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Truong HL, Barreto JN, Mara KC, Hampel PJ, Micallef IN, Nowakowski GS, Thanarajasingam G, Thompson CA, Wang Y, Witzig TE, Herrmann SM, Leung N. Rechallenge With High-Dose Methotrexate After Treatment With Glucarpidase in Adult Patients With Lymphoma. JCO Oncol Pract 2024; 20:797-807. [PMID: 38408299 DOI: 10.1200/op.23.00628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/09/2023] [Accepted: 12/15/2023] [Indexed: 02/28/2024] Open
Abstract
PURPOSE Limited evidence exists regarding methotrexate (MTX) resumption after patients with lymphoma receive glucarpidase for toxic MTX levels and acute kidney injury (AKI). METHODS This retrospective review included adults with lymphoma treated with glucarpidase after MTX at Mayo Clinic between January 31, 2020, and October 10, 2022. Descriptive statistics summarize patient characteristics and clinical outcomes. RESULTS Of 11 patients treated with glucarpidase after MTX, seven (64%) were rechallenged with MTX. Indications for MTX rechallenge included confirmed CNS disease (n = 6, 86%) and intravascular lymphoma (n = 1, 14%). Compared with the nonrechallenged subgroup, before receiving MTX that required glucarpidase rescue, the rechallenged patients had lower median pretreatment serum creatinine (Scr; 0.7 v 1.2 mg/dL), and none had AKI with previous MTX doses, n = 0 (0%) versus n = 2 (50%). During the MTX dose requiring glucarpidase rescue, the rechallenged group had lower median peak Scr (1.26 v 3.32 mg/dL) and lower incidence of AKI stage III (n = 1 [14%] v n = 3 [75%]), and none of the rechallenged patients required renal replacement therapy (RRT; n = 0 [0%] v n = 1 [25%]). At the first rechallenge after glucarpidase administration, the median MTX dose reduction was 56% (range, 46%-75%), and the lowest used dose when prescribed according to each treatment protocol schedule was 1.5 g/m2. Two (29%) patients experienced AKI (n = 1 stage I, n = 1 stage II) after MTX rechallenge. Zero patients required RRT, and zero required another glucarpidase administration. Six (86%) patients completed all recommended MTX doses. CONCLUSION In selected adults with lymphoma who required glucarpidase for toxic MTX levels after administration of high-dose MTX, resumption of MTX therapy at lower doses is safe. Patients selected for MTX resumption had experienced less severe AKI during the previous cycle compared with those not selected for MTX resumption.
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Affiliation(s)
- Huong L Truong
- Department of Pharmacy, Mayo Clinic, Rochester, MN
- Loxo@Lilly, Lilly Corporate Center, Indianapolis, IN
| | | | - Kristin C Mara
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Paul J Hampel
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Ivana N Micallef
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | | | - Gita Thanarajasingam
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Carrie A Thompson
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Yucai Wang
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Thomas E Witzig
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Sandra M Herrmann
- Division of Nephrology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Nelson Leung
- Division of Nephrology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
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Shimada K, Ohmachi K, Machida R, Ota S, Itamura H, Tsujimura H, Takayama N, Shimada T, Kurosawa M, Tabayashi T, Shimoyama T, Ohshima K, Miyazaki K, Maruyama D, Kinoshita T, Ando K, Hotta T, Tsukasaki K, Nagai H. Secondary central nervous system involvement in patients with diffuse large B-cell lymphoma treated with rituximab combined CHOP therapy - a supplementary analysis of JCOG0601. Ann Hematol 2024; 103:2021-2031. [PMID: 38280061 PMCID: PMC11090957 DOI: 10.1007/s00277-024-05620-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 01/08/2024] [Indexed: 01/29/2024]
Abstract
Secondary central nervous system involvement (sCNSi) in diffuse large B-cell lymphoma (DLBCL) is fatal. However, its features in patients with sCNSi who are categorized as lower risk by international prognostic index (IPI) or CNS-IPI are not yet fully understood. In the present analysis, we evaluated DLBCL patients who developed sCNSi at their first progression and who participated in JCOG0601, most of whom were lower risk by IPI. Of 409 patients, 21 (5.1%) developed sCNSi during a median follow-up of 4.9 years. Five-year cumulative incidence of sCNSi were 5.1%; and 4.0%, 5.3%, and 11.5% at low, intermediate, and high risk of CNS-IPI, respectively. The most common locations of extranodal lesions at the time of registration in patients with sCNSi were the stomach (n = 4), paranasal cavity (n = 3), and bone marrow (n = 2). In univariable analysis, paranasal cavity lesion was a high-risk factor for sCNSi (subdistribution hazard ratio, 4.34 [95% confidence interval 1.28-14.73]). Median overall survival after sCNSi was 1.3 years, with a 2-year overall survival rate of 39.3%. The incidence of sCNSi in DLBCL patients at lower risk of CNS-IPI was low, as previously reported, but paranasal cavity lesion might indicate high risk for organ involvement. CLINICAL TRIAL REGISTRATION: JCOG0601 was registered in the UMIN Clinical Trials Registry (UMIN000000929, date of registration; December 04, 2007) and the Japan Registry of Clinical Trials (jRCTs031180139, date of registration; February 20, 2019).
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Affiliation(s)
- Kazuyuki Shimada
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan.
| | - Ken Ohmachi
- Department of Hematology and Oncology, Tokai University School of Medicine, Kanagawa, Japan
| | - Ryunosuke Machida
- Japan Clinical Oncology Group Data Center, National Cancer Center Hospital, Tokyo, Japan
| | - Shuichi Ota
- Department of Hematology, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - Hidekazu Itamura
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Hideki Tsujimura
- Department of Hematology-Oncology, Chiba Cancer Center, Chiba, Japan
| | - Nobuyuki Takayama
- Department of Hematology, Faculty of Medicine, Kyorin University, Mitaka, Japan
| | - Takaki Shimada
- Division of Clinical Oncology/Hematology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Mitsutoshi Kurosawa
- Department of Hematology, National Hospital Organization Hokkaido Cancer Center, Sapporo, Japan
| | - Takayuki Tabayashi
- Department of Hematology, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Tatsu Shimoyama
- Department of Medical Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Koichi Ohshima
- Department of Pathology, Kurume University School of Medicine, Kurume, Japan
| | - Kana Miyazaki
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Dai Maruyama
- Department of Hematology Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomohiro Kinoshita
- Department of Hematology and Cell Therapy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Kiyoshi Ando
- Department of Hematology and Oncology, Tokai University School of Medicine, Kanagawa, Japan
| | - Tomomitsu Hotta
- Department of Hematology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Kunihiro Tsukasaki
- Department of Hematology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Hirokazu Nagai
- Department of Hematology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
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3
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Fischer T, Zing NP, Fortier SC, Schmidt J, Silveira TB, Chiattone CS. Application of the Central Nervous System International Prognostic Index (CNS-IPI) score in daily practice: a retrospective analysis apart from the clinical trial at two centers in Brazil. Hematol Transfus Cell Ther 2024; 46:137-145. [PMID: 37085346 DOI: 10.1016/j.htct.2023.02.003] [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: 08/18/2022] [Revised: 01/12/2023] [Accepted: 02/09/2023] [Indexed: 04/23/2023] Open
Abstract
INTRODUCTION The diffuse large B-cell lymphoma (DLBCL) is the most common type of non-Hodgkin lymphoma (NHL) and, despite all the progress in this field, central nervous system infiltration (CNSi) still occurs at an incidence of 2-10%. The objective of the present study was to evaluate the Central Nervous System International Prognostic Index (CNS-IPI) score in daily practice regarding the reproducibility in a heterogeneous cohort apart from a clinical trial. METHODS Primary DLBCL patients were eligible for this study, between January 2007 and January 2017. All patients were treated with rituximab-based chemotherapy, mostly R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone). The CNSi was diagnosed by liquor (positive cytology and/or immunophenotype), computerized tomography, magnetic resonance image and/or fluorodeoxy-glucose-positron emission tomography, requested only in symptomatic patients when the CNSi was clinically suspected. The CNS-IPI was assessed by graphical comparison and calibration. RESULTS After applying the inclusion/exclusion criteria, 322 patients were available for the analysis. The median follow-up was 60 months and the median age was 58 years. Seven patients experienced CNSi, characterizing an incidence of 2.17% (7/322). Comparing groups of patients with and without CNSi, we observed that the lactate dehydrogenase (LDH), number of extranodal sites, IPI, kidney/adrenal and absence of complete response were statistically different. The CNS-IPI model stratified patients in a three-risk group model as low-, intermediate- and high-risk. In our cohort, using the same stratification, we obtained an equivalent the 2-year rate of CNS relapse of 0.0%, 0.8% and 13.8%, respectively. CONCLUSION Our study reinforces the reproducibility of the CNS-IPI, specifically apart from clinical trials, and suggests the CNS-IPI score as a tool to guide therapy.
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Affiliation(s)
- Thais Fischer
- Santa Casa de Sao Paulo School of Medical Sciences, São Paulo SP, Brazil; Ac Camargo Cancer Center, São Paulo, SP, Brazil.
| | - Natalia Pc Zing
- Santa Casa de Sao Paulo School of Medical Sciences, São Paulo SP, Brazil
| | - Sergio C Fortier
- Santa Casa de Sao Paulo School of Medical Sciences, São Paulo SP, Brazil
| | | | - Talita B Silveira
- Santa Casa de Sao Paulo School of Medical Sciences, São Paulo SP, Brazil; Ac Camargo Cancer Center, São Paulo, SP, Brazil
| | - Carlos S Chiattone
- Santa Casa de Sao Paulo School of Medical Sciences, São Paulo SP, Brazil
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4
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Conconi A, Chiappella A, Ferreri AJM, Stathis A, Botto B, Sassone M, Gaidano G, Balzarotti M, Merli F, Tucci A, Vanazzi A, Tani M, Bruna R, Orsucci L, Cabras MG, Celli M, Annibali O, Liberati AM, Zanni M, Ghiggi C, Pisani F, Pinotti G, Dore F, Esposito F, Pirosa MC, Cesaretti M, Bonomini L, Vitolo U, Zucca E. IELSG30 phase 2 trial: intravenous and intrathecal CNS prophylaxis in primary testicular diffuse large B-cell lymphoma. Blood Adv 2024; 8:1541-1549. [PMID: 38181782 DOI: 10.1182/bloodadvances.2023011251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 11/30/2023] [Accepted: 12/01/2023] [Indexed: 01/07/2024] Open
Abstract
ABSTRACT Primary testicular diffuse large B-cell lymphoma (PTL) is characterized by high risk of contralateral testis and central nervous system (CNS) relapse. Chemoimmunotherapy with intrathecal (IT) CNS prophylaxis and contralateral testis irradiation eliminates contralateral recurrences and reduces CNS relapses. The IELSG30 phase 2 study investigated feasibility and activity of an intensified IT and IV CNS prophylaxis. Patients with stage I/II PTL who had not received treatment received 2 cycles of IV high-dose methotrexate (MTX) (1.5 g/m2) after 6 cycles of the R-CHOP regimen (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone, every 21 days). IT liposomal cytarabine was administered on day 0 of cycles 2 to 5 of 21-day R-CHOP regimen. Contralateral testis radiotherapy (25-30 Gy) was recommended. Fifty-four patients (median age: 66 years) with stage I (n = 32) or II (n = 22) disease were treated with R-CHOP, 53 received at least 3 doses of IT cytarabine, 48 received at least 1 dose of IV MTX, and 50 received prophylactic radiotherapy. No unexpected toxicity occurred. At a median follow-up of 6 years, there was no CNS relapse; 7 patients progressed, and 8 died, with 5-year progression-free and overall survival rates of 91% (95% confidence interval [CI], 79-96) and 92% (95% CI, 81-97), respectively. Extranodal recurrence was documented in 6 patients (in 2 without nodal involvement). In 4 cases, the relapse occurred >6 years after treatment. Causes of death were lymphoma (n = 4), second primary malignancy (n = 1), cerebral vasculopathy (n = 1), unknown (n = 2). Intensive prophylaxis was feasible and effective in preventing CNS relapses. Late relapses, mainly at extranodal sites, represented the most relevant pattern of failure. This trial was registered at www.clinicaltrials.gov as #NCT00945724.
