1
|
Othman T, Quan MA, Zhang S, Gaut D, Young PA, Mahmood O, Abdulhaq H, Shieh K, Reid J, Brem EA, Hariharan N, Heyman B, Tuscano J. 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. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:749-756. [PMID: 37336714 DOI: 10.1016/j.clml.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/27/2023] [Accepted: 06/03/2023] [Indexed: 06/21/2023]
Abstract
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.
Collapse
Affiliation(s)
- Tamer Othman
- Department of Internal Medicine, Division of Cellular Therapy, Bone Marrow Transplantation and Malignant Hematology, University of California Davis School of Medicine, Sacramento, CA
| | - Michelle A Quan
- Department of Internal Medicine, Division of Cellular Therapy, Bone Marrow Transplantation and Malignant Hematology, University of California Davis School of Medicine, Sacramento, CA
| | - Shiliang Zhang
- Division of Hematology Oncology, David Geffen School of Medicine and University of California, Los Angeles, CA
| | - Daria Gaut
- Division of Hematology Oncology, David Geffen School of Medicine and University of California, Los Angeles, CA
| | - Patricia A Young
- Division of Hematology Oncology, David Geffen School of Medicine and University of California, Los Angeles, CA
| | - Omar Mahmood
- Department of Medicine, University of California San Francisco, Fresno campus, Fresno, CA
| | - Haifaa Abdulhaq
- Department of Medicine, University of California San Francisco, Fresno campus, Fresno, CA
| | - Kevin Shieh
- Division of Blood & Marrow Transplant, Department of Medicine, University of California, San Diego Health, La Jolla, CA
| | - Jack Reid
- Division of Blood & Marrow Transplant, Department of Medicine, University of California, San Diego Health, La Jolla, CA
| | - Elizabeth A Brem
- Division of Blood & Marrow Transplant, Department of Medicine, University of California, San Diego Health, La Jolla, CA
| | - Nisha Hariharan
- Moores Cancer Center, University of California, San Diego, La Jolla, CA
| | - Benjamin Heyman
- Moores Cancer Center, University of California, San Diego, La Jolla, CA
| | - Joseph Tuscano
- Department of Internal Medicine, Division of Cellular Therapy, Bone Marrow Transplantation and Malignant Hematology, University of California Davis School of Medicine, Sacramento, CA.
| |
Collapse
|
2
|
Delphine L, Pierre-Edouard D, Bruno R, Bérengère G, Magalie J, Patrick V, Jean-Pierre M, Pierre M. Thiotepa, Busulfan, Cyclophosphamide: Effective but Toxic Conditioning Regimen Prior to Autologous Hematopoietic Stem Cell Transplantation in Central Nervous System Lymphoma. Med Sci (Basel) 2023; 11:medsci11010014. [PMID: 36810481 PMCID: PMC9944873 DOI: 10.3390/medsci11010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/16/2023] [Accepted: 01/22/2023] [Indexed: 02/03/2023] Open
Abstract
In primary central nervous system lymphoma, two-year progression-free survival rates of up to 63 percent have been reported for first-line autologous stem cell transplantation after conditioning with the thiotepa busulfan cyclophosphamide regimen. However, 11 percent of the patients died due to toxicity. Besides conventional survival, progression-free survival and treatment related mortality analyses, a competing-risk analysis was applied to our cohort of twenty-four consecutive patients with primary or secondary central nervous system lymphoma who underwent autologous stem cell transplantation after thiotepa busulfan cyclophosphamide conditioning. The two-year overall survival and progression-free survival rates were 78 percent and 65 percent, respectively. The treatment-related mortality rate was 21 percent. The competing risks analysis demonstrate that age 60 or over and the infusion of less than 4.6 × 106/kg CD34+ stem cells were significant adverse prognostic factors for overall survival. Autologous stem cell transplantation with thiotepa busulfan cyclophosphamide conditioning was associated with sustained remission and survival. Nevertheless, the intensive thiotepa busulfan cyclophosphamide conditioning regimen was highly toxic, especially in older patients. Thus, our results suggest that future studies should aim at identifying the subgroup of patients who will really benefit of the procedure and/or to reduce the toxicity of future conditioning regimen.
Collapse
Affiliation(s)
- Lebon Delphine
- Hématologie Clinique et Thérapie Cellulaire, Centre Hospitalier Universitaire Amiens-Picardie, 80000 Amiens, France
- Correspondence: (L.D.); (D.P.-E.)
| | - Debureaux Pierre-Edouard
- Hématologie Clinique, Hôpital Saint-Louis, Assistance Publique—Hôpitaux de Paris, 75014 Paris, France
- Correspondence: (L.D.); (D.P.-E.)
| | - Royer Bruno
- Hématologie Clinique, Hôpital Saint-Louis, Assistance Publique—Hôpitaux de Paris, 75014 Paris, France
| | - Gruson Bérengère
- Hématologie Clinique et Thérapie Cellulaire, Centre Hospitalier Universitaire Amiens-Picardie, 80000 Amiens, France
| | - Joris Magalie
- Hématologie Clinique et Thérapie Cellulaire, Centre Hospitalier Universitaire Amiens-Picardie, 80000 Amiens, France
| | - Votte Patrick
- Hématologie Clinique et Thérapie Cellulaire, Centre Hospitalier Universitaire Amiens-Picardie, 80000 Amiens, France
| | - Marolleau Jean-Pierre
- Hématologie Clinique et Thérapie Cellulaire, Centre Hospitalier Universitaire Amiens-Picardie, 80000 Amiens, France
| | - Morel Pierre
- Hématologie Clinique et Thérapie Cellulaire, Centre Hospitalier Universitaire Amiens-Picardie, 80000 Amiens, France
| |
Collapse
|
3
|
Steffanoni S, Calimeri T, Marktel S, Nitti R, Foppoli M, Ferreri AJM. Diagnosis and Treatment Using Autologous Stem-Cell Transplantation in Primary Central Nervous System Lymphoma: A Systematic Review. Cancers (Basel) 2023; 15:cancers15020526. [PMID: 36672475 PMCID: PMC9856418 DOI: 10.3390/cancers15020526] [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: 12/23/2022] [Revised: 01/08/2023] [Accepted: 01/10/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Consolidation therapy has improved the outcome of newly diagnosed PCNSL patients. Whole-brain radiotherapy (WBRT) was the first consolidation strategy used and represented the gold standard for many years, but at the expense of a high risk of neurotoxicity. Thus, alternative strategies are being investigated in order to improve disease outcomes and to spare the neurocognitive side effects due to WBRT. METHODS We reviewed published studies on PCNSL patients treated with HDC/ASCT, focusing on the efficacy and safety of the conditioning regimens. Prospective and retrospective studies, published in the English language from 1992 to 2022, in high-quality international journals were identified in PubMed. RESULTS Consolidation with HDC containing highly CNS-penetrating agents (thiotepa, busulfan or BCNU) followed by ASCT provided long-term disease control and survival in PCNSL patients. Two prospective randomized studies, comparing HDC/ASCT versus WBRT, reported similar progression-free survival (PFS) and similar results on the decline in neurocognitive functions in a substantial proportion of patients after WBRT but not after HDC-ASCT. A recent randomized study comparing HDC/ASCT versus non-myeloablative consolidation reported a longer PFS in transplanted patients. CONCLUSION ASCT conditioned with regimens, including highly CNS-penetrating agents, represents, to date, the best choice among the available consolidation strategies for fit newly diagnosed PCNSL patients.
Collapse
Affiliation(s)
- Sara Steffanoni
- Department of Medicine, Division of Hematology, Valduce Hospital, 22100 Como, Italy
- Correspondence:
| | - Teresa Calimeri
- Lymphoma Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Sarah Marktel
- Hematology and BMT Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Rosamaria Nitti
- Hematology and BMT Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Marco Foppoli
- Lymphoma Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | | |
Collapse
|
4
|
Miyao K, Yokota H, Sakemura RL. Is CD19-directed chimeric antigen receptor T cell therapy a smart strategy to combat central nervous system lymphoma? Front Oncol 2023; 12:1082235. [PMID: 36686821 PMCID: PMC9850100 DOI: 10.3389/fonc.2022.1082235] [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: 10/28/2022] [Accepted: 12/02/2022] [Indexed: 01/07/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Kotaro Miyao
- Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan
| | - Hirofumi Yokota
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - R. Leo Sakemura
- T Cell Engineering, Mayo Clinic, Rochester, MN, United States,Division of Hematology, Mayo Clinic, Rochester, MN, United States,*Correspondence: R. Leo Sakemura,
| |
Collapse
|
5
|
Song GY, Jung SH, Kim JS, Eom HS, Moon JH, Yhim HY, Kim K, Min CK, Lee JJ. Busulfan and thiotepa as a conditioning regimen for autologous stem cell transplantation in patients with multiple myeloma: A study of the Korean Multiple Myeloma Working Party (KMMWP-1801 study). Front Oncol 2022; 12:959949. [PMID: 36110935 PMCID: PMC9468269 DOI: 10.3389/fonc.2022.959949] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 07/29/2022] [Indexed: 12/04/2022] Open
Abstract
Background Autologous stem cell transplantation (ASCT) remains the standard of care for patients with newly diagnosed multiple myeloma (MM). Several attempts to improve the efficacy of conditioning regimens have been conducted in MM, but no more effective regimen than conventional high-dose melphalan has been introduced. Objective In this study, the efficacy and toxicity of busulfan and thiotepa (BuTT) and those of high-dose melphalan (HD-MEL) were compared retrospectively as a conditioning regimen for ASCT in patients with MM. Study design Included in the analysis were 114 patients who received BuTT and 114 patients who received HD-MEL treatment between March 2008 and May 2020. The BuTT regimen consisted of intravenous thiotepa 5 mg/kg once a day from days 7 to 6, followed by intravenous busulfan 3.2 mg/kg once a day from days 5 to 3. The HD-MEL conditioning regimen consisted of melphalan 100 mg/m2 once a day from days 3 to 2. Results The overall response rate after ASCT did not differ between BuTT and HD-MEL (94.7% in BuTT vs. 97.4% in HD-MEL, p = 0.333). After a median follow-up of 47.6 months, progression-free survival (PFS) tended to be longer in the BuTT group (median PFS, 41.5 months vs. 30.3 months; hazard ratio (HR), 0.706; 95% confidence interval (CI), 0.497–1.004, p = 0.053). In the subgroup analysis of patients who did not proceed to maintenance or consolidation treatment after ASCT, the difference in PFS became more significant (median PFS, 41.5 months vs. 24.4 months; HR, 0.621; 95% CI, 0.388–0.993; p = 0.047). Additionally, the BuTT group had fewer adverse events, such as grade 3 or 4 stomatitis and diarrhea, than the HD-MEL group (stomatitis, 10.5% vs. 23.7%, p = 0.013; diarrhea, 10.5% vs. 25.4%, p = 0.005). There was no difference in the occurrence of venous-occlusive disease (2.6% in BuTT vs. 0.9% in HD-MEL, p = 0.622). Conclusion Our study results suggest that BuTT is an effective alternative conditioning regimen with reduced toxicity in patients with newly diagnosed MM.
