervals resulted in a durable complete response (CR) in this case of R/R PCNSL. Our report highlights the important role of thiotepa in the treatment of patients with R/R PCNSL.
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Affiliation(s)
- Luyao Wang
- Department of Hematology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yili Fan
- Department of Hematology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Boxiao Chen
- Department of Hematology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jiawei Zhang
- Department of Hematology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Luyu Yang
- Department of Hematology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xi Qiu
- Department of Hematology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Huawei Jiang
- Department of Hematology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jinfan Li
- Department of Pathology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xibin Xiao
- Department of Hematology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Liansheng Huang
- Department of Hematology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yang Xu
- Department of Hematology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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15
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Zuo J, Lei T, Zhong S, Zhou J, Liu R, Wu C, Li S. C-reactive protein levels, the prognostic nutritional index, and the lactate dehydrogenase-to-lymphocyte ratio are important prognostic factors in primary central nervous system lymphoma: a single-center study of 223 patients. Neurosurg Rev 2023; 47:17. [PMID: 38112846 PMCID: PMC10730673 DOI: 10.1007/s10143-023-02248-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/22/2023] [Accepted: 12/09/2023] [Indexed: 12/21/2023]
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare and highly aggressive type of extranodal non-Hodgkin lymphoma (NHL), and the prognosis is poor. Currently, the most used prognostic models are the Memorial Sloan-Kettering Cancer Center (MSKCC) and International Extranodal Lymphoma Study Group (IELSG) scores; however, their predictive effects are changing with increasing incidence and changing treatment regimens. A growing body of evidence has demonstrated that inflammatory and nutritional markers are factors that can determine tumor prognosis. Therefore, the aim of this study was to identify and validate novel prognostic factors for PCNSL. Clinical information was collected from 223 patients with PCNSL. Patients younger than 18 years of age were excluded. Progression-free survival (PFS) and overall survival (OS) were used as endpoints, and receiver operating characteristic (ROC) curve analyses were conducted to determine the cutoff values for the inflammatory indicators. Correlations between variables and PFS or OS were assessed using univariate and multivariate analyses, and positive indicators were selected for survival analysis. A prognostic nutritional index (PNI) < 49.38 was associated with worse PFS (p = 0.003), and outcomes significantly differed between patients with a PNI ≥ 49.38 and < 49.38 (p < 0.001). Age < 60 years (p < 0.001) and C-reactive protein (CRP) levels < 3.14 (p = 0.001) were associated with better OS. In elderly patients (≥ 60 years), a lactate dehydrogenase-to-lymphocyte ratio (LLR) < 95.69 (p = 0.021) was associated with better OS, and the outcome significantly differed between patients with an LLR ≥ 95.69 and LLR < 95.69 (p = 0.015). The PNI and CRP levels are prognostic factors for PCNSL, and CRP was the first time shown to be a prognosis factor of PCNSL. In elderly patients with PCNSL, the LLR can predict prognosis.
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Affiliation(s)
- Jinyi Zuo
- Department of Neuro-Oncology, Sanbo Brain Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Ting Lei
- Department of Neuro-Oncology, Sanbo Brain Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Shuai Zhong
- Department of Neuro-Oncology, Sanbo Brain Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Jiajun Zhou
- Department of Neuro-Oncology, Sanbo Brain Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Rui Liu
- Department of Neuro-Oncology, Sanbo Brain Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Chenxing Wu
- Department of Neuro-Oncology, Sanbo Brain Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Shouwei Li
- Department of Neuro-Oncology, Sanbo Brain Hospital, Capital Medical University, Beijing, People's Republic of China.
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16
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Li C, Zhang L, Jin Q, Jiang H, Wu C. Role and application of chemokine CXCL13 in central nervous system lymphoma. Ann Hematol 2023:10.1007/s00277-023-05560-4. [PMID: 38010409 DOI: 10.1007/s00277-023-05560-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/20/2023] [Indexed: 11/29/2023]
Abstract
Chemokine ligand 13 (CXCL13) and its chemokine receptor 5 (CXCR5) both play significant roles in the tumor microenvironment (TME). CXCL13 in cerebrospinal fluid (CSF) has recently been found to have significant diagnostic and prognostic value in primary and secondary central nervous system (CNS) diffuse large B-cell lymphoma (DLBCL), and the CXCL13-CXCR5 axis has been shown to play an important chemotactic role in the TME of CNS-DLBCL. In this review, we first describe the clinical value of CXCL13 in CSF as a prognostic and diagnostic biomarker for CNS-DLBCL. In addition, this review also discusses the specific mechanisms associated with the CXCL13-CXCR5 axis in tumor immunity of primary diffuse large B cell lymphoma of the central nervous system (PCNS-DLBCL) by reviewing the specific mechanisms of this axis in the immune microenvironment of DLBCL and CNS inflammation, as well as the prospects for the use of CXCL13-CXCR5 axis in immunotherapy in PCNS-DLBCL.
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Affiliation(s)
- Cuicui Li
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China
| | - Litian Zhang
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China
| | - Qiqi Jin
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China
| | - Haoyun Jiang
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China
| | - Chongyang Wu
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China.
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