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Affiliation(s)
| | - Annalisa Chiappella
- Haematology Unit, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Anastasios Stathis
- Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Barbara Botto
- SC Ematologia, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Marianna Sassone
- Lymphoma Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gianluca Gaidano
- SCDU Ematologia, Department of Translational Medicine, University of Eastern Piedmont and AOU Maggiore della Carità, Novara, Italy
| | - Monica Balzarotti
- UO Ematologia, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Francesco Merli
- Hematology Unit, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Alessandra Tucci
- Division of Hematology, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Anna Vanazzi
- Division of Clinical Haemato-Oncology, European Institute of Oncology IRCCS, Milan, Italy
| | - Monica Tani
- UO Ematologia, Dipartimento Oncologia ed Ematologia, Ospedale Santa Maria delle Croci, Ravenna, Italy
| | - Riccardo Bruna
- Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Lorella Orsucci
- Lymphoma Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Melania Celli
- Ospedale degli Infermi, Hematology Unit, Rimini, Italy
| | - Ombretta Annibali
- Area Ematologia Medicina Trasfusionale e Terapia cellulare Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Anna Marina Liberati
- SC Oncoematologia, Azienda Ospedaliera Santa Maria, Università degli studi di Perugia, Terni, Italy
| | - Manuela Zanni
- Antonio e Biagio e Cesare Arrigo Hospital, Hematology Unit, Alessandria, Italy
| | - Chiara Ghiggi
- IRCCS Ospedale Policlinico San Martino UO Ematologia e Terapie Cellulari, Genoa, Italy
| | - Francesco Pisani
- Hematology and Stem Cell Transplantation Unit, IRCCS Istituto Nazionale dei Tumori Regina Elena, Rome, Italy
| | | | | | - Fabiana Esposito
- Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Maria Cristina Pirosa
- Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Institute of Oncology Research, Bellinzona, Switzerland
| | | | | | - Umberto Vitolo
- Medical Oncology, Candiolo Cancer Institute, Fondazione del Piemonte per l'Oncologia-IRCCS, Candiolo, Turin, Italy
| | - Emanuele Zucca
- Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
- Institute of Oncology Research, Bellinzona, Switzerland
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Akimoto M, Miyazaki T, Takahashi H, Saigusa Y, Takeda T, Hibino Y, Tokunaga M, Ohashi T, Matsumura A, Teshigawara H, Suzuki T, Teranaka H, Nakajima Y, Matsumoto K, Hashimoto C, Fujimaki K, Fujita H, Sakai R, Fujisawa S, Nakajima H. Comparison of standardized prophylactic high-dose and intrathecal methotrexate for DLBCL with a high risk of CNS relapse. Int J Hematol 2024; 119:164-172. [PMID: 38233702 DOI: 10.1007/s12185-023-03700-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 12/25/2023] [Accepted: 12/27/2023] [Indexed: 01/19/2024]
Abstract
The efficacy of high-dose methotrexate (HD-MTX) for central nervous system (CNS) relapse prophylaxis in patients with high-risk diffuse large B-cell lymphoma (DLBCL) is controversial. We compared the prophylactic effects of HD-MTX and intrathecal methotrexate (IT-MTX) on CNS relapse in high-risk DLBCL, in a multicenter retrospective study. A total of 132 patients with DLBCL at high risk of CNS relapse who received frontline chemotherapy and IT-MTX from 2003 to 2013 (n = 34) or HD-MTX from 2014 to 2020 (n = 98) were included. After a median follow-up of 52 months (range: 9-174), 11 patients had isolated CNS relapse: six (6.1%) in the HD-MTX group and five (14.7%) in the IT-MTX group. The median time until CNS relapse was 38 months (range: 11-122), and the cumulative incidence of CNS relapse at 3 years was 3.9% in the HD-MTX group and 6.1% in the IT-MTX group (P = 0.93). Similar results were obtained after adjusting for background factors using propensity score-matched analysis (4.5% HD-MTX vs. 7.6% IT-MTX, P = 0.84). The CNS relapse rate in HD-MTX-treated patients was equivalent to that in IT-MTX patients, demonstrating that HD-MTX was not superior to IT-MTX in preventing CNS relapse.
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Affiliation(s)
- Masahiro Akimoto
- Department of Hematology, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Takuya Miyazaki
- Department of Hematology, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, Kanagawa, 232-0024, Japan.
| | - Hiroyuki Takahashi
- Department of Hematology and Medical Oncology, Kanagawa Cancer Center, Yokohama, Japan
| | - Yusuke Saigusa
- Department of Biostatistics, Yokohama City University School of Medicine, Yokohama, Japan
| | - Takaaki Takeda
- Department of Hematology and Medical Oncology, Kanagawa Cancer Center, Yokohama, Japan
| | - Yuto Hibino
- Department of Hematology and Medical Oncology, Kanagawa Cancer Center, Yokohama, Japan
| | - Mayumi Tokunaga
- Department of Hematology and Medical Oncology, Kanagawa Cancer Center, Yokohama, Japan
| | - Takuma Ohashi
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Ayako Matsumura
- Department of Hematology, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Haruka Teshigawara
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Taisei Suzuki
- Department of Hematology, Fujisawa City Hospital, Fujisawa, Japan
| | - Hiroshi Teranaka
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Yuki Nakajima
- Department of Hematology, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Kenji Matsumoto
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Chizuko Hashimoto
- Department of Hematology/Oncology, Yamato Municipal Hospital, Yamato, Japan
| | | | - Hiroyuki Fujita
- Department of Hematology, Saiseikai Yokohama Nanbu Hospital, Yokohama, Japan
| | - Rika Sakai
- Department of Hematology and Medical Oncology, Kanagawa Cancer Center, Yokohama, Japan
| | - Shin Fujisawa
- Department of Hematology, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Hideaki Nakajima
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Yokohama, Japan
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Chan CY, Ou CW, Chang H, Kuo MC, Lin TL, Hung YS, Wu JH, Shih LY, Kao HW. Primary breast diffuse large B-cell lymphoma characterized by CNS relapse and successful hematopoietic stem cell transplantation salvage therapy. J Formos Med Assoc 2024:S0929-6646(24)00053-6. [PMID: 38296697 DOI: 10.1016/j.jfma.2024.01.020] [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: 11/13/2023] [Revised: 01/02/2024] [Accepted: 01/20/2024] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Primary breast diffuse large B-cell lymphoma (PB-DLBCL) is rare, with a high incidence of central nervous system (CNS) relapse. This study aims to investigate clinical characteristics, prognostic factors, and outcomes in Taiwanese PB-DLBCL patients and review the literature on PB-DLBCL. METHODS Thirty-one PB-DLBCL patients diagnosed between 2000 and 2021 were retrospectively enrolled for analysis. RESULTS The median age was 49 (range 26-79) years. The complete remission (CR) rate was 90.3%. Nine (90%) of the ten patients who experienced relapse had CNS involvement at the time of relapse. The one-year, two-year, and five-year progression-free survival (PFS) rates were 86.6% (95% confidence interval [CI] 75.2-99.8), 75.8% (95% CI 61.6-93.2), and 45.1% (95% CI 29.5-68.9), respectively. The five-year overall survival (OS) rate was 64.1% (95 % CI 48.4-85.0). A stage-modified International Prognostic Index (mIPI) less than two (five-year PFS rate 52.5% vs. 17.1%, P = 0.02) and the achievement of CR after first-line treatment (two-year PFS rate 80.3% vs. 33.3%, P < 0.001) were significant favorable prognostic factors for PFS. Hematopoietic stem cell transplantation (HSCT) after the first relapse was associated with significantly improved post-relapse OS (five-year OS rate 85.7% vs. 20.0%, P = 0.02) and PFS (five-year PFS rate 85.7% vs. 20.0%, P = 0.02). CONCLUSION Patients with low-risk mIPI scores, CR after first-line treatment, and those who underwent HSCT after the first relapse had significantly better survival. Intrathecal chemotherapy conferred no benefit in preventing CNS relapse. Further research is needed to assess frontline HSCT's effectiveness in improving outcomes and preventing CNS relapses in PB-DLBCL patients.
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Affiliation(s)
- Chu-Yi Chan
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Che-Wei Ou
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Division of Hematology-Oncology, Department of Internal Medicine, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan
| | - Hung Chang
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Chung Kuo
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tung-Liang Lin
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Yu-Shin Hung
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Jin-Hou Wu
- Division of Hematology-Oncology, Department of Internal Medicine, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan
| | - Lee-Yung Shih
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsiao-Wen Kao
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.
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7
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Chua BJG, Low CE, Yau CE, Tan YH, Chiang J, Chang EWY, Chan JY, Poon EYL, Somasundaram N, Rashid MFBH, Tao M, Lim ST, Yang VS. Recent updates on central nervous system prophylaxis in patients with high-risk diffuse large B-cell lymphoma. Exp Hematol Oncol 2024; 13:1. [PMID: 38173015 PMCID: PMC10765685 DOI: 10.1186/s40164-023-00467-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
The use of central nervous system (CNS) prophylaxis for patients with diffuse large B-cell lymphoma (DLBCL) remains controversial. Although uncommon, CNS relapses are invariably fatal in this otherwise curable disease. Accurate identification of patients at risk and the optimal approach to CNS prophylaxis therefore remains an area of unmet need. The existing literature, largely retrospective in nature, provides mixed conclusions regarding the efficacy of CNS prophylaxis. The utility of CNS prophylaxis has itself been challenged. In this review, we dissect the issues which render the value of CNS prophylaxis uncertain. We first compare international clinical guidelines for CNS prophylaxis. We then interrogate the factors that should be used to identify high-risk patients accurately. We also explore how clinical patterns of CNS relapse have changed in the pre-rituximab and rituximab era. We then discuss the efficacy of CNS-directed approaches, intensification of systemic treatment and other novel approaches in CNS prophylaxis. Improved diagnostics for early detection of CNS relapses and newer therapeutics for CNS prophylaxis are areas of active investigation. In an area where prospective, randomized studies are impracticable and lacking, guidance for the use of CNS prophylaxis will depend on rigorous statistical review of retrospective data.
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Affiliation(s)
- Bernard Ji Guang Chua
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
| | - Chen Ee Low
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Chun En Yau
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Ya Hwee Tan
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
| | - Jianbang Chiang
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
| | - Esther Wei Yin Chang
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
| | - Jason Yongsheng Chan
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
- Duke-NUS Medical School, Oncology Academic Clinical Program, 8 College Road, Singapore, 169857, Singapore
| | - Eileen Yi Ling Poon
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
| | - Nagavalli Somasundaram
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
- Duke-NUS Medical School, Oncology Academic Clinical Program, 8 College Road, Singapore, 169857, Singapore
| | - Mohamed Farid Bin Harunal Rashid
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
- Duke-NUS Medical School, Oncology Academic Clinical Program, 8 College Road, Singapore, 169857, Singapore
| | - Miriam Tao
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
- Duke-NUS Medical School, Oncology Academic Clinical Program, 8 College Road, Singapore, 169857, Singapore
| | - Soon Thye Lim
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
- Duke-NUS Medical School, Oncology Academic Clinical Program, 8 College Road, Singapore, 169857, Singapore
| | - Valerie Shiwen Yang
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore.