Collapse
Affiliation(s)
- Ga-Young Song
- Department of Hematology-Oncology Chonnam National University Hwasun Hospital and Chonnam National University Medical School, Hwasun, South Korea
| | - Sung-Hoon Jung
- Department of Hematology-Oncology Chonnam National University Hwasun Hospital and Chonnam National University Medical School, Hwasun, South Korea
| | - Jin Seok Kim
- Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | | | - Joon Ho Moon
- Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Ho-Young Yhim
- Division of Hematology/Oncology Chonbuk National University Medical School, Jeonju, South Korea
| | - Kihyun Kim
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Chang-Ki Min
- Seoul St. Mary's Hematology Hospital, Catholic University of Korea, Seoul, South Korea
| | - Je-Jung Lee
- Department of Hematology-Oncology Chonnam National University Hwasun Hospital and Chonnam National University Medical School, Hwasun, South Korea
| |
Collapse
|
6
|
Liu J, Guo J, Sun X, Liu Y, Gao C. Efficacy and Safety of Autologous Stem-Cell Transplantation as Part of First-Line Treatment for Newly Diagnosed Primary Central Nervous System Lymphoma: A Systematic Review and Meta-Analysis. Front Oncol 2022; 11:799721. [PMID: 35096600 PMCID: PMC8790123 DOI: 10.3389/fonc.2021.799721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/14/2021] [Indexed: 11/23/2022] Open
Abstract
Objective The reviewed literature supports a treatment regimen for primary central nervous system lymphoma (PCNSL) that includes induction chemotherapy, followed by one consolidation therapy. High-dose chemotherapy supported by autologous stem-cell transplantation (ASCT) is the most studied option, but its effects are controversial. The aim of this study was to evaluate the efficacy and safety of ASCT for newly diagnosed PCNSL by means of a meta-analysis. Methods The PubMed, Embase, and Cochrane Library databases were systematically searched for studies published until May 20, 2021. Included studies were prospective studies of patients with newly diagnosed PCNSL treated with ASCT. The pooled rates and 95% confidence intervals (CIs) were determined for all outcomes. Subgroup analysis was conducted to compare the relative risk (RR) with 95% CIs for the complete remission (CR) rate and the hazard ratios (HRs) with 95% CIs for progression-free survival (PFS) and overall survival (OS). Results Thirteen prospective studies including 348 patients were analyzed. The pooled CR rate, overall response rate, and relapse rate were 80% (95% CI, 71–88%, I2 = 67.06%, p = 0.00), 95% (95% CI, 87–100%, I2 = 73.65%, p= 0.00), and 19% (95% CI, 15–24%, I2 = 76.18%, p = 0.00), respectively. The pooled 2- and 5-year PFS and OS rates were 74% (95% CI, 68–80%, I2 = 3.90%), 65% (95% CI, 51–77%, I2 = 74.61%), 80% (95% CI, 72–88%, I2 = 57.54%), and 69% (95% CI, 53–83%, I2 = 83.89%), respectively. Hematological toxicity and infections were more common adverse events above grade 3. The pooled treatment-related mortality was 3% (95% CI, 1–6%, I2 = 28.18%, p = 0.16). In the group analysis of ASCT compared with whole-brain radiotherapy, there were no significant differences in the CR rate (RR, 1.00, 95% CI, 0.88–1.14, p = 0.971), relapse rate (RR, 0.44, 95% CI, 0.06–3.10, p = 0.408), PFS (HR, 1.28, 95% CI, 0.81–2.01, p = 0.29), or OS (HR, 1.62, 95% CI, 0.97–2.69, p = 0.06). Cognitive functions were preserved or improved after ASCT. Conclusions ASCT is a feasible approach for consolidation with good tolerability for newly diagnosed PCNSL patients. High-quality randomized controlled trials are still needed to confirm the effects of ASCT. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier CRD42021268422.
Collapse
Affiliation(s)
- Jing Liu
- Senior Department of Hematology, The Fifth Medical Center of People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Jiayuan Guo
- School of Medicine, Nankai University, Tianjin, 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
| | - Chunji Gao
- Senior Department of Hematology, The Fifth Medical Center of People's Liberation Army (PLA) General Hospital, Beijing, China
| |
Collapse
|
7
|
Lee JY, Paik JH, Suh KJ, Kim JW, Kim SH, Kim JW, Kim YJ, Lee KW, Kim JH, Bang SM, Lee JS, Lee JO. R-MPV followed by high-dose chemotherapy with thiotepa-based and autologous stem cell transplantation for newly diagnosed primary central nervous system lymphoma: a single-center experience. Blood Res 2021; 56:285-292. [PMID: 34801986 PMCID: PMC8721461 DOI: 10.5045/br.2021.2021073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 08/27/2021] [Accepted: 10/18/2021] [Indexed: 11/17/2022] Open
Abstract
Background High-dose chemotherapy followed by autologous stem cell transplantation (HDC-ASCT) as a consolidation treatment is a promising approach for eligible patients with newly diagnosed primary central nervous system lymphoma (PCNSL). Methods In this retrospective analysis, 22 patients with newly diagnosed PCNSL received chemotherapy with rituximab, methotrexate, procarbazine, and vincristine. Those who showed complete or partial response subsequently received consolidation HDC-ASCT with a thiotepa-based conditioning regimen but did not undergo radiotherapy. Results The PCNSL patients had a median age of 57 years (range, 49‒67 yr); of the total patients, 9.1% had a performance status of 2 or higher, and 72.1% had multiple lesions. Approximately 82% of patients received six cycles of induction chemotherapy, which was well tolerated with excellent disease control. The rate of confirmed or unconfirmed complete response increased from 45.5% at the period of interim analysis to 81.8% prior to the initiation of HDC-ASCT. With a median follow-up of 19.6 months (range, 7.5‒56.5 mo), the 2-year progression-free survival and overall survival estimates were 84% and 88%, respectively. No treatment-related deaths occurred. Grade 3 toxicity was recorded in 90.9% of the patients after undergoing the HDC-ASCT, and the most common grade 3 adverse event was febrile neutropenia without sepsis. Conclusion The discussed treatment approach is feasible in patients with newly diagnosed PCNSL, yielding encouraging results.
Collapse
Affiliation(s)
- Ji Yun Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jin Ho Paik
- Department of Pathology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Koung Jin Suh
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji-Won Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Se Hyun Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jin Won Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yu Jung Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Keun-Wook Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jee Hyun Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Soo-Mee Bang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jong-Seok Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong-Ok Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| |
Collapse
|
8
|
Steffanoni S, Calimeri T, Anzalone N, Mastaglio S, Bernardi M, Ferreri AJ. A narrative review of consolidation strategies for young and fit patients with newly-diagnosed primary central nervous system lymphoma. Expert Rev Hematol 2021; 15:33-43. [PMID: 34904506 DOI: 10.1080/17474086.2022.2018297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION The modern treatment of patients with primary central nervous system lymphoma (PCNSL) consists of two phases: induction, currently represented by a high-dose-methotrexate-based polychemotherapy, and consolidation. The optimal consolidation therapy has not been defined yet, but several strategies, such as whole-brain radiotherapy (WBRT), high-dose chemotherapy supported by autologous stem cell transplantation (HDC/ASCT) or non-myeloablative chemotherapy, have been addressed in important randomized trials. AREAS COVERED This review provides an overview of the current role of consolidation strategies in young and fit patients with newly-diagnosed PCNSL. Publications in English language, peer-reviewed, from high-quality international journals, edited from 2003 to 2021 were identified on PubMed. EXPERT OPINION Consolidation treatment significantly improved outcomes of PCNSL. Radiotherapy had represented for years the only choice in the consolidation therapy, but large randomized trials have demonstrated that HDC/ASCT is equally effective and associated with lower neurotoxicity risk in patients younger than 65-70 years. Encouraging results have been obtained using reduced-dose WBRT, while a recent randomized trial failed to demonstrate that consolidation with non-myeloablative chemotherapy is more effective than HDC/ASCT in PCNSL patients. A personalized consolidation treatment, driven also by a response prediction model based on radiological and molecular details, may improve the management of PCNSL patients.
Collapse
Affiliation(s)
- Sara Steffanoni
- Department of Medicine, Division of Hematology, Valduce Hospital, Como, Italy
| | - Teresa Calimeri
- Lymphoma Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicoletta Anzalone
- Neuroradiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Sara Mastaglio
- Hematology and BMT Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Bernardi
- Hematology and BMT Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrés Jm Ferreri
- Lymphoma Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| |
Collapse
|
9
|
Lee H, Nakamura K, Narayanan S, Brown RA, Nash RA, Griffith LM, Steinmiller KC, Devine SM, Hutton GJ, Popat U, Racke MK, Georges GE, Bowen JD, Arnold DL. Brain volume change after high-dose immunosuppression and autologous hematopoietic cell transplantation for relapsing-remitting multiple sclerosis. Mult Scler Relat Disord 2021; 54:103149. [PMID: 34284316 DOI: 10.1016/j.msard.2021.103149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 06/09/2021] [Accepted: 07/08/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Brain volume loss (BVL) is commonly observed after high-dose immunosuppression and autologous hematopoietic cell transplantation (HDIT/HCT) for treatment of multiple sclerosis (MS). To better understand the mechanisms of underlying BVL associated with this treatment, we characterized the time courses of whole-brain (WB), grey-matter (GM) and white-matter (WM) volume loss in relapsing-remitting MS (RRMS) patients who received BEAM-based HDIT/HCT. METHODS We used Jacobian integration to measure MRI-based WB, GM and WM volume changes up to 5 years after transplant in twenty-four RRMS participants who underwent BEAM-based HDIT/HCT. Using a two-piecewise mixed-effects model, we estimated the short-term (baseline to 1 year) and long-term (beyond 1 year) rates of BVL after HDIT/HCT. We also compared the rates based on the presence of gadolinium-enhancing lesions at baseline, and the maintenance of event-free survival during follow-up. RESULTS On average, accelerated short-term BVL of -1.37% (SE: 0.21), -0.86% (SE: 0.28) and -2.18% (SE: 0.26) occurred in WB, GM and WM, respectively. Baseline T1-weighted MRI WM lesion volume was a significant predictor in the WB (short-term) and the WM (short-term and long-term). The average rates of BVL after the initial acceleration were -0.22%/y (SE: 0.10), -0.13%/y (SE: 0.11) and -0.36%/y (SE: 0.11) in the WB, GM and WM, respectively. Participants with gadolinium-enhancing lesions at baseline had significantly higher short-term rates of GM (-1.56% vs. -0.27%, p = 0.01) and WB volume loss (-1.94% vs. -0.81%, p = 0.006) at 1 year follow-up as compared to those without gadolinium-enhancing lesions. WM volume loss was not significantly different (-2.59% vs. -1.66%, p = 0.16). Participants who maintained event-free survival had similar rates of BVL compared to those who did not. CONCLUSIONS BVL may accelerate for months after HDIT/HCT. However, over the long-term, adequate HDIT/HCT may reduce BVL rates to those similar to normal aging at the WB level.
