Prognostic factors in primary central nervous system lymphoma

Machine Learning-Enhanced Cerebrospinal Fluid N-Glycome for the Diagnosis and Prognosis of Primary Central Nervous System Lymphoma

The diagnosis and prognosis of Primary Central Nervous System Lymphoma (PCNSL) present significant challenges. In this study, the potential use of machine learning algorithms in diagnosing and predicting the prognosis for PCNSL based on cerebrospinal fluid (CSF) N-glycomics was investigated. First, CSF samples obtained from a cohort of 60 PCNSL patients and 30 controls were analyzed by hydrophilic interaction-based ultra performance liquid chromatography (HILIC-UPLC)-fluorescence mass spectrometry. Subsequently, nine machine learning models were established to diagnose PCNSL based on the changes of CSF N-glycome, with the Random Forest algorithm proving to be the most effective, achieving an accuracy of 100% in the training set and 89.3% in the test set. Moreover, a COX proportional-hazard model and a nomogram incorporating CSF N-glycome (GP6 and GP27) along with clinical data (age) were crafted. This nomogram's discrimination capacity was considered satisfactory, as evidenced by a C-index of 0.804 (95% CI: 0.68, 0.927). The study reveals that machine learning models based on CSF N-glycome offer a valuable approach for diagnosing and prognosticating PCNSL, demonstrating high accuracy and sensitivity in both classification and survival analysis. These findings may offer new insights into the molecular mechanisms underlying PCNSL and contribute to the advancement of personalized medicine for patients with this disease.

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

Objective

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

Methods

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

Results

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

Conclusions

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

Central nervous system lymphomas-Assessment and treatment and prevention of central nervous system relapse

In this review focused on lymphoma and the central nervous system (CNS), we summarize recent developments in the management of primary (PCNSL) and secondary CNS lymphoma (SCNSL), treatment of CNS lymphoma in the older population, the neuroradiological assessment of CNS lymphoma and finally highlight the ongoing debate on optimal CNS prophylaxis. The section on PCNSL focuses on the different approaches available for frontline treatment in Europe and the United States and discusses consolidation strategies. We then highlight available strategies to treat PCNSL in the elderly population, an area of unmet need. New therapies aiming at minimizing toxicity and prioritizing quality of life are emerging for these patients. Secondary CNS lymphoma, especially in the relapsed/refractory setting is another area of unmet need, and the efficacy of CAR-T cell therapy is being explored. We provide an overview of the imaging challenges in the neuroradiological assessment of CNS lymphoma. Finally, the section on CNS prophylaxis summarizes recent findings from large retrospective studies challenging the efficacy of present approaches to prophylaxis in higher-risk patients with lymphoma.

Sintilimab (anti-PD-1 antibody) combined with high-dose methotrexate, temozolomide, and rituximab (anti-CD20 antibody) in primary central nervous system lymphoma: a phase 2 study

Primary central nervous system lymphoma (PCNSL) is a rare and frequently fatal lymphoma subtype. The programmed death-1 (PD-1) pathway has emerged as a potential therapeutic target, but the effectiveness of PD-1 antibody sintilimab in combination with immunochemotherapy as a frontline treatment for PCNSL remains to be determined. In this phase 2 trial (ChiCTR1900027433) with a safety run-in, we included patients aged 18-70 with newly diagnosed PCNSL. Participants underwent six 21-day cycles of a SMTR regimen, which includes sintilimab (200 mg, Day 0), rituximab (375 mg/m2, Day 0), methotrexate (3.0 g/m2, Day 1 or 1.0 g/m2 for patients aged ≥65 years), and temozolomide (150 mg/m2/d, Days 1-5). Among 27 evaluable patients, the overall response rate (ORR) was 96.3% (95% confidence interval: 81-99.9%), with 25 complete responses. At a median follow-up of 24.4 months, the medians for duration of response, progression-free survival (PFS), and overall survival were not reached. The most common grade 3-4 treatment-related toxicities were increased levels of alanine aminotransferase (17.9%) and aspartate aminotransferase (14.3%). Additionally, baseline levels of interferon-α and the IL10/IL6 ratio in cerebrospinal fluid emerged as potential predictors of PFS, achieving areas under the curve of 0.88 and 0.84, respectively, at 2 years. Whole-exome sequencing revealed a higher prevalence of RTK-RAS and PI3K pathway mutations in the durable clinical benefit group, while a greater frequency of Notch and Hippo pathway mutations in the no durable benefit group. These findings suggest the SMTR regimen is highly efficacious and tolerable for newly diagnosed PCNSL, warranting further investigation.

Survival outcomes and treatment experience of 124 patients with primary central nervous system lymphoma

PURPOSE

Primary central nervous system lymphoma (PCNSL) is a rare malignancy of the central nervous system with high invasiveness. There is little consensus on the treatment of PCNSL. This study retrospectively studied data from PCNSL patients in a single center to summarize treatment experience and explore prognostic factors.

METHODS

Survival curves were drawn using the Kaplan-Meier method and prognostic factors were analyzed using Cox's hazards model.

RESULTS

In multivariate analysis, cerebrospinal fluid lactic acid dehydrogenase (CSF LDH; p = 0.005 and p = 0.002), neutrophil to lymphocyte ratio (NLR; p = 0.014 and p = 0.038), and completion of four cycles of induction therapy (p < 0.001and p < 0.001) were significant and independent predictors of overall survival (OS) and progression-free survival (PFS), respectively.

CONCLUSION

On the basis of this study, we propose that PCNSL patients should receive early induction therapy with sufficient cycles. Subsequent consolidation therapy can prevent relapses and improve survival. In patients with PCNSL, the independent prognostic factors for OS and PFS were CSF LDH level, NLR, and full cycles of induction therapy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL

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

Primary central nervous system lymphoma (PCNSL) in older patients

INTRODUCTION

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

OBJECTIVE

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

CONCLUSION

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

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

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