- Duke-NUS Medical School, Oncology Academic Clinical Program, 8 College Road, Singapore, 169857, Singapore.
- Translational Precision Oncology Lab, Institute of Molecular and Cell Biology (IMCB), 61 Biopolis Dr Proteos, Singapore, 138673, A*STAR, Singapore.
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8
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Lewis KL, Jakobsen LH, Villa D, Smedby KE, Savage KJ, Eyre TA, Cwynarski K, Bishton MJ, Fox CP, Hawkes EA, Maurer MJ, El-Galaly TC, Cheah CY. High-Dose Methotrexate as CNS Prophylaxis in High-Risk Aggressive B-Cell Lymphoma. J Clin Oncol 2023; 41:5376-5387. [PMID: 37797284 DOI: 10.1200/jco.23.00365] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 07/01/2023] [Accepted: 07/28/2023] [Indexed: 10/07/2023] Open
Abstract
PURPOSE CNS progression or relapse is an uncommon but devastating complication of aggressive B-cell lymphoma. There is no consensus regarding the optimal approach to CNS prophylaxis. This study was designed to determine whether high-dose methotrexate (HD-MTX) is effective at preventing CNS progression in patients at high risk of this complication. PATIENTS AND METHODS Patients age 18-80 years with aggressive B-cell lymphoma and high risk of CNS progression, treated with curative-intent anti-CD20-based chemoimmunotherapy, were included in this international, retrospective, observational study. Cause-specific hazard ratios (HRs) and cumulative risks of CNS progression were calculated according to use of HD-MTX, with time to CNS progression calculated from diagnosis for all patients (all-pts) and from completion of frontline systemic lymphoma induction therapy, for patients in complete response at completion of chemoimmunotherapy (CR-pts). RESULTS Two thousand four hundred eighteen all-pts (HD-MTX; n = 425) and 1,616 CR-pts (HD-MTX; n = 356) were included. CNS International Prognostic Index was 4-6 in 83.4% all-pts. Patients treated with HD-MTX had a lower risk of CNS progression (adjusted HR, 0.59 [95% CI, 0.38 to 0.90]; P = .014), but significance was not retained when confined to CR-pts (adjusted HR, 0.74 [95% CI, 0.42 to 1.30]; P = .29), with 5-year adjusted risk difference of 1.6% (95% CI, -1.5 to 4.4; all-pts) and 1.4% (95% CI, -1.5 to 4.1; CR-pts). Subgroups were underpowered to draw definitive conclusions regarding the efficacy of HD-MTX in individual high-risk clinical scenarios; however, there was no clear reduction in CNS progression risk with HD-MTX in any high-risk subgroup. CONCLUSION In this large study, high-risk patients receiving HD-MTX had a 7.2% 2-year risk of CNS progression, consistent with the progression risk in previously reported high-risk cohorts. Use of HD-MTX was not associated with a clinically meaningful reduction in risk of CNS progression.
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Affiliation(s)
- Katharine L Lewis
- Linear Clinical Research, Nedlands, WA, Australia
- Division of Haematology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- Division of Internal Medicine, Medical School, University of Western Australia, Perth, WA, Australia
| | - Lasse H Jakobsen
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark
| | - Diego Villa
- BC Cancer Centre for Lymphoid Cancer, The University of British Columbia, Vancouver, BC, Canada
| | - Karin E Smedby
- Department of Medicine Solna, Division of Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - Kerry J Savage
- BC Cancer Centre for Lymphoid Cancer, The University of British Columbia, Vancouver, BC, Canada
| | - Toby A Eyre
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Kate Cwynarski
- University College London Hospital NHS Foundation Trust, London, United Kingdom
| | - Mark J Bishton
- Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- University of Nottingham, Nottingham, United Kingdom
| | - Christopher P Fox
- Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- University of Nottingham, Nottingham, United Kingdom
| | - Eliza A Hawkes
- Olivia Newton-John Cancer Research & Wellness Centre at Austin Health, Heidelberg, VIC, Australia
- Monash University School of Public Health and Preventive Medicine, Melbourne, VIC, Australia
| | - Matthew J Maurer
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | - Tarec C El-Galaly
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark
| | - Chan Y Cheah
- Linear Clinical Research, Nedlands, WA, Australia
- Division of Haematology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- Division of Internal Medicine, Medical School, University of Western Australia, Perth, WA, Australia
- Department of Haematology, PathWest, Nedlands, WA, Australia
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9
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Cui JY, Liu YF, Gao B, Mi L, Deng LJ, Zhu J, Hou SL. Model for Predicting Central Nervous System Relapse in Diffuse Large B-Cell Lymphoma and Discussion of Prophylaxis Measures. World Neurosurg 2023; 179:e387-e396. [PMID: 37652134 DOI: 10.1016/j.wneu.2023.08.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 09/02/2023]
Abstract
OBJECTIVE Relapse of the central nervous system (CNS) is a rare but fatal complication in diffuse large B-cell lymphoma (DLBCL). The purpose of this study is to learn how to identify high-risk patients and take effective preventive measures. METHODS We retrospectively analyzed 1,290 adult patients with DLBCL at Peking University Cancer Hospital and Shanxi Bethune Hospital between 2010 and 2020. RESULTS There were 55 patients with CNS relapse who had a median follow-up of 5 years. The risk of CNS relapse was 1.58% in the low-risk group, 5.66% in the moderate-risk group, and 11.67% in the high-risk group based on CNS International Prognostic Index (CNS-IPI). We found that CNS-IPI and testicular involvement were risk factors for CNS relapse, with OR 1.913 (95% CI: 1.036∼3.531; P = 0.038) versus. OR 3.526 (95% CI: 1.335∼9.313; P = 0.011), respectively. Intrathecal MTX and/or cytarabine prophylaxis was used in 166 patients (13.94%), intravenous (IV) high-dose methotrexate (HD-MTX) prophylaxis in 8 patients (0.67%), and intrathecal plus intravenous prophylaxis in 15 patients (1.26%). There was no significant difference in CNS relapse risk between IT, HD-MTX, and no prophylaxis recipients (12.7% vs. 0% vs. 23.6%, respectively, P = 0.170). The risk of CNS relapse was similar whether or not patients accepted prophylaxis (5-year risk 4.1% vs. 2.2%, P = 0.140). CONCLUSIONS Central nervous system (CNS) relapse is associated with high risk CNS-IPI and testicular involvement. Therefore, it is necessary to pursue novel prophylactic strategies for CNS relapse.
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Affiliation(s)
- Ju-Ya Cui
- Department of Lymphoma, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Yan-Fei Liu
- Department of Lymphoma, Peking University Cancer Hospital & Institute (Beijing Cancer Hospital), Beijing, China
| | - Ben Gao
- College of Mathematics, Taiyuan University of Technology, Taiyuan, Shanxi, China
| | - Lan Mi
- Department of Lymphoma, Peking University Cancer Hospital & Institute (Beijing Cancer Hospital), Beijing, China
| | - Li-Juan Deng
- Department of Lymphoma, Peking University Cancer Hospital & Institute (Beijing Cancer Hospital), Beijing, China
| | - Jun Zhu
- Department of Lymphoma, Peking University Cancer Hospital & Institute (Beijing Cancer Hospital), Beijing, China
| | - Shu-Ling Hou
- Department of Lymphoma, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China.
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10
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Bobillo S, Wilson MR, Cwynarski K. Controversies in central nervous system prophylaxis of high-risk diffuse large B-cell lymphoma. Curr Opin Oncol 2023; 35:382-388. [PMID: 37551947 DOI: 10.1097/cco.0000000000000973] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
PURPOSE OF REVIEW Central nervous system (CNS) relapse in patients with diffuse large B-cell lymphoma (DLBCL) is an uncommon but devastating complication with an overall survival of less than 6 months. This article will review the recent updates on CNS prophylaxis including new potential advances in the identification of high-risk patients. RECENT FINDINGS The identification of patients at a high risk of CNS relapse is based on clinical and biological features has improved over recent years; however, the of different CNS prophylaxis strategies including intrathecal chemotherapy and high-dose methotrexate have been recently questioned in several large retrospective studies. The analysis of cell-free circulating tumor DNA (ctDNA) in the cerebrospinal fluid has been shown to identify patients with a high risk of CNS involvement and work is ongoing to identify how this can be used as a prognostic biomarker. SUMMARY Recent clinical retrospective data have questioned the effectiveness of intrathecal and high-dose methotrexate in the prevention of CNS relapse in high-risk DLBCL patients. The role of more sensitive methods to detect CNS involvement and the benefit of novel therapies in CNS relapse prevention are currently under evaluation.
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Affiliation(s)
- Sabela Bobillo
- Department of Haematology, Vall d'Hebron Institute of Oncology, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Matthew R Wilson
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow
| | - Kate Cwynarski
- Department of Haematology, University College London Hospital, London, UK
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11
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Lantz J, Portell CA, Ayers EC. Central nervous system prophylaxis in diffuse large B-cell lymphoma: What does the evidence tell us? Blood Rev 2023; 61:101101. [PMID: 37258362 DOI: 10.1016/j.blre.2023.101101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 05/19/2023] [Accepted: 05/23/2023] [Indexed: 06/02/2023]
Abstract
Secondary involvement of the central nervous system (CNS) by diffuse large b-cell lymphoma (DLBCL) is a rare yet often catastrophic event for DLBCL patients. As standard first-line therapy for DLBCL with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) does not cross the blood-brain barrier, one approach to lessen the risk of CNS relapse has been to include additional agents, primarily methotrexate, directed at the CNS with standard R-CHOP although the timing, dose, and mode of administration differs widely across treating physicians. This practice derives from decades of non-randomized, often retrospective data with inconsistent outcomes. The current available tools and risk models are imprecise in their ability to predict which patients are truly at risk of secondary CNS relapse and more recent, large-scale real-world analyses call into question these longstanding practices. In a field lacking any prospective, randomized studies, this review synthesizes the available data investigating the utility of CNS prophylaxis in patients with DLBCL receiving 1st line therapy.
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Affiliation(s)
- Jeffrey Lantz
- Division of Hematology and Oncology and Comprehensive Cancer Center, Department of Medicine, University of Virginia School of Medicine; Charlottesville, VA, USA.
| | - Craig A Portell
- Division of Hematology and Oncology and Comprehensive Cancer Center, Department of Medicine, University of Virginia School of Medicine; Charlottesville, VA, USA.
| | - Emily C Ayers
- Division of Hematology and Oncology and Comprehensive Cancer Center, Department of Medicine, University of Virginia School of Medicine; Charlottesville, VA, USA.
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12
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Ghione P, Lewis KL, Bobillo S, Nayak L, Schorb E, Nichelli L, Ng A, Savage KJ, McKay P, Nastoupil L, Soussain C, Cwynarski K. Central nervous system lymphomas-Assessment and treatment and prevention of central nervous system relapse. Hematol Oncol 2023. [PMID: 37381737 DOI: 10.1002/hon.3197] [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: 04/08/2023] [Revised: 05/30/2023] [Accepted: 06/07/2023] [Indexed: 06/30/2023]
Abstract
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.