Collapse
Affiliation(s)
- Hyunwoo Lee
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada; Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Kunio Nakamura
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada; Department of Biomedical Engineering, Cleveland Clinic Lerner Research Institute, Cleveland, OH, USA
| | - Sridar Narayanan
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada; NeuroRx Research Inc., Montreal, QC, Canada
| | - Robert A Brown
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada; ShadowLab Research Inc., Toronto, ON, Canada
| | | | - Linda M Griffith
- Division of Allergy, Immunology and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | | | - Steven M Devine
- Be The Match BioTherapies, National Marrow Donor Program (NMDP)/Be The Match, Center for International Blood and Marrow Transplant Research (CIBMTR), Minneapolis, MN, USA
| | - George J Hutton
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Uday Popat
- Department of Stem Cell Transplantation, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael K Racke
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | | | - Douglas L Arnold
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada; NeuroRx Research Inc., Montreal, QC, Canada
| |
Collapse
|
10
|
Scordo M, Wang TP, Ahn KW, Chen Y, Ahmed S, Awan FT, Beitinjaneh A, Chen A, Chow VA, Dholaria B, Epperla N, Farooq U, Ghosh N, Grover N, Hamad N, Hildebrandt GC, Holmberg L, Hong S, Inwards DJ, Jimenez-Jimenez A, Karmali R, Kenkre VP, Khimani F, Klyuchnikov E, Krem MM, Munshi PN, Nieto Y, Prestidge T, Ramakrishnan Geethakumari P, Rezvani AR, Riedell PA, Seo S, Shah NN, Solh M, Yared JA, Kharfan-Dabaja MA, Herrera A, Hamadani M, Sauter CS. Outcomes Associated With Thiotepa-Based Conditioning in Patients With Primary Central Nervous System Lymphoma After Autologous Hematopoietic Cell Transplant. JAMA Oncol 2021; 7:993-1003. [PMID: 33956047 DOI: 10.1001/jamaoncol.2021.1074] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Importance Primary central nervous system lymphoma (PCNSL) requires induction and consolidation to achieve potential cure. High-dose therapy and autologous hematopoietic cell transplant (AHCT) is an accepted and effective consolidation strategy for PCNSL, but no consensus exists on the optimal conditioning regimens. Objective To assess the outcomes in patients with PCNSL undergoing AHCT with the 3 most commonly used conditioning regimens: thiotepa/busulfan/cyclophosphamide (TBC), thiotepa/carmustine (TT-BCNU), and carmustine/etoposide/cytarabine/melphalan (BEAM). Design, Setting, and Participants This observational cohort study used registry data from the Center for International Blood and Marrow Transplant Research registry. The Center is a working group of more than 380 transplantation centers worldwide that contributed detailed data on HCT to a statistical center at the Medical College of Wisconsin, Milwaukee. The participant data were from 603 adult patients with PCNSL who underwent AHCT as initial, or subsequent, consolidation between January 2010 and December 2018. Patients were excluded if they had a non-Hodgkin lymphoma subtype other than diffuse large B-cell lymphoma, systemic non-Hodgkin lymphoma, or HIV; received an uncommon conditioning regimen; or were not in partial remission or complete remission prior to AHCT. Statistical analysis was performed from July 5, 2020, to March 1, 2021. Interventions Patients received 1 of 3 conditioning regimens: TBC (n = 263), TT-BCNU (n = 275), and BEAM (n = 65). Main Outcomes and Measures The primary outcome was progression-free survival. Secondary outcomes included hematopoietic recovery, incidence of relapse, nonrelapse mortality, and overall survival. Results Of 603 patients, the mean age was 57 (range, 19-77) years and 318 (53%) were male. The 3-year adjusted progression-free survival rates were higher in the TBC cohort (75%) and TT-BCNU cohort (76%) compared with the BEAM cohort (58%) (P = .03) owing to a higher relapse risk in the BEAM cohort (hazard ratio [HR], 4.34; 95% CI, 2.45-7.70; P < .001). In a multivariable regression analysis, compared with the TBC cohort, patients who received TT-BCNU had a higher relapse risk (HR, 1.79; 95% CI, 1.07-2.98; P = .03), lower risk of nonrelapse mortality (NRM) (HR, 0.50; 95% CI, 0.29-0.87; P = .01), and similar risk of all-cause mortality more than 6 months after HCT (HR, 1.54; 95% CI, 0.93-2.55; P = .10). Age of 60 years or older, Karnofsky performance status less than 90, and an HCT-comorbidity index greater than or equal to 3 were associated with lower rates of survival across all 3 cohorts. Subgroup analyses demonstrated that patients aged 60 years and older had considerably higher NRM with TBC. Conclusions and Relevance In this cohort study, thiotepa-based conditioning regimen was associated with higher rates of survival compared with BEAM, despite higher rates of early toxic effects and NRM; these findings may assist clinicians in choosing between TBC or TT-BCNU based on patient and disease characteristics.
Collapse
Affiliation(s)
- Michael Scordo
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Trent P Wang
- Division of Transplantation and Cellular Therapy, University of Miami Miller School of Medicine, Miami, Florida
| | - Kwang W Ahn
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee.,Institute for Health and Equity, Division of Biostatistics, Medical College of Wisconsin, Milwaukee
| | - Yue Chen
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Sairah Ahmed
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Farrukh T Awan
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Amer Beitinjaneh
- Division of Transplantation and Cellular Therapy, University of Miami Miller School of Medicine, Miami, Florida
| | - Andy Chen
- Department of Medicine, Oregon Health and Science University, Portland
| | - Victor A Chow
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Narendranath Epperla
- The James Cancer Hospital and Solove Research Institute, Division of Hematology, Department of Medicine, The Ohio State University, Columbus
| | - Umar Farooq
- Division of Hematology, Oncology and Blood & Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City
| | - Nilanjan Ghosh
- Levine Cancer Institute, Department of Hematologic Oncology and Blood Disorders, Atrium Health, Charlotte, North Carolina
| | - Natalie Grover
- Department of Medicine, University of North Carolina Hospitals, Chapel Hill
| | - Nada Hamad
- St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | | | - Leona Holmberg
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Sanghee Hong
- Blood and Marrow Transplant Program, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | | | - Antonio Jimenez-Jimenez
- Division of Transplantation and Cellular Therapy, University of Miami Miller School of Medicine, Miami, Florida
| | - Reem Karmali
- Department of Medicine, Northwestern University, Chicago, Illinois
| | | | - Farhad Khimani
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Evgeny Klyuchnikov
- Department for Stem Cell Transplantation, University Cancer Center, Hamburg, Germany
| | | | - Pashna N Munshi
- Department of Medicine, Georgetown University Hospital, Washington, DC
| | - Yago Nieto
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston
| | - Tim Prestidge
- Blood and Cancer Centre, Starship Children's Hospital, Auckland, New Zealand
| | | | - Andrew R Rezvani
- Division of Blood & Marrow Transplantation, Stanford University, Stanford, California
| | - Peter A Riedell
- Department of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Sachiko Seo
- Department of Hematology and Oncology, Dokkyo Medical University, Tochigi, Japan
| | - Nirav N Shah
- Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Melhem Solh
- The Blood and Marrow Transplant Group of Georgia, Northside Hospital, Atlanta
| | - Jean A Yared
- Blood & Marrow Transplantation Program, Greenebaum Comprehensive Cancer Center, Division of Hematology/Oncology, Department of Medicine, University of Maryland, Baltimore
| | - Mohamed A Kharfan-Dabaja
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, Florida
| | - Alex Herrera
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Mehdi Hamadani
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Craig S Sauter
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medical College, New York, New York
| |
Collapse
|
11
|
Steinhardt MJ, Krummenast FC, Rosenwald A, Gerhard-Hartmann E, Heidemeier A, Einsele H, Topp MS, Duell J. R-CHOP intensification with mid-cycle methotrexate and consolidating AraC/TT with BCNU/aHSCT in primary aggressive lymphoma with CNS involvement. J Cancer Res Clin Oncol 2021; 148:205-214. [PMID: 34085097 PMCID: PMC8752544 DOI: 10.1007/s00432-021-03663-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 05/11/2021] [Indexed: 11/30/2022]
Abstract
Purpose Patients suffering from aggressive systemic peripheral lymphoma with primary central nervous system involvement (PCL) are a rare and sparsely investigated population. Recommended treatment regimens include a combination of intrathecal and systemic chemotherapy as well as whole brain radiotherapy while offering relatively poor survival. Methods We conducted a single-center retrospective study that analyzed safety and outcome of 4 + 4 cycles Rituximab (R)-CHOP and R-high-dose Methotrexate (HD-MTX) for newly diagnosed, transplant-eligible patients (“Ping-Pong”), followed by Cytarabine (AraC)/Thiotepa (TT), BCNU/TT, and autologous hematologic stem cell transplantation (aHSCT). We retrospectively analyzed a set of 16 patients with high–intermediate or high-risk IPI status. Results Overall response rate to Ping-Pong was 100% measured by CT/MRI, including 93.75% complete remissions after BCNU/TT followed by PBSCT. One patient failed to qualify for high-dose chemotherapy due to progression when receiving Cytarabine/TT. All patients experienced grade III adverse events, 3 of them a grade IV adverse event. Estimated progression-free survival is 93.75% after a 4.8-year follow-up currently. Conclusion Our study suggests high effectivity of R-CHOP with mid-cycle MTX with aHSCT consolidation towards acceptable OS results in this challenging patient population.
Collapse
Affiliation(s)
- Maximilian J Steinhardt
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany.,Department of Internal Medicine II, University Hospital Würzburg, Oberdürrbacher Street 6, 97080, Würzburg, Germany
| | - Franziska C Krummenast
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - Andreas Rosenwald
- Institut für Pathologie der Universität Würzburg, Universitätsklinikum Würzburg, Josef-Schneider-Straße 2, 97080, Würzburg, Germany
| | - Elena Gerhard-Hartmann
- Institut für Pathologie der Universität Würzburg, Universitätsklinikum Würzburg, Josef-Schneider-Straße 2, 97080, Würzburg, Germany
| | - Anke Heidemeier
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - Hermann Einsele
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - Max S Topp
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - Johannes Duell
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany.
| |
Collapse
|
12
|
Young PA, Gaut D, Kimaiyo DK, Grotts J, Romero T, Chute J, Schiller G, de Vos S, Eradat HA, Timmerman J. Durable Survival Outcomes in Primary and Secondary Central Nervous System Lymphoma After High-dose Chemotherapy and Autologous Stem Cell Transplantation Using a Thiotepa, Busulfan, and Cyclophosphamide Conditioning Regimen. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2020; 20:468-479. [PMID: 32229199 PMCID: PMC7138188 DOI: 10.1016/j.clml.2020.02.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/31/2020] [Accepted: 02/09/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND High-dose chemotherapy (HDC) with autologous stem cell transplantation (ASCT) has been investigated in patients with primary central nervous system lymphoma (PCNSL) and non-Hodgkin lymphoma (NHL) with CNS involvement and has shown promising results. PATIENTS AND METHODS A retrospective analysis was performed of 48 consecutive patients who had undergone HDC/ASCT with TBC (thiotepa, busulfan, cyclophosphamide) conditioning for PCNSL (27 patients), secondary CNS lymphoma (SCNSL) (8 patients), or relapsed disease with CNS involvement (13 patients) from July 2006 to December 2017. Of the 27 patients with PCNSL, 21 had undergone ASCT at first complete remission (CR1). RESULTS The 2-year progression-free survival (PFS) rate was 80.5% (95% confidence interval [CI], 69.9-92.9) and the 2-year overall survival (OS) rate was 80.1% (95% CI, 69.2%-92.7%) among all patients. The 2-year PFS and OS rate for patients with PCNSL in CR1 was 95.2% (95% CI, 86.6%-100%) and 95.2% (95% CI, 86.6%-100%), respectively. On univariate analysis of the patients with PCNSL, ASCT in CR1 was the only variable statistically significant for outcome (P = .007 for PFS; P = .008 for OS). Among patients with SCNSL or CNS relapse, the 2-year PFS and OS rate were comparable at 75.9% (95% CI, 59.5%-96.8%) and 75.3% (95% CI, 58.6%-98.6%), respectively. The most common side effects were febrile neutropenia (89.6%; of which 66.7% had an infectious etiology identified), nausea/vomiting (85.4%), diarrhea (93.8%), mucositis (89.6%), and electrolyte abnormalities (89.6%). Four patients (8.3%) died of treatment-related overwhelming infection; of these patients, 3 had SCNSL. CONCLUSION HDC and ASCT using TBC conditioning for both PCNSL and secondary CNS NHL appears to have encouraging long-term efficacy with manageable side effects.
Collapse
Affiliation(s)
- Patricia A Young
- Division of Hematology and Oncology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.
| | - Daria Gaut
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Davis K Kimaiyo
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Jonathan Grotts
- Division of General Internal Medicine and Health Services Research, Department of Medicine Statistics Core, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Tahmineh Romero
- Division of General Internal Medicine and Health Services Research, Department of Medicine Statistics Core, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - John Chute
- Division of Hematology and Oncology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Gary Schiller
- Division of Hematology and Oncology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Sven de Vos
- Division of Hematology and Oncology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Herbert A Eradat
- Division of Hematology and Oncology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - John Timmerman
- Division of Hematology and Oncology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| |
Collapse
|
13
|
Hu B. A Tale of Two Eras: The Story of Autologous Stem Cell Transplantation with and without Thiotepa for Primary Central Nervous System Lymphoma. Biol Blood Marrow Transplant 2019; 25:e141-e142. [PMID: 30878604 DOI: 10.1016/j.bbmt.2019.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 03/08/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Bei Hu
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute/Atrium Health, Charlotte, North Carolina.
| |
Collapse
|
14
|
Gaut D, Schiller GJ. Hematopoietic stem cell transplantation in primary central nervous system lymphoma: a review of the literature. Int J Hematol 2019; 109:260-277. [PMID: 30671909 DOI: 10.1007/s12185-019-02594-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 12/14/2018] [Accepted: 01/08/2019] [Indexed: 12/26/2022]
Abstract
Primary central nervous system lymphoma (PCNSL) is an uncommon variant of extranodal non-Hodgkin lymphoma (NHL) with an aggressive course and worse outcomes compared with other lymphomas of similar tumor burden and histologic subtype. High-dose chemotherapy supported by autologous stem cell transplantation (HDC/ASCT) is an option for therapy for this disease in both the relapse setting and as post-remission consolidation. Data are currently limited to only several single-arm phase II trials with small sample sizes, but randomized trials are now ongoing. In this review, we discuss the efficacy, feasibility, and toxicity of HDC/ASCT for PCNSL and its role in the treatment of this aggressive malignancy, both in the first-line and relapse settings. We also bring to attention the current data on allogeneic stem cell transplantation (allo-SCT) in PCNSL.