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Affiliation(s)
- Paola Ghione
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Katharine L Lewis
- Sir Charles Gairdner Hospital and Linear Clinical Research, Nedlands, Western Australia, Australia
| | | | - Laksmi Nayak
- Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Elisabeth Schorb
- Department of Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Lucia Nichelli
- Hôpitaux Universitaires La Pitié Salpêtrière, Paris, France
| | - Andrea Ng
- Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Kerry J Savage
- Centre for Lymphoid Cancer, Division of Medical Oncology, BC Cancer, Vancouver, British Columbia, Canada
| | | | - Loretta Nastoupil
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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13
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Velicu MA, Lavrador JP, Sibtain N, Vergani F, Bhangoo R, Gullan R, Ashkan K. Neurosurgical Management of Central Nervous System Lymphoma: Lessons Learnt from a Neuro-Oncology Multidisciplinary Team Approach. J Pers Med 2023; 13:jpm13050783. [PMID: 37240953 DOI: 10.3390/jpm13050783] [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: 03/29/2023] [Revised: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023] Open
Abstract
Central nervous system lymphoma (CNSL) represents one of the most aggressive forms of extranodal lymphoma. The gold standard for CNSL diagnosis remains the stereotactic biopsy, with a limited role for cytoreductive surgery that has not been supported by historical data. Our study aims to provide a comprehensive overview of neurosurgery's role in the diagnosis of systemic relapsed and primary CNSL, with an emphasis on the impact on management and survival. This is a single center retrospective cohort study with data collected between August 2012 and August 2020, including patients referred with a potential diagnosis of CNSL to the local Neuro-oncology Multidisciplinary Team (MDT). The concordance between the MDT outcome and histopathological confirmation was assessed using diagnostic statistics. A Cox regression is used for overall survival (OS) risk factor analysis, and Kaplan-Meier statistics are performed for three prognostic models. The diagnosis of lymphoma is confirmed in all cases of relapsed CNSL, and in all but two patients who underwent neurosurgery. For the relapsed CNSL group, the highest positive predictive value (PPV) is found for an MDT outcome when lymphoma had been considered as single or topmost probable diagnosis. Neuro-oncology MDT has an important role in establishing the diagnosis in CNSL, not only to plan tissue diagnosis but also to stratify the surgical candidates. The MDT outcome based on history and imaging has good predictive value for cases where lymphoma is considered the most probable diagnosis, with the best prediction for cases of relapsed CNSL, questioning the need for invasive tissue diagnosis in the latter group.
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Affiliation(s)
- Maria Alexandra Velicu
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK
| | - Jose Pedro Lavrador
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK
| | - Naomi Sibtain
- Department of Neuroradiology, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK
| | - Francesco Vergani
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK
| | - Ranjeev Bhangoo
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK
| | - Richard Gullan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK
| | - Keyoumars Ashkan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK
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14
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Zhang N, Xu D, Liu B, Shi X, Xie X, Wang Z. Prophylaxis strategies containing high dose intravenous methotrexate on preventing CNS relapse for patients with diffuse large B-cell lymphoma at intermediate to high risk: A study based on 12 cohorts in the rituximab era. Int Immunopharmacol 2022; 113:109299. [DOI: 10.1016/j.intimp.2022.109299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/19/2022] [Accepted: 09/27/2022] [Indexed: 11/05/2022]
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15
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Lewis KL, Cheah CY. About time: why central nervous system prophylaxis timing in diffuse large B-cell lymphoma matters and does the protocol need updating? Expert Rev Hematol 2022; 15:959-962. [PMID: 36278876 DOI: 10.1080/17474086.2022.2140138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Katharine Louise Lewis
- Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,University of Western Australia, Nedlands, Western Australia, Australia.,Linear Clinical Research, Nedlands, Western Australia, Australia
| | - Chan Yoon Cheah
- Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,University of Western Australia, Nedlands, Western Australia, Australia.,Pathwest, Nedlands, Western Australia, Australia
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16
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Eyre TA, Savage KJ, Cheah CY, El-Galaly TC, Lewis KL, McKay P, Wilson MR, Evens AM, Bobillo S, Villa D, Maurer MJ, Cwynarski K, Ferreri AJM. CNS prophylaxis for diffuse large B-cell lymphoma. Lancet Oncol 2022; 23:e416-e426. [DOI: 10.1016/s1470-2045(22)00371-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 05/30/2022] [Accepted: 06/01/2022] [Indexed: 11/25/2022]
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17
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Lin Z, Chen X, Liu L, Zeng H, Li Z, Xu B. The role of central nervous system (CNS) prophylaxis in preventing DLBCL patients from CNS relapse: A network meta-analysis. Crit Rev Oncol Hematol 2022; 176:103756. [PMID: 35809794 DOI: 10.1016/j.critrevonc.2022.103756] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 06/25/2022] [Accepted: 07/02/2022] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Secondary central nervous system (CNS) relapses are an uncommon yet devastating complication in diffuse large B cell lymphoma (DLBCL). Although several prophylaxis attempts were employed clinically in order to reduce the CNS relapse rate, the optimal management remained uncertain. METHODS We employed conventional meta-analysis along with Network meta-analysis to investigate an optimal prophylactic strategy. The primary outcome was CNS relapse rate. RESULTS A total of thirty-six studies comprising 5 RCTs, one clinical trial and 30 observational studies were included. Rituximab overall was superior in reducing CNS relapse rate, and the statistical significance exists (RR 0.79(0.68-0.93), p = 0.004). In rituximab era, none of intravenous, intrathecal administration or novel target agents could significantly decrease CNS relapse rate in high CNS risk patients. Intensive chemotherapy regimen containing HD-MTX with HD-Ara-C (SUCRA 93.4 %) was ranked as the first in reducing CNS relapse rate followed by no prophylaxis (SUCRA 57.5 %), HD-MTX (SUCRA 53.1 %), IT (SUCRA 34.5 %) and lenalidomide maintenance (SUCRA 11.5 %). In addition, intercalated HD-MTX had a trend of reducing CNS relapse but without statistical significance (RR 0.86(0.44-1.68), p = 0.67). However, i-HD-MTX was associated with increased grade 3-4 toxicities and prolonged inpatient stay. Early HD-MTX exposure also increased the treatment related death. CONCLUSION Our network meta-analysis provides an overview of the relative efficacy of all available CNS prophylaxis strategies in DLBCL. In rituximab era, none of intravenous, intrathecal administration or novel target agents could significantly decrease CNS relapse rate in high CNS risk patients. Further studies with prospective, randomized clinical trials as well as with more focus on novel target agents that could spread blood-brain barriers are suggested.
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Affiliation(s)
- Zhijuan Lin
- Department of Hematology, the First Affiliated Hospital of Xiamen University and Institute of Hematology, School of Medicine, Xiamen University, Xiamen, China; Key Laboratory of Xiamen for Diagnosis and Treatment of Hematological Malignancy, Xiamen, China
| | - Xing Chen
- Department of Nephrology, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Long Liu
- Department of Hematology, the First Affiliated Hospital of Xiamen University and Institute of Hematology, School of Medicine, Xiamen University, Xiamen, China; Key Laboratory of Xiamen for Diagnosis and Treatment of Hematological Malignancy, Xiamen, China
| | - Hanyan Zeng
- Department of Hematology, the First Affiliated Hospital of Xiamen University and Institute of Hematology, School of Medicine, Xiamen University, Xiamen, China; Key Laboratory of Xiamen for Diagnosis and Treatment of Hematological Malignancy, Xiamen, China
| | - Zhifeng Li
- Department of Hematology, the First Affiliated Hospital of Xiamen University and Institute of Hematology, School of Medicine, Xiamen University, Xiamen, China; Key Laboratory of Xiamen for Diagnosis and Treatment of Hematological Malignancy, Xiamen, China.
| | - Bing Xu
- Department of Hematology, the First Affiliated Hospital of Xiamen University and Institute of Hematology, School of Medicine, Xiamen University, Xiamen, China; Key Laboratory of Xiamen for Diagnosis and Treatment of Hematological Malignancy, Xiamen, China.
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18
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Shichijo T, Tatetsu H, Nosaka K, Higuchi Y, Kikukawa Y, Inoue Y, Toyoda K, Yasunaga J, Matsuoka M. Predictive impact of soluble interleukin‐2 receptor and number of extranodal sites for identification of patients at very high risk of CNS relapse in diffuse large B‐cell lymphoma. EJHAEM 2022; 3:385-393. [PMID: 35846027 PMCID: PMC9175809 DOI: 10.1002/jha2.393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/14/2022] [Accepted: 01/18/2022] [Indexed: 11/23/2022]
Abstract
There remains an unmet clinical need to identify which patients with diffuse large B‐cell lymphoma (DLBCL) would benefit from central nervous system (CNS) prophylaxis, due to the low positive predictive value (PPV; 10%–15%) of the currently available predictive models. To stratify patients at high risk of developing CNS relapse, we retrospectively analyzed 182 patients with DLBCL initially treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R‐CHOP), or a R‐CHOP‐like regimen. Among them, 17 patients relapsed with CNS involvement, and the 2‐year rate of CNS relapse was 7.9%. Upon carrying out multivariate analysis, ≥3 extranodal sites and elevated soluble interleukin‐2 receptor (sIL‐2R) levels at diagnosis were identified as independent risk factors for CNS relapse. The 2‐year and 3.5‐year rates of CNS relapse were 57.1% and 78.6%, respectively, in patients with both elevated sIL‐2R and ≥3 extranodal sites. Furthermore, combined use of these risk factors of both elevated sIL‐2R and ≥3 extranodal sites resulted in a high PPV (71.4%), negative predictive value (93.1%), and overall accuracy (92.3%) for undergoing CNS relapse. In conclusion, we propose a simple and valuable tool to predict patients with DLBCL at very high risk of CNS relapse.
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Affiliation(s)
- Takafumi Shichijo
- Department of Hematology, Rheumatology and Infectious Diseases Kumamoto University Hospital Kumamoto Japan
| | - Hiro Tatetsu
- Department of Hematology, Rheumatology and Infectious Diseases Kumamoto University Hospital Kumamoto Japan
| | - Kisato Nosaka
- Department of Hematology, Rheumatology and Infectious Diseases Kumamoto University Hospital Kumamoto Japan
| | - Yusuke Higuchi
- Department of Hematology, Rheumatology and Infectious Diseases Kumamoto University Hospital Kumamoto Japan
| | - Yoshitaka Kikukawa
- Department of Hematology and Oncology Kumamoto City Hospital Kumamoto Japan
| | - Yoshitaka Inoue
- Department of Hematology, Rheumatology and Infectious Diseases Kumamoto University Hospital Kumamoto Japan
| | - Kosuke Toyoda
- Department of Hematology, Rheumatology and Infectious Diseases Kumamoto University Hospital Kumamoto Japan
| | - Jun‐ichirou Yasunaga
- Department of Hematology, Rheumatology and Infectious Diseases Kumamoto University Hospital Kumamoto Japan
| | - Masao Matsuoka
- Department of Hematology, Rheumatology and Infectious Diseases Kumamoto University Hospital Kumamoto Japan
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19
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Timing of high dose methotrexate CNS prophylaxis in DLBCL: a multicenter international analysis of 1,384 patients. Blood 2022; 139:2499-2511. [DOI: 10.1182/blood.2021014506] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 12/30/2021] [Indexed: 11/20/2022] Open
Abstract
Prophylactic high-dose methotrexate (HD-MTX) is often used for diffuse large B-cell lymphoma (DLBCL) patients at high risk of central nervous system (CNS) relapse, despite limited evidence demonstrating efficacy or the optimal delivery method. We conducted a retrospective, international analysis of 1,384 patients receiving HD-MTX CNS prophylaxis either intercalated (i-HD-MTX) (n=749) or at the end (n=635) of R-CHOP/R-CHOP-like therapy (EOT). There were 78 CNS relapses (3-year rate 5.7%), with no difference between i-HD-MTX and EOT; 5.7% vs 5.8%, p=0.98, 3-year difference: 0.04% (-2.0% to 3.1%). Conclusions were unchanged on adjusting for baseline prognostic factors or on 6-month landmark analysis (n=1,253). In patients with high CNS international prognostic index (n=600), 3-year CNS relapse rate was 9.1% with no difference between i-HD-MTX and EOT. On multivariable analysis, increasing age and renal/adrenal involvement were the only independent risk factors for CNS relapse. Concurrent intrathecal prophylaxis was not associated with reduction in CNS relapse. R-CHOP delays of ≥7 days were significantly increased with i-HD-MTX versus EOT, with 308/1573 (19.6%) i-HD-MTX treatments resulting in delay to subsequent R-CHOP (median 8 days). Increased risk of delay occurred in older patients when delivery was later than day 10 in the R-CHOP cycle. In summary, we found no evidence that EOT delivery increases CNS relapse risk versus i-HD-MTX. Findings in high-risk subgroups were unchanged. Rates of CNS relapse in this HD-MTX-treated cohort were similar to comparable cohorts receiving infrequent CNS prophylaxis. If HD-MTX is still considered for certain high-risk patients, delivery could be deferred until R-CHOP completion.
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Fang Y, Su N, Ma S, Cai J, Zhong L, Li W, Huang H, Li Z, Huang H, Xia Y, Liu P, Guo L, Li Z, Wu Y, Tian X, Wang J, Zhang Y, Cai Q. Optimization of high-dose methotrexate prophylaxis for central nervous system relapse in diffuse large B-cell lymphoma: a multicenter analysis. Ann Hematol 2022; 101:595-605. [DOI: 10.1007/s00277-021-04739-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 12/02/2021] [Indexed: 11/01/2022]
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21
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Ho G, Tan C, de Mel S, Poon L, Chan EHL, Lee J, Liu X, Chng WJ, Chee YL, Soon YY, Jeyasekharan AD. Central nervous system (CNS) prophylaxis in antiCD20-CHOP treated DLBCL at intermediate to high risk for CNS relapse: A systematic review and meta-analysis. Crit Rev Oncol Hematol 2021; 167:103507. [PMID: 34656744 DOI: 10.1016/j.critrevonc.2021.103507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/10/2021] [Indexed: 12/27/2022] Open
Abstract
CNS prophylaxis is commonly used in Diffuse Large B-Cell Lymphoma (DLBCL) patients with risk features for CNS relapse. This systematic review and meta-analysis compares CNS relapse rates with and without CNS prophylaxis, for patients at intermediate to high CNS relapse risk. Studies reporting CNS relapse risk category and CNS outcomes with and without CNS prophylaxis for antiCD20-CHOP treated DLBCL patients were included. 10 studies with 3770 patients at intermediate to high CNS relapse risk were analyzed. No significant difference in the pooled Absolute Risk Difference (ARD 0.01, 95 % CI -0.01 to 0.02, P = 0.61) or Risk (RR 1.22, 95 % CI 0.81-1.83, P = 0.34) was noted in patients with and without CNS prophylaxis. There were also no differences within pre-specified subgroups of IV Methotrexate or IT chemotherapy. However, the quality of evidence supporting these observations was low. A meta-analysis of individual patient data will help evaluate the benefit of CNS prophylaxis strategies.
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Affiliation(s)
- Guiyi Ho
- Department of Haematology-Oncology, National University Hospital, Singapore
| | - Cherie Tan
- Department of Haematology-Oncology, National University Hospital, Singapore
| | - Sanjay de Mel
- Department of Haematology-Oncology, National University Hospital, Singapore
| | - Limei Poon
- Department of Haematology-Oncology, National University Hospital, Singapore
| | - Esther H L Chan
- Department of Haematology-Oncology, National University Hospital, Singapore
| | - Joanne Lee
- Department of Haematology-Oncology, National University Hospital, Singapore
| | - Xin Liu
- Department of Haematology-Oncology, National University Hospital, Singapore
| | - Wee Joo Chng
- Department of Haematology-Oncology, National University Hospital, Singapore; Cancer Science Institute of Singapore, National University of Singapore, Singapore
| | - Yen Lin Chee
- Department of Haematology-Oncology, National University Hospital, Singapore
| | - Yu Yang Soon
- Department of Radiation Oncology, National University Hospital, Singapore.
| | - Anand D Jeyasekharan
- Department of Haematology-Oncology, National University Hospital, Singapore; Cancer Science Institute of Singapore, National University of Singapore, Singapore.
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Zing N, Fischer T, Federico M, Chiattone C, Ferreri AJM. Diagnosis, prevention and treatment of central nervous system involvement in peripheral t-cell lymphomas. Crit Rev Oncol Hematol 2021; 167:103496. [PMID: 34653598 DOI: 10.1016/j.critrevonc.2021.103496] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/23/2021] [Accepted: 09/08/2021] [Indexed: 11/24/2022] Open
Abstract
Non-Hodgkin lymphomas with T-cell immunophenotype encompass a heterogeneous group of infrequent neoplasms that follow variable clinical courses but prevalently include aggressive behavior and high mortality rates. The involvement of the central nervous system (CNS) is an uncommon event in T-cell lymphomas, with wide variability among the different disease entities. CNS can be affected either at initial diagnosis or at recurrence, and both forms are considered "secondary CNS T-cell lymphoma". Given the low incidence of secondary CNS T-cell lymphoma, related literature is sparse, contradictory, and primarily constituted by small case series and single case reports. However, reported studies uniformly suggest high mortality rates related to this event. Therefore, to improve our ability to identify high-risk patients and offer them successful CNS prophylaxis or timely and effective treatment once the event has occurred may prevent CNS-related T-cell lymphomas deaths. For example, some entities like aggressive adult T-cell leukemia/lymphoma, extranodal natural killer/T-cell lymphoma, and other peripheral T-cell lymphomas with involvement of two or more extranodal organs are prone to CNS dissemination and should be considered for personalized CNS prophylaxis. The level of evidence suggesting an increased risk of CNS recurrence for other T-cell lymphomas and for other risk factors is lower. Published case series show that, following the example of aggressive B-cell lymphomas, patients with T-cell lymphomas and putative increased CNS risk receive different forms of prophylaxis, mostly methotrexate and cytarabine delivered by intrathecal and/or intravenous routes, with varied success. To date, achievements in the treatment of CNS involvement in patients with aggressive B-cell lymphoma were not replicated in secondary CNS T-cell lymphomas, and identification of effective therapies remains an urgent research target. This review is focused on clinical findings, diagnosis, treatment, and prognosis of patients with T-cell lymphoma experiencing CNS dissemination either at presentation or relapse. It aims to provide logical and, oftentimes, evidence-based answers to the most common questions on the most probable risk factors to CNS involvement in patients with T-cell lymphoma, the indications and strategies to prevent this life-threating event, and the management of patients with CNS disease.
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Affiliation(s)
- Natalia Zing
- Departament of Onco-Hematology, Hospital Beneficência Portuguesa de São Paulo, Brazil; T-cell Brazil Project, Brazil
| | - Thais Fischer
- Hospital AC Camargo Cancer Center, Brazil; T-cell Brazil Project, Brazil
| | - Massimo Federico
- Medical Oncology, CHIMOMO Department, University of Modena and Reggio Emilia, Modena, Italy; T-cell Brazil Project, Brazil
| | - Carlos Chiattone
- Hospital Samaritano de São Paulo, Brazil; T-cell Brazil Project, Brazil; Santa Casa de Sao Paulo School of Medical Sciences, São Paulo, Brazil
| | - Andrés J M Ferreri
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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Puckrin R, Stewart DA. Prophylactic high-dose methotrexate in diffuse large B cell lymphoma, authors' response. Am J Hematol 2021; 96:E339-E341. [PMID: 34050955 DOI: 10.1002/ajh.26256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 05/20/2021] [Accepted: 05/24/2021] [Indexed: 11/06/2022]
Affiliation(s)
| | - Douglas A. Stewart
- University of Calgary and Tom Baker Cancer Centre Calgary Alberta Canada
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Martinez‐Calle N, Wilson MR, Eyre TA, Cwynarski K, McKay P, Fox CP. Interpretation of retrospective data evaluating high-dose methotrexate as central nervous system prophylaxis in diffuse large B-cell lymphoma; caution required. Am J Hematol 2021; 96:E338-E339. [PMID: 34050962 DOI: 10.1002/ajh.26257] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 05/21/2021] [Accepted: 05/24/2021] [Indexed: 01/24/2023]
Affiliation(s)
- Nicolas Martinez‐Calle
- Department of Clinical Haematology Nottingham University Hospitals NHS Trust Nottingham UK
- School of Medicine University of Nottingham Nottingham UK
| | - Matthew R. Wilson
- Department of Haematology Beatson West of Scotland Cancer Centre Glasgow UK
| | - Toby A. Eyre
- Department of Clinical Haematology Oxford Cancer and Haematology Centre, Churchill Hospital, Oxford University Hospitals NHS Trust Oxford UK
| | - Kate Cwynarski
- Department of Haematology University College Hospital London UK
| | - Pamela McKay
- Department of Haematology Beatson West of Scotland Cancer Centre Glasgow UK
| | - Christopher P. Fox
- Department of Clinical Haematology Nottingham University Hospitals NHS Trust Nottingham UK
- School of Medicine University of Nottingham Nottingham UK
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25
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Xie J, Jang A, Uemura M, Nakazawa S, Calimeri T, Ferreri AJ, Chen SR, Schmid JL, Brown TC, Socola F, Safah H, Saba NS. Systemic vs. intrathecal central nervous system prophylaxis in primary adrenal/renal diffuse large b-cell LYMPHOMA: A multi-institution retrospective analysis and systematic review. Leuk Res Rep 2021; 16:100263. [PMID: 34401320 PMCID: PMC8355911 DOI: 10.1016/j.lrr.2021.100263] [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: 04/04/2021] [Accepted: 07/28/2021] [Indexed: 11/24/2022] Open
Abstract
Primary adrenal lymphoma (PAL) and primary renal lymphoma (PRL) are rare extranodal lymphomas, predominantly of diffuse large B-cell lymphoma subtype. Primary adrenal and renal lymphomas (PARL) exhibit a high predilection for the central nervous system (CNS). Therefore, current guidelines support the use of CNS prophylaxis in PARL, particularly in cases of high-risk Central Nervous System International Prognostic Index (CNS-IPI). However, the route of administration (i.e. systemic vs. intrathecal chemotherapy) has not been clearly elucidated. With this in mind, we initiated an international collaboration and literature review to analyze 50 patient cases, 20 of which received CNS prophylaxis. Based on our analysis, we conclude that PARL may indicate a need for CNS chemo-prophylaxis in the form of systemic high-dose methotrexate (HD-MTX) over intrathecal methotrexate (IT-MTX), although IT-MTX may still have utility in certain cases.