Collapse
Affiliation(s)
- Daria Gaut
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Gary J Schiller
- Hematological Malignancies/Stem Cell Transplantation Unit, Division of Hematology/Oncology, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 10833 Le Conte Ave, Room 42-121 CHS, Los Angeles, CA, 90095, USA.
| |
Collapse
|
15
|
Ichikawa T. Primary CNS Lymphoma Treatment : Current Status and Future Directions. ACTA ACUST UNITED AC 2018. [DOI: 10.7887/jcns.27.99] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Tomotsugu Ichikawa
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences
| |
Collapse
|
16
|
Saraceni F, Labopin M, Hamladji RM, Mufti G, Socié G, Shimoni A, Delage J, Deconinck E, Chevallier P, Blaise D, Sanz J, Huynh A, Forcade E, Savani BN, Mohty M, Nagler A. Thiotepa-busulfan-fludarabine compared to busulfan-fludarabine for sibling and unrelated donor transplant in acute myeloid leukemia in first remission. Oncotarget 2017; 9:3379-3393. [PMID: 29423053 PMCID: PMC5790470 DOI: 10.18632/oncotarget.23273] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 11/20/2017] [Indexed: 11/29/2022] Open
Abstract
Background A preparatory regimen consisting of thiotepa-busulfan-fludarabine (TBF) has been associated with reduced relapse in patients with haematological malignancies after haploidentical and cord blood transplants; however, few data exist regarding TBF conditioning in sibling (MSD) and unrelated donor (URD) transplants for AML. Results Among patients receiving a myeloablative (MAC) regimen, TBF-MAC was associated with significantly lower relapse (HR 0.47, p = 0.005) however higher non-relapse mortality (NRM, HR 2.69, p < 10–4) as compared to BF. This led to similar leukemia-free (LFS) and overall survival (OS) between the two regimens (LFS: p = 0.6; OS: p = 0.27). When we selected TBF-MAC patients receiving busulfan 9.6 mg/kg, NRM resulted still higher but no more significantly different as compared to BF-MAC with busulfan 12.8 mg/kg (HR 1.53, p = 0.12); despite the lower busulfan dose, relapse remained inferior with TBF-MAC (HR 0.45, p = 0.01), however no difference in survival could be demonstrated (LFS: p = 0.31; OS: 0.82). Among patients receiving a reduced-intensity (RIC) regimen, similar outcome was observed with TBF-RIC and BF-RIC (LFS: p = 0.77; OS: p = 0.88). Conclusions TBF-MAC as conditioning regimen for transplant from MSD and URD in AML patients in first remission provided stronger anti-leukemic activity but higher NRM as compared to BF-MAC, thus leading to similar survival. TBF-MAC with busulfan 9.6 mg/kg was associated with low relapse and acceptable NRM, however again with no survival benefit. TBF-RIC and BF-RIC resulted in comparable outcome. Methods We conducted a registry-based study comparing outcomes of patients with AML in first remission undergoing transplant from MSD or URD prepared with either TBF (n = 212) or BF (n = 2698) conditioning.
Collapse
Affiliation(s)
| | - Myriam Labopin
- EBMT Paris Study Office, Saint Antoine Hospital, Paris, France
| | - Rose-Marie Hamladji
- Centre Pierre et Marie Curie, Service Hématologie Greffe de Moëlle, Alger, Algeria
| | - Ghulam Mufti
- GKT School of Medicine, Department of Haematological Medicine, London, United Kingdom
| | - Gerard Socié
- Hopital St. Louis, Department of Hematology-BMT, Paris, France
| | - Avichai Shimoni
- Chaim Sheba Medical Center, Department of Bone Marrow Transplantation, Tel-Hashomer, Israel
| | - Jeremy Delage
- CHU Lapeyronie, Département d'Hématologie Clinique, Montpellier, France
| | - Eric Deconinck
- Hopital Jean Minjoz, Service d'Hématologie, Besançon, France
| | | | - Didier Blaise
- Programme de Transplantation and Therapie Cellulaire, Centre de Recherche en Cancérologie de Marseille, Institut Paoli Calmettes, Marseille, France
| | - Jaime Sanz
- Hospital Universitario La Fe, Servicio de Hematologia, Valencia, Spain
| | - Anne Huynh
- Institut Universitaire du Cancer Toulouse, Oncopole, I.U.C.T-O, Toulouse, France
| | | | - Bipin N Savani
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mohamad Mohty
- Department of Haematology, Saint Antoine Hospital, Paris, France
| | - Arnon Nagler
- EBMT Paris Study Office, Saint Antoine Hospital, Paris, France.,Chaim Sheba Medical Center, Department of Bone Marrow Transplantation, Tel-Hashomer, Israel
| | | |
Collapse
|
17
|
Ferreri AJM. Therapy of primary CNS lymphoma: role of intensity, radiation, and novel agents. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:565-577. [PMID: 29222306 PMCID: PMC6142584 DOI: 10.1182/asheducation-2017.1.565] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Primary central nervous system (CNS) lymphomas represent a subgroup of malignancies with specific characteristics, an aggressive course, and unsatisfactory outcome in contrast with other lymphomas comparable for tumor burden and histological type. Despite the high sensitivity to conventional chemotherapy and radiotherapy, remissions are frequently short lasting. Treatment efficacy is limited by several factors, including the biology and microenvironment of this malignancy and the "protective" effect of the blood-brain barrier, which limits the access of most drugs to the CNS. Patients who survive are at high risk of developing treatment-related toxicity, mainly disabling neurotoxicity, raising the question of how to balance therapy intensification with the control of side effects. Recent therapeutic progress and effective international cooperation have resulted in a significantly improved outcome over the past 2 decades, with a higher proportion of patients receiving treatment with curative intent. Actual front-line therapy consists of high-dose methotrexate-based polychemotherapy. Evidence supporting the addition of an alkylating agent and rituximab is growing, and a recent randomized trial demonstrated that the combination of methotrexate, cytarabine, thiotepa, and rituximab (MATRix regimen) is associated with a significantly better overall survival. Whole-brain irradiation and high-dose chemotherapy supported by autologous stem cell transplantation are 2 effective consolidation strategies in patients with a disease responsive to induction chemotherapy. Different strategies such as alkylating maintenance, conservative radiotherapy, and nonmyeloablative consolidation are being addressed in large randomized trials and a more accurate knowledge of the molecular and biological characteristics of this malignancy are leading to the development of target therapies in refractory/relapsing patients, with the overall aim to incorporate new active agents as part of first-line treatment. The pros and cons of these approaches together with the best candidates for each therapy are outlined in this article.
Collapse
Affiliation(s)
- Andrés José María Ferreri
- Unit of Lymphoid Malignancies, Department of Oncohematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| |
Collapse
|
18
|
Role of radiation therapy in primary central nervous system lymphoma. J Neurooncol 2017; 135:629-638. [DOI: 10.1007/s11060-017-2616-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 09/04/2017] [Indexed: 12/18/2022]
|
19
|
High-dose chemotherapy and autologous stem cell transplantation for primary central nervous system lymphoma: a multi-centre retrospective analysis from the United Kingdom. Bone Marrow Transplant 2017; 52:1268-1272. [DOI: 10.1038/bmt.2017.101] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 03/29/2017] [Accepted: 04/25/2017] [Indexed: 12/21/2022]
|
20
|
DeFilipp Z, Li S, El-Jawahri A, Armand P, Nayak L, Wang N, Batchelor TT, Chen YB. High-dose chemotherapy with thiotepa, busulfan, and cyclophosphamide and autologous stem cell transplantation for patients with primary central nervous system lymphoma in first complete remission. Cancer 2017; 123:3073-3079. [PMID: 28369839 DOI: 10.1002/cncr.30695] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 03/07/2017] [Accepted: 03/08/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND High-dose chemotherapy and autologous stem cell transplantation (HDC-ASCT) is a therapeutic option for patients with primary central nervous system lymphoma (PCNSL). To the authors' knowledge, data are limited regarding its use among patients in first complete remission (CR1) with the CNS-directed conditioning regimen of thiotepa, busulfan, and cyclophosphamide (TBC). METHODS A retrospective analysis of patients with PCNSL in CR1 who underwent transplantation using a TBC-based conditioning regimen at 2 academic institutions was performed. RESULTS Forty-six consecutive patients who underwent HDC-ASCT while in CR1 were identified. The most common induction regimen was high-dose methotrexate plus temozolomide and rituximab (59%). No patients received whole-brain radiotherapy. A total of 40 patients (87%) received cytarabine before undergoing ASCT as either induction intensification, early consolidation therapy, or mobilization. The median time from diagnosis to transplantation was 6 months (range, 4-15 months). The median age of the patients at the time of transplantation was 59 years (range, 27-69 years). With a median follow-up of 2.7 years after ASCT (range, 6 months-7.5 years), the Kaplan-Meier estimates of 2-year overall survival and progression-free survival were 95% (95% confidence interval [95% CI], 80%-99%) and 92% (95% CI, 77%-97%), respectively. The most common toxicities were severe mucositis (35%) and bacterial infections occurring within 100 days of transplantation (35%). The estimated 2-year nonrecurrence mortality rate was 2.9% (95% CI, 0.2%-13.4%). CONCLUSIONS HDC-ASCT with a CNS-directed conditioning regimen such as TBC should be considered for patients with PCNSL who are in CR1 because this approach is associated with encouraging disease control and survival in this select patient population. Cancer 2017;123:3073-79. © 2017 American Cancer Society.
Collapse
Affiliation(s)
- Zachariah DeFilipp
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Shuli Li
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Areej El-Jawahri
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Philippe Armand
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lakshmi Nayak
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Nancy Wang
- Stephen E. and Catherine Pappas Center for Neuro-Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Tracy T Batchelor
- Stephen E. and Catherine Pappas Center for Neuro-Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Yi-Bin Chen
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
21
|
Carmustine replacement in intensive chemotherapy preceding reinjection of autologous HSCs in Hodgkin and non-Hodgkin lymphoma: a review. Bone Marrow Transplant 2017; 52:941-949. [DOI: 10.1038/bmt.2016.340] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 11/08/2016] [Accepted: 11/16/2016] [Indexed: 11/08/2022]
|
22
|
Kerbauy MN, Moraes FY, Lok BH, Ma J, Kerbauy LN, Spratt DE, Santos FPS, Perini GF, Berlin A, Chung C, Hamerschlak N, Yahalom J. Challenges and opportunities in primary CNS lymphoma: A systematic review. Radiother Oncol 2017; 122:352-361. [PMID: 28104300 DOI: 10.1016/j.radonc.2016.12.033] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 12/29/2016] [Accepted: 12/29/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Historically, high-dose methotrexate (HD-MTX) plus consolidation chemotherapy and/or whole brain radiotherapy (WBRT) has been the gold standard on Primary Central Nervous System Lymphoma (PCNSL) management. We sought to examine and summarize the data, on clinical trial (CT) setting, investigating multi-modality treatment to PCNSL. METHODS We performed a systematic review of electronic databases (Medline, EMBASE, Cochrane Database and clinicaltrials.gov) and a manual search to identify original PCNSL phase 2 and phase 3 CT from the last 10years. After a 4stage Prisma based selection process, 32 published (3 Randomized CT and 29 phases 2 CT) studies ultimately were selected for review. Four ongoing clinical trials found on clinicaltrial.gov were reviewed. Two investigators reviewed titles, abstracts, and articles independently. Two investigators abstracted data sequentially and evaluated each study independently. FINDINGS Treatment of PCNSL requires a multidisciplinary approach. HD-MTX represents the most accepted standard of care induction therapy for newly diagnosed PCNSL. When HD-MTX is given with WBRT for consolidation delayed neurotoxicity can be an important complication, particularly in elderly patients. Studies have suggested that WBRT may be deferred until relapse without compromising survival and deferring WBRT may be the best approach in elderly patients. Results from dose-reduced WBRT and consolidative HD-Ara-C are encouraging. High-dose chemotherapy in combination with autologous stem cell transplantation (HDC-ASCT) as chemotherapy alone has emerged as an important consolidative treatment for selected population. The optimal salvage therapy is still to be defined. CONCLUSION WBRT for consolidation is a well-studied modality; however emerging options to selected population such as HDC-ASCT, dose-reduced WBRT or chemotherapy alone are associated with similar survival outcome and less neurotoxicity in selected series. Ongoing and future clinical trials will better define the best approach on this rare disease.
Collapse
Affiliation(s)
- Mariana N Kerbauy
- Department of Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Fabio Y Moraes
- Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo, Brazil; Department of Radiation Oncology, University of Toronto, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.
| | - Benjamin H Lok
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Jennifer Ma
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Lucila N Kerbauy
- Department of Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan Medical Center, Ann Arbor, USA
| | - Fabio P S Santos
- Department of Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Guilherme F Perini
- Department of Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Caroline Chung
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, USA
| | - Nelson Hamerschlak
- Department of Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Joachim Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| |
Collapse
|
23
|
Lee MY, Kim HS, Lee JY, Lim SH, Kang ES, Ko YH, Kim SJ, Kim WS. Efficacy and feasibility of autologous stem cell transplantation in patients with diffuse large B‑cell lymphoma with secondary central nervous system involvement. Int J Hematol 2016; 102:678-88. [PMID: 26493833 DOI: 10.1007/s12185-015-1874-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 09/09/2015] [Accepted: 09/18/2015] [Indexed: 10/22/2022]
Abstract
Secondary central nervous system (CNS) involvement is a fatal complication of diffuse large B-cell lymphoma (DLBCL). We evaluated the efficacy and feasibility of high-dose chemotherapy containing busulfan and thiotepa followed by autologous stem cell transplantation (HDC-ASCT) in DLBCL with secondary CNS involvement. Thirty-one patients with secondary CNS involvement including CNS involvement at diagnosis (n = 9), isolated CNS relapse (n = 14), and CNS involvement with systemic disease progression or relapse (n = 8) were selected and analyzed from our prospective cohorts. Of these, 12 patients, including seven with isolated CNS relapse, successfully completed HDC-ASCT without engraftment failure or transplantation-related mortality. After ASCT, six patients were alive; however, three patients experienced post-transplantation relapse. With a median follow-up of 29 months after secondary CNS involvement, the median overall survival of 31 patients was 9 months (95% CI 5–12 months). The survival outcomes of patients who had undergone HDC-ASCT were significantly better than those of patients who did not (p < 0.01). Accordingly, patients with isolated CNS relapse tended to have a longer survival outcome than other cases. Our results suggest that HDC-ASCT may provide survival benefits in DLBCL patients with secondary CNS involvement, especially in case of isolated CNS relapse.
Collapse
|
24
|
Illerhaus G, Kasenda B, Ihorst G, Egerer G, Lamprecht M, Keller U, Wolf HH, Hirt C, Stilgenbauer S, Binder M, Hau P, Edinger M, Frickhofen N, Bentz M, Möhle R, Röth A, Pfreundschuh M, von Baumgarten L, Deckert M, Hader C, Fricker H, Valk E, Schorb E, Fritsch K, Finke J. High-dose chemotherapy with autologous haemopoietic stem cell transplantation for newly diagnosed primary CNS lymphoma: a prospective, single-arm, phase 2 trial. LANCET HAEMATOLOGY 2016; 3:e388-97. [PMID: 27476790 DOI: 10.1016/s2352-3026(16)30050-3] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 05/19/2016] [Accepted: 05/20/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND High-dose methotrexate-based chemotherapy is standard for primary CNS lymphoma, but most patients relapse. High-dose chemotherapy with autologous stem cell transplantation (HCT-ASCT) is supposed to overcome the blood-brain barrier and eliminate residual disease in the CNS. We aimed to investigate the safety and efficacy of HCT-ASCT in patients with newly diagnosed primary CNS lymphoma. METHODS In this prospective, single-arm, phase 2 trial, we recruited patients aged 18-65 years with newly diagnosed primary CNS lymphoma and immunocompetence, with no limitation on clinical performance status, from 15 hospitals in Germany. Patients received five courses of intravenous rituximab 375 mg/m(2) (7 days before first high-dose methotrexate course and then every 10 days) and four courses of intravenous high-dose methotrexate 8000 mg/m(2) (every 10 days) and then two courses of intravenous rituximab 375 mg/m(2) (day 1), cytarabine 3 g/m(2) (days 2 and 3), and thiotepa 40 mg/m(2) (day 3). 3 weeks after the last course, patients commenced intravenous HCT-ASCT (rituximab 375 mg/m(2) [day 1], carmustine 400 mg/m(2) [day 2], thiotepa 2 × 5 mg/kg [days 3 and 4], and infusion of stem cells [day 7]), irrespective of response status after induction. We restricted radiotherapy to patients without complete response after HCT-ASCT. The primary endpoint was complete response at day 30 after HCT-ASCT in all registered eligible patients who received at least 1 day of study treatment. This trial is registered at ClinicalTrials.gov, number NCT00647049. FINDINGS Between Jan 18, 2007, and May 23, 2011, we recruited 81 patients, of whom two (2%) were excluded, therefore we included 79 (98%) patients in the analysis. All patients started induction treatment; 73 (92%) commenced HCT-ASCT. 61 (77·2% [95% CI 66·1-86·6]) patients achieved a complete response. During induction treatment, the most common grade 3 toxicity was anaemia (37 [47%]) and the most common grade 4 toxicity was thrombocytopenia (50 [63%]). During HCT-ASCT, the most common grade 3 toxicity was fever (50 [68%] of 73) and the most common grade 4 toxicity was leucopenia (68 [93%] of 73). We recorded four (5%) treatment-related deaths (three [4%] during induction and one [1%] 4 weeks after HCT-ASCT). INTERPRETATION HCT-ASCT with thiotepa and carmustine is an effective treatment option in young patients with newly diagnosed primary CNS lymphoma, but further comparative studies are needed. FUNDING University Hospital Freiburg and Amgen.
Collapse
Affiliation(s)
- Gerald Illerhaus
- Department of Haematology/Oncology and Palliative Care, Klinikum Stuttgart, Stuttgart, Germany; Department of Hematology, Oncology, and Stem-Cell Transplantation, University Medical Hospital and Faculty of Medicine, Albert-Ludwigs University, Freiburg, Germany.
| | - Benjamin Kasenda
- Department of Haematology/Oncology and Palliative Care, Klinikum Stuttgart, Stuttgart, Germany; Department of Medicine, Royal Marsden Hospital, London, UK
| | - Gabriele Ihorst
- Clinical Trials Unit, University of Freiburg Medical Centre, Freiburg, Germany
| | - Gerlinde Egerer
- Department of Haematology and Oncology, Heidelberg University, Heidelberg, Germany
| | - Monika Lamprecht
- Department of Internal Medicine II, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Ulrich Keller
- III Medical Department, Technische Universität München, Munich, Germany
| | - Hans-Heinrich Wolf
- Department of Haematology and Oncology, University Hospital Halle, Halle, Germany
| | - Carsten Hirt
- Hematology and Oncology, Clinic for Internal Medicine C, University of Greifswald, Greifswald, Germany
| | | | - Mascha Binder
- Department of Internal Medicine II, Oncology, Hematology, and Bone Marrow Transplantation with section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Hau
- Department of Neurology and Wilhelm Sander-NeuroOncology Unit, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Edinger
- Department of Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Norbert Frickhofen
- Department of Haematology and Oncology, HELIOS Dr Horst Schmidt Kliniken, Wiesbaden, Germany
| | - Martin Bentz
- Medizinische Klinik, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Robert Möhle
- Department of Haematology and Oncology, University of Tübingen, Tübingen, Germany
| | - Alexander Röth
- Department of Haematology, Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | | | | | - Martina Deckert
- Institute of Neuropathology, University Hospital of Cologne, Cologne, Germany
| | - Claudia Hader
- Department of Neuroradiology, University Hospital Freiburg, Freiburg, Germany
| | - Heidi Fricker
- Department of Hematology, Oncology, and Stem-Cell Transplantation, University Medical Hospital and Faculty of Medicine, Albert-Ludwigs University, Freiburg, Germany
| | - Elke Valk
- Department of Haematology/Oncology and Palliative Care, Klinikum Stuttgart, Stuttgart, Germany
| | - Elisabeth Schorb
- Department of Hematology, Oncology, and Stem-Cell Transplantation, University Medical Hospital and Faculty of Medicine, Albert-Ludwigs University, Freiburg, Germany
| | - Kristina Fritsch
- Department of Hematology, Oncology, and Stem-Cell Transplantation, University Medical Hospital and Faculty of Medicine, Albert-Ludwigs University, Freiburg, Germany
| | - Jürgen Finke
- Department of Hematology, Oncology, and Stem-Cell Transplantation, University Medical Hospital and Faculty of Medicine, Albert-Ludwigs University, Freiburg, Germany
| |
Collapse
|
25
|
The role of autologous stem cell transplantation in primary central nervous system lymphoma. Blood 2016; 127:1642-9. [PMID: 26834241 DOI: 10.1182/blood-2015-10-636340] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 01/27/2016] [Indexed: 12/17/2022] Open
Abstract
Primary central nervous system lymphoma (PCNSL) treatment includes 2 phases: induction and consolidation. Induction consists of high-dose methotrexate-based polychemotherapy for most patients, with regimen and dose variations according to patient characteristics and country. Several strategies have been proposed for the consolidation phase, with whole-brain irradiation (WBRT) the most common. However, some authorities recommend avoiding WBRT because of its related risk of severe neurotoxicity. The most relevant alternatives to WBRT are high-dose chemotherapy supported by autologous stem cell transplantation (HDC/ASCT) or nonmyeloablative chemotherapy, the former supported by several single-arm phase 2 trials. Moreover, HDC/ASCT is the only strategy that is assessed in comparison with WBRT in ongoing randomized trials. The rationale for using HDC/ASCT in PCNSL patients is based on the fact that the delivery of high doses could achieve therapeutic drug concentrations in the brain and cerebrospinal fluid, and that non-cross-resistant drugs used for conditioning (eg, alkylating agents) could favor elimination of residual chemoresistant lymphoma cells. Worldwide experience with HDC/ASCT is limited to few single-arm phase 2 trials, but overall results are encouraging, mostly when thiotepa-containing conditioning regimens are used, both in newly diagnosed and relapsed patients. However, several questions on efficacy and feasibility of HDC/ASCT, as well as the best candidates for this strategy, the optimal conditioning regimen, the best time for response assessment, and acute and late effects, remain unanswered. In this review, we critically analyze reported studies on HDC/ASCT in PCNSL and discuss its current role and future perspectives in treating this aggressive malignancy.