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Affiliation(s)
- John Xie
- Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA, United States
| | - Albert Jang
- Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA, United States
| | - Motohide Uemura
- Department of Urology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shigeaki Nakazawa
- Department of Urology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Teresa Calimeri
- Lymphoma Unit, Dept of Onco-hematology, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Andres Jm Ferreri
- Lymphoma Unit, Dept of Onco-hematology, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Shuang R Chen
- Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA, United States
| | - Janet L Schmid
- Department of Pathology, Tulane University, New Orleans, LA, United States
| | - Theresa C Brown
- Hayward Genetics Center, Tulane University School of Medicine, New Orleans, Louisiana, United States
| | - Francisco Socola
- Section of Hematology and Medical Oncology, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, United States
| | - Hana Safah
- Section of Hematology and Medical Oncology, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, United States
| | - Nakhle S Saba
- Section of Hematology and Medical Oncology, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, United States
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26
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High-dose methotrexate is effective for prevention of isolated CNS relapse in diffuse large B cell lymphoma. Blood Cancer J 2021; 11:143. [PMID: 34385415 PMCID: PMC8361130 DOI: 10.1038/s41408-021-00535-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 12/24/2022] Open
Abstract
The role of central nervous system (CNS) prophylaxis with high-dose methotrexate (HDMTX) in DLBCL is controversial. In this retrospective study, we evaluated the efficacy of prophylactic HDMTX on isolated CNS relapse, concomitant CNS and systemic relapse, systemic relapse, and survival outcomes in 226 patients with newly diagnosed DLBCL and high-risk CNS International Prognostic Index (CNS-IPI) score treated with RCHOP. The three-year risk of isolated CNS relapse was significantly lower in patients who received HDMTX, at 3.1% compared to 14.6% (P = 0.032) in those who did not. However, neither concomitant CNS-systemic relapse rates, systemic relapse rates, nor three-year PFS and OS were significantly different between treatment groups in multivariable analysis. Among propensity score-matched patients (N = 102), HDMTX was also associated with significantly lower isolated CNS relapse rates (HR 0.06, 95% CI 0.004–0.946, P = 0.046). HDMTX was well tolerated with manageable toxicities when given at a dose of 3 g/m2 by day 3 of RCHOP chemotherapy. Using propensity score matching and multivariable regression to yield treatment groups with well-balanced covariates, we showed that prophylactic HDMTX improved isolated CNS relapse rates but did not decrease concomitant CNS-systemic relapse rates, systemic relapse rates, or improve survival outcomes.
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27
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Incidence of central nervous system relapses in patients with DLBCL treated with lenalidomide as maintenance after R-CHOP. Blood Adv 2021; 5:2965-2968. [PMID: 34338754 DOI: 10.1182/bloodadvances.2021004766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/02/2021] [Indexed: 01/03/2023] Open
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28
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Faqah A, Asif S, Goksu SY, Sheikh HS. Real-World Data (RWD) on the 3-Year Follow-Up Outcomes of Different CNS Prophylaxis Strategies Across CNS-IPI Risk Groups in Patients With Diffuse Large B-Cell Non-Hodgkin Lymphoma. JCO Glob Oncol 2021; 7:486-494. [PMID: 33835825 PMCID: PMC8162514 DOI: 10.1200/go.20.00422] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE CNS relapse in patients with diffuse large B-cell lymphoma (DLBCL) is associated with poor prognosis with a median survival of about 2.5 months. Data demonstrating best prophylactic strategy remain controversial and need further definition. PATIENTS AND METHODS We present data of 110 patients with DLBCL treated with standard systemic therapy divided into four groups based on primary CNS prophylaxis strategy and CNS International Prognostic Index (IPI) risk categories. We compared their 3-year CNS relapse rate and overall survival in each group. RESULTS The CNS prophylaxis strategy consisted of intrathecal (IT) methotrexate (MTX) in group 1, high-dose (HD) MTX in group 2, combination IT and HD MTX in group 3, and IT and/or HD MTX with intensive chemotherapy in group 4. At 3 years, CNS relapse rate was 8.6% (4/46), 8.3% (1/12), 4.8% (2/42), and 18% (2/11) in groups 1-4 (P = .64), respectively. According to CNS IPI, the CNS relapse rate was 16.6%, 10.1%, and 0% in high-, intermediate-, and low-risk groups, respectively. The 3-year overall survival rate was 69%, 75%, 80%, and 45% in groups 1-4 (P = .71), respectively. CONCLUSION Our study while did not find statistical significance did indicate a lower incidence of CNS relapse with the addition of systemic HD MTX to IT MTX in the high-risk DLBCL population.
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Affiliation(s)
- Anadil Faqah
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Summaiya Asif
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
| | - Suleyman Yasin Goksu
- Department of Internal Medicine, Division of Hematology and Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Hassan S Sheikh
- Department of Medical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan
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30
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Puckrin R, El Darsa H, Ghosh S, Peters A, Owen C, Stewart D. Ineffectiveness of high-dose methotrexate for prevention of CNS relapse in diffuse large B-cell lymphoma. Am J Hematol 2021; 96:764-771. [PMID: 33811794 DOI: 10.1002/ajh.26181] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/24/2021] [Accepted: 04/01/2021] [Indexed: 12/12/2022]
Abstract
Central nervous system (CNS) relapse affects 5% of diffuse large B-cell lymphoma (DLBCL) patients and portends a poor prognosis. Prophylactic intravenous high-dose methotrexate (HD-MTX) is frequently employed to reduce this risk, but there is limited evidence supporting this practice. We conducted a multicenter retrospective study to determine the CNS relapse risk with HD-MTX in DLBCL patients aged 18-70 years treated in Alberta, Canada between 2012 and 2019. Provincial guidelines recommended HD-MTX for patients at high-risk of CNS relapse based upon CNS-IPI score, double-hit lymphoma, or testicular involvement. Among 906 patients with median follow-up 35.3 months (range 0.29-105.7), CNS relapse occurred in 1.9% with CNS-IPI 0-1, 4.9% with CNS-IPI 2-3, and 12.2% with CNS-IPI 4-6 (p < .001). HD-MTX was administered to 115/326 (35.3%) high-risk patients, of whom 96 (83.5%) had CNS-IPI score 4-6, 45 (39.1%) had double-hit lymphoma, and four (3.5%) had testicular lymphoma. The median number of HD-MTX doses was two (range 1-3). Central nervous system relapse risk was similar with versus without HD-MTX (11.2% vs. 12.2%, p = .82) and comparable to previous reports of high-risk patients who did not receive CNS prophylaxis (10-12%). In multivariate and propensity score analyses, HD-MTX demonstrated no association with CNS relapse, progression-free survival, or overall survival. This study did not demonstrate a benefit of prophylactic HD-MTX in this high-risk patient population. Further study is required to determine the optimal strategy to prevent CNS relapse in DLBCL.
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Affiliation(s)
- Robert Puckrin
- Postgraduate Medical Education, University of Calgary, Calgary, Alberta, Canada
| | - Haidar El Darsa
- Postgraduate Medical Education, University of Alberta, Edmonton, Alberta, Canada
| | - Sunita Ghosh
- Alberta Health Services Cancer Control Alberta, Edmonton, Alberta, Canada
| | - Anthea Peters
- University of Alberta and Cancer Cross Institute, Edmonton, Alberta, Canada
| | - Carolyn Owen
- University of Calgary and Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Douglas Stewart
- University of Calgary and Tom Baker Cancer Centre, Calgary, Alberta, Canada
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Bobillo S, Joffe E, Sermer D, Mondello P, Ghione P, Caron PC, Hamilton A, Hamlin PA, Horwitz SM, Kumar A, Matasar MJ, Batlevi CL, Moskowitz A, Noy A, Owens CN, Palomba ML, Straus D, von Keudell G, Dogan A, Zelenetz AD, Seshan VE, Younes A. Prophylaxis with intrathecal or high-dose methotrexate in diffuse large B-cell lymphoma and high risk of CNS relapse. Blood Cancer J 2021; 11:113. [PMID: 34135307 PMCID: PMC8209097 DOI: 10.1038/s41408-021-00506-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 04/29/2021] [Accepted: 05/10/2021] [Indexed: 02/07/2023] Open
Abstract
Although methotrexate (MTX) is the most widely used therapy for central nervous system (CNS) prophylaxis in patients with diffuse large B-cell lymphoma (DLBCL), the optimal regimen remains unclear. We examined the efficacy of different prophylactic regimens in 585 patients with newly diagnosed DLBCL and high-risk for CNS relapse, treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) or R-CHOP-like regimens from 2001 to 2017, of whom 295 (50%) received prophylaxis. Intrathecal (IT) MTX was given to 253 (86%) and high-dose MTX (HD-MTX) to 42 (14%). After a median follow-up of 6.8 years, 36 of 585 patients relapsed in the CNS, of whom 14 had received prophylaxis. The CNS relapse risk at 1 year was lower for patients who received prophylaxis than patients who did not: 2% vs. 7.1%. However, the difference became less significant over time (5-year risk 5.6% vs. 7.5%), indicating prophylaxis tended to delay CNS relapse rather than prevent it. Furthermore, the CNS relapse risk was similar in patients who received IT and HD-MTX (5-year risk 5.6% vs. 5.2%). Collectively, our data indicate the benefit of MTX for CNS prophylaxis is transient, highlighting the need for more effective prophylactic regimens. In addition, our results failed to demonstrate a clinical advantage for the HD-MTX regimen.
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Affiliation(s)
- Sabela Bobillo
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Hematology, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
- Department of Medicine, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Erel Joffe
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David Sermer
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Patrizia Mondello
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paola Ghione
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Philip C Caron
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Audrey Hamilton
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paul A Hamlin
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Steven M Horwitz
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Anita Kumar
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Matthew J Matasar
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Connie L Batlevi
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Alison Moskowitz
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Ariela Noy
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Collette N Owens
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - M Lia Palomba
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - David Straus
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Gottfried von Keudell
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Ahmet Dogan
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew D Zelenetz
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Venkatraman E Seshan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anas Younes
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Weill Cornell Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
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32
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Mercier M, Orvain C, Drieu La Rochelle L, Marchand T, Nunes Gomes C, Giltat A, Paillassa J, Clavert A, Farhi J, Rousselet MC, Gyan E, Houot R, Moles-Moreau MP, Hunault-Berger M. Impact of High-Dose Methotrexate on the Outcome of Patients with Diffuse Large B-Cell Lymphoma and Skeletal Involvement. Cancers (Basel) 2021; 13:cancers13122945. [PMID: 34204600 PMCID: PMC8231126 DOI: 10.3390/cancers13122945] [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: 05/18/2021] [Revised: 06/04/2021] [Accepted: 06/08/2021] [Indexed: 11/16/2022] Open
Abstract
Diffuse large B-cell lymphoma (DLBCL) with extra nodal skeletal involvement is rare. It is currently unclear whether these lymphomas should be treated in the same manner as those without skeletal involvement. We retrospectively analyzed the impact of combining high-dose methotrexate (HD-MTX) with an anthracycline-based regimen and rituximab as first-line treatment in a cohort of 93 patients with DLBCL and skeletal involvement with long follow-up. Fifty patients (54%) received upfront HD-MTX for prophylaxis of CNS recurrence (high IPI score and/or epidural involvement) or because of skeletal involvement. After adjusting for age, ECOG, high LDH levels, and type of skeletal involvement, HD-MTX was associated with an improved PFS and OS (HR: 0.2, 95% CI: 0.1-0.3, p < 0.001 and HR: 0.1, 95% CI: 0.04-0.3, p < 0.001, respectively). Patients who received HD-MTX had significantly better 5-year PFS and OS (77% vs. 39%, p <0.001 and 83 vs. 58%, p < 0.001). Radiotherapy was associated with an improved 5-year PFS (74 vs. 48%, p = 0.02), whereas 5-year OS was not significantly different (79% vs. 66%, p = 0.09). A landmark analysis showed that autologous stem cell transplantation was not associated with improved PFS or OS. The combination of high-dose methotrexate and an anthracycline-based immunochemotherapy is associated with an improved outcome in patients with DLBCL and skeletal involvement and should be confirmed in prospective trials.