Collapse
|
26
|
Oh DH, Chua N, Street L, Stewart DA. Treatment of patients with secondary central nervous system lymphoma with high-dose busulfan/thiotepa-based conditioning and autologous stem cell transplant. Leuk Lymphoma 2015; 57:28-33. [DOI: 10.3109/10428194.2015.1026901] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
27
|
Bojic M, Berghoff AS, Troch M, Agis H, Sperr WR, Widhalm G, Wöhrer A, Kalhs P, Preusser M, Rabitsch W. Haematopoietic stem cell transplantation for treatment of primary CNS lymphoma: single-centre experience and literature review. Eur J Haematol 2015; 95:75-82. [DOI: 10.1111/ejh.12482] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Marija Bojic
- Unit for Bone Marrow and Stem Cell Transplantation; Department of Medicine I; Medical University of Vienna; Vienna Austria
| | - Anna S. Berghoff
- Department of Medicine I; Clinical Division of Oncology; Medical University of Vienna; Vienna Austria
| | - Marlene Troch
- Unit for Bone Marrow and Stem Cell Transplantation; Department of Medicine I; Medical University of Vienna; Vienna Austria
| | - Hermine Agis
- Department of Medicine I; Clinical Division of Oncology; Medical University of Vienna; Vienna Austria
| | - Wolfgang R. Sperr
- Department of Medicine I; Clinical Division of Haematology and Hemostaseology; Medical University of Vienna; Vienna Austria
| | - Georg Widhalm
- Department of Neurosurgery; Medical University of Vienna; Vienna Austria
| | - Adelheid Wöhrer
- Institute of Neurology; Medical University of Vienna; Vienna Austria
| | - Peter Kalhs
- Unit for Bone Marrow and Stem Cell Transplantation; Department of Medicine I; Medical University of Vienna; Vienna Austria
| | - Matthias Preusser
- Department of Medicine I; Clinical Division of Oncology; Medical University of Vienna; Vienna Austria
| | - Werner Rabitsch
- Unit for Bone Marrow and Stem Cell Transplantation; Department of Medicine I; Medical University of Vienna; Vienna Austria
| |
Collapse
|
28
|
Kasenda B, Schorb E, Fritsch K, Finke J, Illerhaus G. Prognosis after high-dose chemotherapy followed by autologous stem-cell transplantation as first-line treatment in primary CNS lymphoma—a long-term follow-up study. Ann Oncol 2015; 26:608-11. [DOI: 10.1093/annonc/mdv002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
|
29
|
Bellefqih S, Mezouri I, Khalil J, Bazine A, Diakité A, El Kacimi H, Kebdani T, Benjaafar N. [Primary central nervous lymphoma: what is the role for radiotherapy?]. Cancer Radiother 2014; 18:685-92. [PMID: 25451676 DOI: 10.1016/j.canrad.2014.06.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 05/23/2014] [Accepted: 06/06/2014] [Indexed: 10/24/2022]
Abstract
Primary central nervous system lymphoma is a rare extranodal form of non-Hodgkin lymphoma with an aggressive course and unsatisfactory outcome. Historically, whole-brain radiotherapy was the sole treatment for patients with primary central nervous system lymphoma, with high response rates but typically, this did not result in long-lasting remissions. The addition of high-dose methotrexate-based chemotherapy regimens to whole-brain radiotherapy has significantly improved patients' outcome, but has resulted in a higher incidence of late neurotoxicity, particularly in elderly patients. To date, the role of consolidation radiotherapy is controversial, and some investigators have developed alternative strategies aiming at avoiding immediate irradiation or using a reduced radiotherapy dose to the whole-brain with promising results.
Collapse
Affiliation(s)
- S Bellefqih
- Service de radiothérapie, Institut national d'oncologie, avenue Allal El-Fassi, 10100 Rabat, Maroc; Université Mohammed-V Souissi, 10100 Rabat, Maroc.
| | - I Mezouri
- Service de radiothérapie, Institut national d'oncologie, avenue Allal El-Fassi, 10100 Rabat, Maroc; Université Mohammed-V Souissi, 10100 Rabat, Maroc
| | - J Khalil
- Service de radiothérapie, Institut national d'oncologie, avenue Allal El-Fassi, 10100 Rabat, Maroc; Université Mohammed-V Souissi, 10100 Rabat, Maroc
| | - A Bazine
- Service de radiothérapie, Institut national d'oncologie, avenue Allal El-Fassi, 10100 Rabat, Maroc; Université Mohammed-V Souissi, 10100 Rabat, Maroc
| | - A Diakité
- Service de radiothérapie, Institut national d'oncologie, avenue Allal El-Fassi, 10100 Rabat, Maroc; Université Mohammed-V Souissi, 10100 Rabat, Maroc
| | - H El Kacimi
- Service de radiothérapie, Institut national d'oncologie, avenue Allal El-Fassi, 10100 Rabat, Maroc; Université Mohammed-V Souissi, 10100 Rabat, Maroc
| | - T Kebdani
- Service de radiothérapie, Institut national d'oncologie, avenue Allal El-Fassi, 10100 Rabat, Maroc; Université Mohammed-V Souissi, 10100 Rabat, Maroc
| | - N Benjaafar
- Service de radiothérapie, Institut national d'oncologie, avenue Allal El-Fassi, 10100 Rabat, Maroc; Université Mohammed-V Souissi, 10100 Rabat, Maroc
| |
Collapse
|
30
|
Milgrom SA, Yahalom J. The role of radiation therapy in the management of primary central nervous system lymphoma. Leuk Lymphoma 2014; 56:1197-204. [PMID: 25219590 DOI: 10.3109/10428194.2014.961014] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Primary central nervous system lymphoma (PCNSL) is an aggressive neoplasm with a poor prognosis. Early studies of whole brain radiation therapy (WBRT) alone revealed a robust initial response but high rates of local recurrence with long-term follow-up. The addition of high-dose methotrexate (HDMTX)-based chemotherapy improved the durability of disease control. However, delayed neurotoxicity emerged as an important complication, mainly in elderly patients. Therefore, researchers have investigated eliminating WBRT or reducing its dose. Multiple studies of chemotherapy alone have demonstrated inferior disease control. On the other hand, a phase III trial reported that WBRT may be deferred until relapse without compromising survival; however, this trial is fraught with flaws. A recent study of immunochemotherapy and dose-reduced WBRT demonstrated excellent outcomes. Currently, this regimen is being studied in a multi-institutional trial by the Radiation Therapy Oncology Group. WBRT maintains an important position in the armamentarium against PCNSL. This article aims to describe its evolving role.
Collapse
Affiliation(s)
- Sarah A Milgrom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center , New York, NY , USA
| | | |
Collapse
|
31
|
Chen YB, Batchelor T, Li S, Hochberg E, Brezina M, Jones S, Del Rio C, Curtis M, Ballen KK, Barnes J, Chi AS, Dietrich J, Driscoll J, Gertsner ER, Hochberg F, LaCasce AS, McAfee SL, Spitzer TR, Nayak L, Armand P. Phase 2 trial of high-dose rituximab with high-dose cytarabine mobilization therapy and high-dose thiotepa, busulfan, and cyclophosphamide autologous stem cell transplantation in patients with central nervous system involvement by non-Hodgkin lymphoma. Cancer 2014; 121:226-33. [PMID: 25204639 DOI: 10.1002/cncr.29023] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 06/16/2014] [Accepted: 06/19/2014] [Indexed: 01/21/2023]
Abstract
BACKGROUND High-dose thiotepa, busulfan, and cyclophosphamide (TBC) with autologous stem cell transplantation (ASCT) has been used in patients with central nervous system (CNS) involvement by non-Hodgkin lymphoma (NHL). Despite limited penetration into the CNS, rituximab is active in primary CNS NHL. Therefore, high-dose rituximab was combined with TBC for ASCT in patients with CNS NHL. METHODS A single-arm phase 2 trial using high-dose rituximab with cytarabine for stem cell mobilization followed by high-dose rituximab combined with thiotepa, busulfan, and cyclophosphamide (R-TBC) for ASCT was conducted. Doses of rituximab at 1000 mg/m(2) were given on days 1 and 8 of mobilization and on days -9 and -2 of TBC. The primary endpoint was efficacy. RESULTS Thirty patients were enrolled. Eighteen patients had primary CNS NHL (12 with complete remission (CR)/first partial remission (PR1) and 6 with CR/PR2), and 12 patients had secondary CNS lymphoma (5 with CR/PR1 and 7 with CR/PR2 or beyond). All patients were in partial or complete remission. Twenty-nine patients proceeded to R-TBC ASCT. Two patients developed significant neurotoxicity. The 100-day nonrelapse mortality rate was 0%, and 1 patient died because of nonrelapse causes 5 months after ASCT. For all patients, at a median follow-up of 24 months (range, 12-40 months), the estimated 2-year progression-free survival rate was 81% (95% confidence interval, 59%-92%), and the 2-year overall survival rate was 93% (95% confidence interval, 76%-98%). There were no relapses or deaths among the 18 patients with primary CNS lymphoma. CONCLUSIONS For patients with CNS involvement by B-cell NHL and especially for patients with primary CNS NHL, R-TBC ASCT shows encouraging activity and merits further study.
Collapse
Affiliation(s)
- Yi-Bin Chen
- Bone Marrow Transplant Unit, Massachusetts General Hospital, Boston, Massachusetts
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Welch MR, Sauter CS, Matasar MJ, Faivre G, Weaver SA, Moskowitz CH, Omuro AM. Autologous stem cell transplant in recurrent or refractory primary or secondary central nervous system lymphoma using thiotepa, busulfan and cyclophosphamide. Leuk Lymphoma 2014; 56:361-7. [PMID: 24745937 DOI: 10.3109/10428194.2014.916800] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The prognosis for patients with central nervous system (CNS) involvement by recurrent or refractory diffuse large B-cell lymphoma is poor, with overall survival (OS) of 4-10 months. High-dose chemotherapy (HDC) and autologous stem cell transplant (ASCT) is a potential treatment alternative. We reviewed patients with recurrent primary (PCNSL) or secondary (SCNSL) CNS lymphoma referred for consolidation HDC-ASCT utilizing thiotepa, busulfan and cyclophosphamide (TBC). Among the 17 patients included, all had achieved a complete remission after salvage induction chemotherapy, which incorporated methotrexate in 82% of patients. Two patients failed stem-cell harvesting and 15 (88%) underwent transplant. The estimated 3-year progression-free survival (PFS) and OS were both 93% (95% confidence interval 61-99%). Median PFS and OS were not reached. There was no transplant-related mortality. These results confirm the benefit of TBC followed by ASCT in select patients with recurrent PCNSL and suggest a potential role for the regimen in those with SCNSL. Further investigation is warranted.
Collapse
Affiliation(s)
- Mary R Welch
- Department of Neurology, Memorial Sloan-Kettering Cancer Center , New York, NY , USA
| | | | | | | | | | | | | |
Collapse
|
33
|
Upfront autologous stem-cell transplantation with melphalan, cyclophosphamide, etoposide, and dexamethasone (LEED) in patients with newly diagnosed primary central nervous system lymphoma. Int J Hematol 2014; 100:152-8. [PMID: 24947495 DOI: 10.1007/s12185-014-1608-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 05/22/2014] [Accepted: 05/28/2014] [Indexed: 10/25/2022]
Abstract
Treatment of primary central nervous system lymphoma (PCNSL) improved in recent years. However, the high neurotoxicity and low survival rates associated with this condition remain unresolved. We report 13 consecutive patients with PCNSL for whom upfront melphalan, cyclophosphamide, etoposide, and dexamethasone (known as LEED) followed by autologous stem-cell transplantation (ASCT) was planned at the Anjo Kosei Hospital. All patients were pathologically diagnosed with diffuse large B-cell lymphoma and were negative for human immunodeficiency virus. All patients were to receive three cycles of high-dose methotrexate-based induction chemotherapy, two cycles of high-dose AraC-based chemotherapy, and LEED followed by ASCT. All 13 patients achieved a partial response, and the 3-year overall survival (OS) rate was 76.2 %. Seven of the 13 patients were alive at the last follow-up, without any adverse events, including neurotoxicity. Six of the 13 (46.2 %) patients underwent ASCT and the 3-year OS rate was 80.0 %. Although this study included only a limited number of patients, these preliminary signs of efficacy and tolerability merit further consideration. To make further improvements in survival, the rate of patients undergoing ASCT should be increased. Other prospective studies involving greater numbers of patients are required to confirm these findings.
Collapse
|
34
|
Kokolo MB, Fergusson D, O'Neill J, Tay J, Tinmouth AT, Stewart D, Bredeson C. Effectiveness and safety of thiotepa as conditioning treatment prior to stem cell transplant in patients with central nervous system lymphoma. Leuk Lymphoma 2014; 55:2712-20. [PMID: 24491026 DOI: 10.3109/10428194.2014.889825] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Thiothepa is a cytostatic agent used in managing solid malignancies, and also as conditioning treatment before hematopoietic stem cell transplantation [HSCT]. This systematic review summarizes evidence on its effectiveness and safety, in patients with central nervous system [CNS] lymphoma. METHODS We searched 3 databases for clinical studies. When feasible, we performed meta-analyses. RESULTS We identified 13 eligible studies, none of which with a priori controls. So data synthesis focused on the 226 patients who received thiotepa. Based on pooled estimates, 75.9% of thiotepa-treated patients achieved a complete remission (95% confidence interval [CI] = 67.5-82.8), and 61.7% had a progression-free survival for up to 125 months post-treatment (95% CI = 49.4-72.7). However, 25.5% relapsed, 24.6% experienced infection, and 13.2% experienced neurotoxicity. DISCUSSION Thiotepa-based conditioning followed by HSCT may be effective in most CNS lymphoma patients, with a manageable toxicity profile. But adequately powered randomized trials are needed to better evaluate and isolate the effects of thiotepa.
Collapse
|
35
|
Wang XX, Huang HQ, Bai B, Cai QQ, Cai QC, Gao Y, Xia YF, Xia ZJ, Jiang WQ. Clinical outcomes of patients with newly diagnosed primary central nervous system lymphoma are comparable on treatment with high-dose methotrexate plus temozolomide and with high-dose methotrexate plus cytarabine: a single-institution experience. Leuk Lymphoma 2014; 55:2497-501. [PMID: 24605911 DOI: 10.3109/10428194.2014.889823] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The role of temozolomide in untreated PCNSL patients has not yet been clearly defined. The purpose of this study was to compare the efficacy and toxicity of MT and MC chemotherapy in this population. A total of 41 consecutive patients were enrolled from March 2001 to July 2011. The ORR and CRR for MT vs. MC were 70% vs. 61.9% and 45% vs. 38.1% on ITT basis, (p = NS); 73.7% vs. 68.4% and 47.4% vs. 42.1% on PP basis, respectively (p = NS). Grade 3-4 hematological toxicities were more common in MC than in MT group (85.7% vs. 15%, p = 0.0001). One treatment-related death was observed in each group. The 5-year PFS and OS of MT (36% and 62.2%) were comparable to MC (32.6% and 46.7%), (p = NS). In summary, our preliminary results suggest that MT combination may be a simplified and effective regimen comparable to MC for newly diagnosed PCNSL.
Collapse
Affiliation(s)
- Xiao-xiao Wang
- Departments of Medical Oncology, Sun Yat-sen University Cancer Center
| | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Citterio G, María Ferreri AJ, Reni M. Current uses of radiation therapy in patients with primary CNS lymphoma. Expert Rev Anticancer Ther 2014; 13:1327-37. [DOI: 10.1586/14737140.2013.851007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Giovanni Citterio
- Department of Onco-Hematology, San Raffaele Scientific Institute,
Milano, Italy
| | | | - Michele Reni
- Medical Oncology Unit, Department of Oncology,
San Raffaele Scientific Institute, via Olgettina 60, Milano 20132, Italy
| |
Collapse
|
37
|
Park SJ, Yoon DH, Kim S, Lee K, Park JS, Jang S, Park CJ, Chi HS, Park CS, Huh J, Suh C. Remobilization of hematopoietic stem cells with high-dose methotrexate and cytarabine in patients with non-Hodgkin's lymphoma and multiple myeloma after failure to mobilize with chemotherapy and cytokines. Transfusion 2013; 54:509-15. [PMID: 23800093 DOI: 10.1111/trf.12314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 05/04/2013] [Accepted: 05/09/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND High-dose chemotherapy supported by autologous stem cell transplantation is an effective treatment for patients with relapsed or refractory non-Hodgkin's lymphomas (NHLs) and fit patients with multiple myeloma (MM). However, failure rates of hematopoietic stem cell mobilization are estimated to be between 5 and 30%, respectively. Thus, we investigated the efficacy of the combination chemotherapy of high-dose methotrexate (MTX) and cytarabine with granulocyte-colony-stimulating factor (G-CSF) as a remobilization method in those who failed a prior mobilization and collection with chemotherapy and G-CSF. STUDY DESIGN AND METHODS Mobilization failure was defined as a collection of fewer than 5 × 10(6) CD34+ cells after three to five apheresis procedures. MTX (3500 mg/m(2) in a 120-min infusion) on Day 1 and cytarabine (3000 mg/m(2) infusion for 120 min) on Day 4 and Day 5 were followed by G-CSF (10 μg/kg daily). RESULTS A total of eight patients (six NHL and two MM; median age, 55 years) who had failed in prior mobilization with conventional chemotherapy and G-CSF underwent the second mobilization as described in the method. Successful collection of CD34+ cells (> 5 × 10(6) /kg) was achieved in six patients (75%) with three to five apheresis procedures. The total yield of CD34+ cells/kg body weight was 6.28 × 10(6) /kg (median; range, 1.53 × 10(6) -10.09 × 10(6) /kg). CONCLUSIONS This preliminary result warrants further investigation of high-dose MTX and cytarabine plus G-CSF as a means to remobilize stem cells in those with prior failure to mobilize stem cells with chemotherapy and G-CSF.
Collapse
Affiliation(s)
- Seong Joon Park
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea; Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea; Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Abstract
Primary CNS lymphoma (PCNSL) is a rare lymphoma that is confined to the CNS, with low tendency for systemic dissemination and a relatively aggressive course. Outcome in patients with PCNSL is often poor. Owing to its low incidence, current knowledge about optimal treatment of PCNSL is fragmentary. Chemotherapy regimens based on high-dose methotrexate are currently standard treatment for all patients with PCNSL who can tolerate such drugs. Whole-brain radiotherapy alone can lead to remission in up to 90% of patients, but often results in poor long-term disease control when given alone, and in delayed neurotoxicity when given after high-dose methotrexate. In this Review, we describe current approaches to diagnosis and treatment of PCNSL, and discuss novel therapeutic approaches that are currently in development, such as the use of rituximab and high-dose chemotherapy followed by autologous stem-cell transplantation. The possible use of intrathecal and intraventricular chemotherapy, optimal salvage treatment, and specific treatment approaches in elderly, paediatric and immunocompromised patients, are also considered.
Collapse
Affiliation(s)
- Agnieszka Korfel
- Department of Haematology and Oncology, Charité-Campus Benjamin Franklin, University Medicine Berlin, Hindenburgdamm 30, 12200 Berlin, Germany.
| | | |
Collapse
|
39
|
Management of Elderly Patients with Primary Central Nervous System Lymphoma. Curr Neurol Neurosci Rep 2013; 13:344. [DOI: 10.1007/s11910-013-0344-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
40
|
Schäfer N, Glas M, Herrlinger U. Primary CNS lymphoma: a clinician's guide. Expert Rev Neurother 2013; 12:1197-206. [PMID: 23082736 DOI: 10.1586/ern.12.120] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Primary CNS lymphoma is a high malignant disease of the brain which can lead rapidly to death if diagnosis and/or the start of treatment is delayed. The age at time of diagnosis is a strong factor influencing prognosis so that in younger patients <65 years of age long-term survival may be achieved in a substantial percentage of patients, while in elderly patients long-term survival is seen much more rarely. First-line therapy consists of high-dose methotrexate-based (poly)chemotherapy. This review provides an overview of clinical presentation, steps to diagnosis, detailed information about current treatment concepts and specific information for particular clinical situations.
Collapse
Affiliation(s)
- Niklas Schäfer
- Division of Clinical Neurooncology, Department of Neurology, University Hospital of Bonn, Bonn, Germany
| | | | | |
Collapse
|
41
|
Gregory G, Arumugaswamy A, Leung T, Chan KL, Abikhair M, Tam C, Bajel A, Cher L, Grigg A, Ritchie D, Opat S. Rituximab is associated with improved survival for aggressive B cell CNS lymphoma. Neuro Oncol 2013; 15:1068-73. [PMID: 23502429 DOI: 10.1093/neuonc/not032] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The optimal treatment strategy in patients with aggressive B cell central nervous system lymphoma suitable to receive intensive therapy is unknown. The benefit of incorporating rituximab in systemic therapy remains unclear. We performed a retrospective study examining the impact of rituximab in the context of concomitant therapies, including methotrexate, cytarabine, and radiotherapy, in patients treated with curative intent at 4 university teaching hospitals during 1996-2011. METHODS A retrospective study of CNS lymphoma cases treated at the participating institutions was performed in accordance with institutional ethical guidelines. Patients were included if they received a diagnosis of primary diffuse large B cell lymphoma of the CNS, were HIV negative, and were treated with curative intent. RESULTS One hundred twenty patients aged 21-81 years were identified. Rituximab recipients and nonrecipients were similar, except for rituximab recipients being more likely to have received a diagnosis after 2004. The median follow-up of surviving patients was 30 months. The 5-year overall survival was 46%. Univariate analysis revealed age ≤60 years, ECOG performance status ≤1, normal lactate dehydrogenase, diagnosis after 2004, and treatment with cytarabine and rituximab as predictive of favorable overall survival. Multivariate analysis identified age to be an independent predictor of overall survival, with a trend toward improved survival from the other variables that were significant in univariate analyses. CONCLUSIONS In this retrospective analysis, the addition of rituximab to high-dose methotrexate-based chemotherapy in patients with aggressive B cell CNS lymphoma was associated with improved overall survival. Further studies are underway to prospectively validate these findings.
Collapse
Affiliation(s)
- Gareth Gregory
- Inter-hospital Multi-institution Project Alliance and Collaboration Taskforce, Monash Medical Centre, Clayton, Australia.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Mappa S, Marturano E, Licata G, Frezzato M, Frungillo N, Ilariucci F, Stelitano C, Ferrari A, Sorarù M, Vianello F, Baldini L, Proserpio I, Foppoli M, Assanelli A, Reni M, Caligaris-Cappio F, Ferreri AJM. Salvage chemoimmunotherapy with rituximab, ifosfamide and etoposide (R-IE regimen) in patients with primary CNS lymphoma relapsed or refractory to high-dose methotrexate-based chemotherapy. Hematol Oncol 2012; 31:143-50. [PMID: 23161567 DOI: 10.1002/hon.2037] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 10/03/2012] [Accepted: 10/05/2012] [Indexed: 11/11/2022]
Abstract
Despite a high proportion of patients with primary CNS lymphoma (PCNSL) experiences failure after/during first-line treatment, a few studies focused on salvage therapy are available, often with disappointing results. Herein, we report feasibility and activity of a combination of rituximab, ifosfamide and etoposide (R-IE regimen) in a multicentre series of patients with PCNSL relapsed or refractory to high-dose methotrexate-based chemotherapy. We considered consecutive HIV-negative patients ≤75 years old with failed PCNSL treated with R-IE regimen (rituximab 375 mg/m(2) , day 0; ifosfamide 2 g/m(2) /day, days1-3; etoposide 250 mg/m(2) , day 1; four courses). Twenty-two patients (median age 60 years; range 39-72; male/female ratio: 1:4) received R-IE as second-line (n = 18) or third-line (n = 4) treatment. Eleven patients had refractory PCNSL, and 11 had relapsing disease. Twelve patients had been previously irradiated. Sixty (68%) of the 88 planned courses were actually delivered; only one patient interrupted R-IE because of toxicity. Grade 4 hematological toxicity was manageable; a single case of grade 4 non-hematological toxicity (transient hepatotoxicity) was recorded. Response was complete in six patients and partial in three (overall response rate = 41%; 95%CI: 21-61%). Seven patients were successfully referred to autologous peripheral blood stem cell collection; four responders were consolidated with high-dose chemotherapy supported by autologous stem cell transplant. At a median follow-up of 24 months, eight responders did not experience relapse, two of them died of neurological impairment while in remission. Six patients are alive, with a 2-year survival after relapse of 25 ± 9%. We concluded that R-IE is a feasible and active combination for patients with relapsed/refractory PCNSL. This regimen allows stem cell collection and successful consolidation with high-dose chemotherapy and autologous transplant.