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Affiliation(s)
- Mélanie Mercier
- Maladies du Sang, CHU d’Angers, 49000 Angers, France; (C.N.G.); (A.G.); (J.P.); (A.C.); (J.F.); (M.-P.M.-M.); (M.H.-B.)
- Service d’Hématologie, CH Bretagne Atlantique, 56000 Vannes, France
- Correspondence: (M.M.); (C.O.); Tel.: +33-(0)-241-35-44-72 (C.O.); Fax: +33-(0)-241-35-53-81 (C.O.)
| | - Corentin Orvain
- Maladies du Sang, CHU d’Angers, 49000 Angers, France; (C.N.G.); (A.G.); (J.P.); (A.C.); (J.F.); (M.-P.M.-M.); (M.H.-B.)
- Fédération Hospitalo-Universitaire Grand-Ouest Acute Leukemia (FHU-GOAL), 49033 Angers, France; (L.D.L.R.); (E.G.)
- Université d’Angers, Inserm, CRCINA, 49000 Angers, France
- Correspondence: (M.M.); (C.O.); Tel.: +33-(0)-241-35-44-72 (C.O.); Fax: +33-(0)-241-35-53-81 (C.O.)
| | - Laurianne Drieu La Rochelle
- Fédération Hospitalo-Universitaire Grand-Ouest Acute Leukemia (FHU-GOAL), 49033 Angers, France; (L.D.L.R.); (E.G.)
- Service d’Hématologie et Thérapie Cellulaire, Centre Hospitalier Universitaire, Université de Tours, 37000 Tours, France
| | - Tony Marchand
- Service d’Hématologie Clinique, CHU de Rennes, 35000 Rennes, France; (T.M.); (R.H.)
| | - Christopher Nunes Gomes
- Maladies du Sang, CHU d’Angers, 49000 Angers, France; (C.N.G.); (A.G.); (J.P.); (A.C.); (J.F.); (M.-P.M.-M.); (M.H.-B.)
| | - Aurélien Giltat
- Maladies du Sang, CHU d’Angers, 49000 Angers, France; (C.N.G.); (A.G.); (J.P.); (A.C.); (J.F.); (M.-P.M.-M.); (M.H.-B.)
| | - Jérôme Paillassa
- Maladies du Sang, CHU d’Angers, 49000 Angers, France; (C.N.G.); (A.G.); (J.P.); (A.C.); (J.F.); (M.-P.M.-M.); (M.H.-B.)
| | - Aline Clavert
- Maladies du Sang, CHU d’Angers, 49000 Angers, France; (C.N.G.); (A.G.); (J.P.); (A.C.); (J.F.); (M.-P.M.-M.); (M.H.-B.)
| | - Jonathan Farhi
- Maladies du Sang, CHU d’Angers, 49000 Angers, France; (C.N.G.); (A.G.); (J.P.); (A.C.); (J.F.); (M.-P.M.-M.); (M.H.-B.)
| | | | - Emmanuel Gyan
- Fédération Hospitalo-Universitaire Grand-Ouest Acute Leukemia (FHU-GOAL), 49033 Angers, France; (L.D.L.R.); (E.G.)
- Service d’Hématologie et Thérapie Cellulaire, Centre Hospitalier Universitaire, Université de Tours, 37000 Tours, France
| | - Roch Houot
- Service d’Hématologie Clinique, CHU de Rennes, 35000 Rennes, France; (T.M.); (R.H.)
| | - Marie-Pierre Moles-Moreau
- Maladies du Sang, CHU d’Angers, 49000 Angers, France; (C.N.G.); (A.G.); (J.P.); (A.C.); (J.F.); (M.-P.M.-M.); (M.H.-B.)
| | - Mathilde Hunault-Berger
- Maladies du Sang, CHU d’Angers, 49000 Angers, France; (C.N.G.); (A.G.); (J.P.); (A.C.); (J.F.); (M.-P.M.-M.); (M.H.-B.)
- Fédération Hospitalo-Universitaire Grand-Ouest Acute Leukemia (FHU-GOAL), 49033 Angers, France; (L.D.L.R.); (E.G.)
- Université d’Angers, Inserm, CRCINA, 49000 Angers, France
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33
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Efficacy and safety of prophylactic high-dose MTX in high-risk DLBCL: a treatment intent-based analysis. Blood Adv 2021; 5:2142-2152. [PMID: 33881464 DOI: 10.1182/bloodadvances.2020003947] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 01/24/2021] [Indexed: 01/03/2023] Open
Abstract
Despite central nervous system (CNS) relapse occurring in >10% of high-risk diffuse large B-cell lymphoma (DLBCL) patients, the role of CNS-directed prophylaxis is controversial in the absence of randomized controlled trials. In this retrospective study, we aimed to evaluate the safety and efficacy of prophylactic high-dose methotrexate (HD-MTX) on CNS relapse and survival outcomes in 258 newly diagnosed R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone)-treated high-risk DLBCL patients, based on the initial treatment intent (ITT) of the physician on the use of prophylactic HD-MTX. Patients were classified into an ITT HD-MTX group (n = 128) and a non-ITT HD-MTX group (n = 130). The CNS relapse rate was not significantly different between these groups, with 2-year CNS relapse rates of 12.4% and 13.9%, respectively (P = 0.96). Three-year progression-free survival and overall survival rates in the ITT HD-MTX and non-ITT HD-MTX groups were 62.4% vs 64.5% (P = 0.94) and 71.7% vs 71.4% (P = 0.7), respectively. Also, propensity score-matched analyses showed no significant differences in the time-to-CNS-relapse, progression-free survival, or overall survival. The ITT HD-MTX group showed a higher incidence of grade ≥ 3 oral mucositis and elevated alanine aminotransferase. Prophylactic HD-MTX does not improve CNS relapse rate or survival outcomes in high-risk DLBCL patients, and it is accompanied by increased toxicities.
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34
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Patients with high-risk DLBCL benefit from dose-dense immunochemotherapy combined with early systemic CNS prophylaxis. Blood Adv 2021; 4:1906-1915. [PMID: 32380536 DOI: 10.1182/bloodadvances.2020001518] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/26/2020] [Indexed: 01/04/2023] Open
Abstract
Survival of patients with high-risk diffuse large B-cell lymphoma (DLBCL) is suboptimal, and the risk of central nervous system (CNS) progression is relatively high. We conducted a phase 2 trial in 139 patients aged 18 to 64 years who had primary DLBCL with an age-adjusted International Prognostic Index (aaIPI) score of 2 to 3 or site-specific risk factors for CNS recurrence. The goal was to assess whether a dose-dense immunochemotherapy with early systemic CNS prophylaxis improves the outcome and reduces the incidence of CNS events. Treatment consisted of 2 courses of high-dose methotrexate in combination with biweekly rituximab (R), cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP-14), followed by 4 courses of R-CHOP-14 with etoposide (R-CHOEP) and 1 course of high-dose cytarabine with R. In addition, liposomal cytarabine was administered intrathecally at courses 1, 3, and 5. Coprimary endpoints were failure-free survival and CNS progression rates. Thirty-six (26%) patients experienced treatment failure. Progression occurred in 23 (16%) patients, including three (2.2%) CNS events. At 5 years of median follow-up, failure-free survival, overall survival, and CNS progression rates were 74%, 83%, and 2.3%, respectively. Treatment reduced the risk of progression compared with our previous trial, in which systemic CNS prophylaxis was given after 6 courses of biweekly R-CHOEP (hazard ratio, 0.49; 95% CI, 0.31-0.77; P = .002) and overcame the adverse impact of an aaIPI score of 3 on survival. In addition, outcome of the patients with BCL2/MYC double-hit lymphomas was comparable to the patients without the rearrangements. The results are encouraging, with a low toxic death rate, low number of CNS events, and favorable survival rates. This trial was registered at www.clinicaltrials.gov as #NCT01325194.
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35
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Timing of high-dose methotrexate CNS prophylaxis in DLBCL: an analysis of toxicity and impact on R-CHOP delivery. Blood Adv 2021; 4:3586-3593. [PMID: 32761231 DOI: 10.1182/bloodadvances.2020002421] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 06/29/2020] [Indexed: 01/08/2023] Open
Abstract
High-dose methotrexate (HD-MTX) is increasingly used as prophylaxis for patients with diffuse large B-cell lymphoma (DLBCL) at high risk of central nervous system (CNS) relapse. However, there is limited evidence to guide whether to intercalate HD-MTX (i-HD-MTX) between R-CHOP-21 (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone given at 21-day intervals) or to give it at the end of treatment (EOT) with R-CHOP-21. We conducted a retrospective, multicenter analysis of 334 patients with DLBCL who received CNS prophylaxis with i-HD-MTX (n = 204) or EOT HD-MTX (n = 130). Primary end points were R-CHOP delay rates and HD-MTX toxicity. Secondary end points were CNS relapse rate, progression-free survival, and overall survival. The EOT group had more patients with a high CNS international prognostic index (58% vs 39%; P < .001) and more concurrent intrathecal prophylaxis (56% vs 34%; P < .001). Of the 409 cycles of i-HD-MTX given, 82 (20%) were associated with a delay of next R-CHOP (median, 7 days). Delays were significantly increased when i-HD-MTX was given after day 9 post-R-CHOP (26% vs 16%; P = .01). On multivariable analysis, i-HD-MTX was independently associated with increased R-CHOP delays. Increased mucositis, febrile neutropenia, and longer median inpatient stay were recorded with i-HD-MTX delivery. Three-year cumulative CNS relapse incidence was 5.9%, with no differences between groups. There was no difference in survival between groups. We report increased toxicity and R-CHOP delay with i-HD-MTX compared with EOT delivery but no difference in CNS relapse or survival. Decisions on HD-MTX timing should be individualized and, where i-HD-MTX is favored, we recommend scheduling before day 10 of R-CHOP cycles.