Collapse
Affiliation(s)
- Silvia Mappa
- Unit of Lymphoid Malignancies, Division of Onco-Hematological Medicine, Department of Onco-Hematology, San Raffaele Scientific Institute, Milan, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Prodduturi P, Bierman PJ. Current and emerging pharmacotherapies for primary CNS lymphoma. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2012; 6:219-31. [PMID: 22654527 PMCID: PMC3362327 DOI: 10.4137/cmo.s7752] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Primary central nervous system lymphoma (PCNSL) constitutes a rare group of extranodal non-Hodgkin's lymphoma (NHL) primarily of B cell origin. It occurs in both immuno-competent and immune-compromised patients. High dose m ethotrexate (HD-MTX) based chemotherapy is the standard therapy. Chemotherapy with whole brain radiation therapy (WBRT) improves response rates and survival compared with WBRT alone. However, due to the increased risk for neurotoxicity with WBRT, recent studies have focused on using chemotherapy alone. Methotrexate based multi-agent chemotherapy without WBRT is associated with similar t reatment rates and survival compared with regimens that include WBRT although controlled trials have not been performed. Because of the low incidence of this disease, it is difficult to conduct randomized controlled trials. In this article we have discussed about the past, present and emerging treatment options in patients with PCNSL.
Collapse
Affiliation(s)
- Prathima Prodduturi
- University of Nebraska Medical Center, Division of Hematology and Oncology, Omaha, NE, USA 68198-7680
| | | |
Collapse
|
44
|
Kasenda B, Schorb E, Fritsch K, Finke J, Illerhaus G. Prognosis after high-dose chemotherapy followed by autologous stem-cell transplantation as first-line treatment in primary CNS lymphoma--a long-term follow-up study. Ann Oncol 2012; 23:2670-2675. [PMID: 22473593 DOI: 10.1093/annonc/mds059] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND High-dose chemotherapy followed by autologous stem-cell transplantation (HCT-ASCT) is a promising approach in eligible patients with primary central nervous system lymphoma (PCNSL). We report long-term data of patients who were treated according to HCT-ASCT containing protocols. PATIENTS AND METHODS We analyzed survival and relapse rates in 43 (<67 years) immunocompetent patients with newly diagnosed PCNSL being treated according to two different high-dose methotrexate-based protocols followed by high-dose carmustine/thiotepa (BCNU/TT) plus ASCT (±whole brain irradiation). Analysis was conducted for all patients (intention-to-treat) and those patients who actually received HCT-ASCT (per-protocol). RESULTS Thirty-four patients achieved complete remission, of those 12 relapsed (35%), while 6 of them relapsed 5 years after diagnosis. After a median follow-up of 120 months, median overall survival (OS) was reached after 104 months. Two- and 5-year OS was 81% and 70% and 2- and 5-year event-free survival (EFS) was 81% and 67%, respectively. In per-protocol analysis (N = 34), 5-year OS and EFS was 82% and 79%, respectively. HCT-ASCT associated related mortality was not observed. CONCLUSIONS Sequential high-dose MTX containing chemotherapy followed by high-dose carmustine/thiotepa plus ASCT (±whole brain irradiation) is safe and leads to high survival rates in eligible patients with newly diagnosed PCNSL.
Collapse
Affiliation(s)
- B Kasenda
- Department of Hematology and Oncology, University Medical Center Freiburg, Freiburg, Germany; Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - E Schorb
- Department of Hematology and Oncology, University Medical Center Freiburg, Freiburg, Germany
| | - K Fritsch
- Department of Hematology and Oncology, University Medical Center Freiburg, Freiburg, Germany
| | - J Finke
- Department of Hematology and Oncology, University Medical Center Freiburg, Freiburg, Germany
| | - G Illerhaus
- Department of Hematology and Oncology, University Medical Center Freiburg, Freiburg, Germany.
| |
Collapse
|
45
|
|
46
|
Alimohamed N, Daly A, Owen C, Duggan P, Stewart DA. Upfront thiotepa, busulfan, cyclophosphamide, and autologous stem cell transplantation for primary CNS lymphoma: a single centre experience. Leuk Lymphoma 2011; 53:862-7. [PMID: 22023529 DOI: 10.3109/10428194.2011.633250] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Treatment of primary central nervous system lymphoma (PCNSL) with high-dose methotrexate-based chemotherapy and whole-brain radiotherapy (WBRT) is associated with high rates of relapse and severe neurotoxicity. In an attempt to improve upon these poor results, we treated 21 patients with PCNSL aged 34-69 years (median 56) with high-dose thiotepa, busulfan, cyclophosphamide (TBC) and autologous stem cell transplant (ASCT) as part of front-line therapy, without WBRT. Patient characteristics included: Karnofsky performance status (KPS) <70% (n = 17), age >60 years (n = 8), deep brain involvement (n = 16). Treatment-induced neurotoxicity was not observed in any of these patients. Currently, 11 of 21 patients (52%) are alive and progression-free at a median follow-up of 60 (7-125) months post-ASCT. Causes of death included progressive PCNSL (n = 4), progressive systemic lymphoma (n = 1), early treatment-related mortality (TRM, n = 3) and two late deaths from pneumonia 3 years post-ASCT. All patients who died of TRM were over 60 years of age and had poor performance status. In conclusion, TBC/ASCT offers potential long-term progression-free survival without neurotoxicity when used as part of upfront therapy for PCNSL. However, efforts to reduce TRM through improved patient selection and possibly through decreased intensity of the TBC regimen for older or less fit patients are recommended.
Collapse
Affiliation(s)
- Nimira Alimohamed
- Department of Oncology and Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | | | | | | |
Collapse
|
47
|
Reddy N, Savani BN. Primary central nervous system lymphoma: implication of high-dose chemotherapy followed by auto-SCT. Bone Marrow Transplant 2011; 47:1265-8. [PMID: 22002486 DOI: 10.1038/bmt.2011.204] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Primary central nervous system lymphoma is a rare and distinct subtype of non-Hodgkin's lymphoma that is sensitive to radiation and chemotherapy. Decisions regarding the initial therapeutic approach are influenced by age and risk of therapy-related neurotoxicity. Despite several albeit small phase II studies, and the acknowledged need for larger prospective trials, there is supporting evidence to consider auto-SCT following induction chemotherapy in patients with good performance status. The international extranodal lymphoma study group is conducting a randomized phase II study comparing consolidative radiation therapy to high-dose therapy. Novel therapeutic options including early aggressive approach with upfront auto-SCT and strategies to prevent relapse following transplantation is an area of focus.
Collapse
Affiliation(s)
- N Reddy
- Hematology and Stem Cell Transplantation Section, Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| | | |
Collapse
|
48
|
Gonzalez-Aguilar A, Houillier C, Soussain C, Hoang-Xuan K. [Management of primary central nervous system lymphoma]. Rev Neurol (Paris) 2011; 167:721-8. [PMID: 21906768 DOI: 10.1016/j.neurol.2011.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 08/02/2011] [Indexed: 11/18/2022]
Abstract
Primary CNS lymphoma is the malignant brain tumor whose prognosis has improved the most the two past decades. The majority of the patients achieve a complete remission with treatment and a substantial minority may hope to be cured. The treatment includes high-dose methotrexate polychemotherapy combined or not with whole brain radiotherapy (WBRT). Elderly patients who are exposed to a high risk of treatment induced neurotoxicity need a specific management avoiding or defering WBRT. In young patients, the main questions concerning the treatment are the role of consolidation WBRT and intensive chemotherapy with peripheral blood stem cell rescue in the initial treatment of PCNSL. As recently shown, national and international collaborative efforts make now possible randomized trials for this rare disease, which would contribute to better define the treatment strategy. New insights in PCNSL tumorigenesis would help to better understand the heterogeneity of outcome and to develop efficient targeted therapies.
Collapse
Affiliation(s)
- A Gonzalez-Aguilar
- UPMC, Service de neurologie Mazarin, groupe hospitalier Pitié-Salpêtrière, 47 boulevard de l'Hôpital, Paris cedex 13, France
| | | | | | | |
Collapse
|
49
|
Abstract
Abstract
Primary CNS lymphoma (PCNSL) is a rare malignancy with peculiar clinical and biologic features, aggressive course, and unsatisfactory outcome. It represents a challenge for multidisciplinary clinicians and scientists as therapeutic progress is inhibited by several issues. Molecular and biologic knowledge is incomplete, limiting the identification of new therapeutic targets, and the particular microenvironment of this malignancy, and sanctuary sites where tumor cells grow undisturbed, strongly affects treatment efficacy. Moreover, active treatments are known to be associated with disabling neurotoxicity, posing the dilemma of whether to intensify therapy to improve the cure rate or to de-escalate treatment to avoid sequels. The execution of prospective trials is also difficult because of the rarity of the tumor and the impaired general condition and poor performance status of patients. Thus, level of evidence is low, with consequent uncertainties in therapeutic decisions and lack of consensus on primary endpoints for future trials. Despite this unfavorable background, laboratory and clinical researchers are coordinating efforts to develop new ideas, resulting in the recent publication of studies on PCNSL's biology and molecular mechanisms and of the first international randomized trials. Herein, these important contributions are analyzed to provide recommendations for everyday practice and the rationale for future trials.
Collapse
|
50
|
Cote GM, Hochberg EP, Muzikansky A, Hochberg FH, Drappatz J, McAfee SL, Batchelor TT, LaCasce AS, Fisher DC, Abramson JS, Armand P, Chen YB. Autologous stem cell transplantation with thiotepa, busulfan, and cyclophosphamide (TBC) conditioning in patients with CNS involvement by non-Hodgkin lymphoma. Biol Blood Marrow Transplant 2011; 18:76-83. [PMID: 21749848 DOI: 10.1016/j.bbmt.2011.07.006] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Accepted: 07/06/2011] [Indexed: 10/18/2022]
Abstract
Primary central nervous system non-Hodgkin lymphoma (PCNSL) carries a poor prognosis and, although it responds to chemotherapy, fewer than 20% of patients are long-term disease-free survivors. Secondary CNS non-Hodgkin lymphoma (SCNSL) has an even worse prognosis with a median survival of only months and very few reported long-term survivors. For both of these groups of patients, there has been interest in using high-dose chemotherapy with autologous stem cell transplantation (ASCT) following conditioning with thiotepa, busulfan, and cyclophosphamide (TBC). We performed a retrospective review (from 2006-2010) of 32 patients from the Dana-Farber Cancer Institute and Massachusetts General Hospital with PCNSL or SCNSL who underwent ASCT with TBC conditioning. Of the 32 patients, 56% received TBC/ASCT after achieving brain magnetic resonance imaging (MRI) and/or cerebrospinal fluid complete response in brain, and 44% of patients were treated with TBC/ASCT in the setting of measurable CNS disease. The 100-day transplant-related mortality rate was only 3%. The most common nonhematologic grade 3 or 4 toxicity was mucositis, which occurred in 73% of patients. Notably, there was only 1 patient with prolonged significant neurologic toxicity that manifested as ataxia and dysphagia. The 1-year OS estimate is 93% (95% confidence interval [CI]: 75%-98%), and the 1-year progression-free survival (PFS) estimate is 90% (95% CI: 72%-96%) from the date of transplantation. Although these outcomes are encouraging, longer follow-up is required and comparison with other traditional ASCT regimens used for patients with non-Hodgkin lymphoma (NHL) is warranted.
Collapse
Affiliation(s)
- Gregory M Cote
- MGH Cancer Center, Boston, Massachusetts 02114-2617, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|