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36
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Ferreri AJM, Calimeri T, Lopedote P, Francaviglia I, Daverio R, Iacona C, Belloni C, Steffanoni S, Gulino A, Anghileri E, Diffidenti A, Finardi A, Gagliardi F, Anzalone N, Nonis A, Furlan R, De Lorenzo D, Terreni MR, Martinelli V, Sassone M, Foppoli M, Angelillo P, Guggiari E, Falini A, Mortini P, Filippi M, Tarantino V, Eoli M, Ciceri F, Doglioni C, Tripodo C, Locatelli M, Cangi MG, Ponzoni M. MYD88 L265P mutation and interleukin-10 detection in cerebrospinal fluid are highly specific discriminating markers in patients with primary central nervous system lymphoma: results from a prospective study. Br J Haematol 2021; 193:497-505. [PMID: 33620087 DOI: 10.1111/bjh.17357] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/13/2021] [Indexed: 01/02/2023]
Abstract
Reliable biomarkers are needed to avoid diagnostic delay and its devastating effects in patients with primary central nervous system (CNS) lymphoma (PCNSL). We analysed the discriminating sensitivity and specificity of myeloid differentiation primary response (88) (MYD88) L265P mutation (mut-MYD88) and interleukin-10 (IL-10) in cerebrospinal fluid (CSF) of both patients with newly diagnosed (n = 36) and relapsed (n = 27) PCNSL and 162 controls (118 CNS disorders and 44 extra-CNS lymphomas). The concordance of MYD88 mutational status between tumour tissue and CSF sample and the source of ILs in PCNSL tissues were also investigated. Mut-MYD88 was assessed by TaqMan-based polymerase chain reaction. IL-6 and IL-10 messenger RNA (mRNA) was assessed on PCNSL biopsies using RNAscope technology. IL levels in CSF were assessed by enzyme-linked immunosorbent assay. Mut-MYD88 was detected in 15/17 (88%) PCNSL biopsies, with an 82% concordance in paired tissue-CSF samples. IL-10 mRNA was detected in lymphomatous B cells in most PCNSL; expression of IL-6 transcripts was negligible. In CSF samples, mut-MYD88 and high IL-10 levels were detected, respectively, in 72% and 88% of patients with newly diagnosed PCNSL and in 1% of controls; conversely, IL-6 showed a low discriminating sensitivity and specificity. Combined analysis of MYD88 and IL-10 exhibits a sensitivity and specificity to distinguish PCNSL of 94% and 98% respectively. Similar figures were recorded in patients with relapsed PCNSL. In conclusion, high detection rates of mut-MYD88 and IL-10 in CSF reflect, respectively, the MYD88 mutational status and synthesis of this IL in PCNSL tissue. These biomarkers exhibit a very high sensitivity and specificity in detecting PCNSL both at initial diagnosis and relapse. Implications of these findings in patients with lesions unsuitable for biopsy deserve to be investigated.
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Affiliation(s)
- Andrés J M Ferreri
- Lymphoma Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Teresa Calimeri
- Lymphoma Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Lopedote
- Lymphoma Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | | | - Rita Daverio
- Division of Lab Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Chiara Iacona
- Pathology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cristina Belloni
- Division of Lab Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sara Steffanoni
- Lymphoma Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Gulino
- Tumor Immunology Unit, Department of Health Sciences, University of Palermo School of Medicine, Palermo, Italy
| | - Elena Anghileri
- Molecular Neuro-Oncology Unit, IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Angelo Diffidenti
- Lymphoma Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Annamaria Finardi
- Clinical Neuroimmunology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Filippo Gagliardi
- Neurosurgery 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
| | | | - Roberto Furlan
- Clinical Neuroimmunology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Daniela De Lorenzo
- Lymphoma Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Maria R Terreni
- Pathology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Vittorio Martinelli
- Neurology Unit, Neurorehabilitation Unit, and Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marianna Sassone
- Lymphoma Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Marco Foppoli
- Lymphoma Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Piera Angelillo
- Lymphoma Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Elena Guggiari
- Hematology and BMT Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Falini
- Neuroradiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Pietro Mortini
- Neurosurgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Filippi
- Vita-Salute San Raffaele University, Milan, Italy.,Neurology Unit, Neurorehabilitation Unit, and Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Vittoria Tarantino
- Lymphoma Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Marica Eoli
- Molecular Neuro-Oncology Unit, IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Fabio Ciceri
- Vita-Salute San Raffaele University, Milan, Italy.,Hematology and BMT Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Claudio Doglioni
- Pathology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Claudio Tripodo
- Tumor Immunology Unit, Department of Health Sciences, University of Palermo School of Medicine, Palermo, Italy
| | - Massimo Locatelli
- Division of Lab Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Maurilio Ponzoni
- Pathology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
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37
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Truong H, Leung N. Fixed-Dose Glucarpidase for Toxic Methotrexate Levels and Acute Kidney Injury in Adult Lymphoma Patients: Case Series. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2021; 21:e497-e502. [PMID: 33563580 DOI: 10.1016/j.clml.2021.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 01/09/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Huong Truong
- Department of Pharmacy, Mayo Clinic, Rochester, MN.
| | - Nelson Leung
- Division of Nephrology, Mayo Clinic, Rochester, MN
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38
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First-Line Treatment for Primary Breast Diffuse Large B-Cell Lymphoma Using Immunochemotherapy and Central Nervous System Prophylaxis: A Multicenter Phase 2 Trial. Cancers (Basel) 2020; 12:cancers12082192. [PMID: 32781541 PMCID: PMC7463683 DOI: 10.3390/cancers12082192] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 11/17/2022] Open
Abstract
There are limited data from prospective controlled trials regarding optimal treatment strategies in patients with primary breast diffuse large B-cell lymphoma (DLBCL). In this phase 2 study (NCT01448096), we examined the efficacy and safety of standard immunochemotherapy and central nervous system (CNS) prophylaxis using intrathecal methotrexate (IT-MTX). Thirty-three patients with newly diagnosed primary breast DLBCL received six cycles of rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) and four fixed doses of IT-MTX (12 mg). The median age was 50 years (range, 29-75), and all patients were females. According to the CNS-International Prognostic Index, most patients (n = 28) were categorized as the low-risk group. Among the 33 patients, 32 completed R-CHOP, and 31 completed IT-MTX as planned. With a median follow-up of 46.1 months (interquartile range (IQR), 31.1-66.8), the 2-year progression-free and overall survival rates were 81.3% and 93.5%, respectively. Six patients experienced treatment failures, which included the CNS in four patients (two parenchyma and two leptomeninges) and breast in two patients (one ipsilateral and one contralateral). The 2-year cumulative incidence of CNS relapse was 12.5%. Although standard R-CHOP and IT-MTX without routine radiotherapy show clinically meaningful survival outcomes, this strategy may not be optimal for reducing CNS relapse and warrants further investigation.
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39
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McKay P, Wilson MR, Chaganti S, Smith J, Fox CP, Cwynarski K. The prevention of central nervous system relapse in diffuse large B-cell lymphoma: a British Society for Haematology good practice paper. Br J Haematol 2020; 190:708-714. [PMID: 32433789 DOI: 10.1111/bjh.16866] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/15/2020] [Accepted: 05/19/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Pamela McKay
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Matthew R Wilson
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Sridhar Chaganti
- Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - Jeffery Smith
- Department of Haematology, Aintree University Hospital, Liverpool, UK
| | - Christopher P Fox
- Department of Clinical Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Division of Cancer and Stem Cells, University of Nottingham, Nottingham, UK
| | - Kate Cwynarski
- Department of Haematology, University College Hospital, London, UK
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40
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Kuitunen H, Kaprio E, Karihtala P, Makkonen V, Kauppila S, Haapasaari KM, Kuusisto M, Jantunen E, Turpeenniemi-Hujanen T, Kuittinen O. Impact of central nervous system (CNS) prophylaxis on the incidence of CNS relapse in patients with high-risk diffuse large B cell/follicular grade 3B lymphoma. Ann Hematol 2020; 99:1823-1831. [PMID: 32577843 PMCID: PMC7340636 DOI: 10.1007/s00277-020-04140-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 06/10/2020] [Indexed: 12/22/2022]
Abstract
Although overall survival in diffuse large B cell lymphomas (DLBCL) has improved, central nervous system (CNS) relapse is still a fatal complication of DLBCL. For this reason, CNS prophylaxis is recommended for patients at high risk of CNS disease. However, no consensus exists on definition of high-risk patient and optimal CNS prophylaxis. Systemic high-dose methotrexate in combination with R-CHOP has been suggested as a potential prophylactic method, since methotrexate penetrates the blood-brain barrier and achieves high concentration in the CNS. In this retrospective analysis, we report treatment outcome of 95 high-risk DLBCL/FL grade 3B patients treated with R-CHOP or its derivatives with (N = 57) or without (N = 38) CNS prophylaxis. At a median follow-up time (51 months), CNS relapses were detected in twelve patients (12.6%). Ten out of twelve (83%) of CNS events were confined to CNS system only. Median overall survival after CNS relapse was 9 months. Five-year isolated CNS relapse rates were 5% in the prophylaxis group and 26% in the group without prophylaxis. These findings suggest that high-dose methotrexate-containing prophylaxis decreases the risk of CNS failure.
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Affiliation(s)
- Hanne Kuitunen
- Medical Research Center, Department of Oncology and Radiotherapy, Oulu University Hospital, University of Oulu, Kajaanintie 50, P.O. Box 5000, 900l4, Oulu, Finland.,Cancer and Translational Medicine Research Unit, University of Oulu, Kajaanintie 50, P.O. Box 5000, 900l4, Oulu, Finland
| | - Elina Kaprio
- Medical Research Center, Department of Oncology and Radiotherapy, Oulu University Hospital, University of Oulu, Kajaanintie 50, P.O. Box 5000, 900l4, Oulu, Finland. .,Cancer Center, Kuopio University Hospital, Puijonlaaksontie 2, 70210, Kuopio, Finland.
| | - Peeter Karihtala
- Medical Research Center, Department of Oncology and Radiotherapy, Oulu University Hospital, University of Oulu, Kajaanintie 50, P.O. Box 5000, 900l4, Oulu, Finland.,Comprehensive Cancer Center, University of Helsinki and Helsinki University Hospital, P.O. Box 100, FI-00029, Helsinki, Finland
| | - Ville Makkonen
- Medical Research Center, Department of Oncology and Radiotherapy, Oulu University Hospital, University of Oulu, Kajaanintie 50, P.O. Box 5000, 900l4, Oulu, Finland.,The North Karelia Central Hospital, Tikkamäentie 16, 80210, Joensuu, Finland
| | - Saila Kauppila
- Cancer and Translational Medicine Research Unit, University of Oulu, Kajaanintie 50, P.O. Box 5000, 900l4, Oulu, Finland.,Medical Research Center, Department of Pathology, Oulu University Hospital, University of Oulu, Kajaanintie 50, P.O. Box 5000, 900l4, Oulu, Finland
| | - Kirsi-Maria Haapasaari
- Cancer and Translational Medicine Research Unit, University of Oulu, Kajaanintie 50, P.O. Box 5000, 900l4, Oulu, Finland.,Medical Research Center, Department of Pathology, Oulu University Hospital, University of Oulu, Kajaanintie 50, P.O. Box 5000, 900l4, Oulu, Finland
| | - Milla Kuusisto
- Medical Research Center, Department of Oncology and Radiotherapy, Oulu University Hospital, University of Oulu, Kajaanintie 50, P.O. Box 5000, 900l4, Oulu, Finland.,The North Karelia Central Hospital, Tikkamäentie 16, 80210, Joensuu, Finland
| | - Esa Jantunen
- Department of Medicine, Kuopio University Hospital, Puijonlaaksontie 2, 70210, Kuopio, Finland
| | - Taina Turpeenniemi-Hujanen
- Medical Research Center, Department of Oncology and Radiotherapy, Oulu University Hospital, University of Oulu, Kajaanintie 50, P.O. Box 5000, 900l4, Oulu, Finland.,Cancer and Translational Medicine Research Unit, University of Oulu, Kajaanintie 50, P.O. Box 5000, 900l4, Oulu, Finland
| | - Outi Kuittinen
- Medical Research Center, Department of Oncology and Radiotherapy, Oulu University Hospital, University of Oulu, Kajaanintie 50, P.O. Box 5000, 900l4, Oulu, Finland.,Cancer and Translational Medicine Research Unit, University of Oulu, Kajaanintie 50, P.O. Box 5000, 900l4, Oulu, Finland.,Cancer Center, Kuopio University Hospital, Puijonlaaksontie 2, 70210, Kuopio, Finland.,Faculty of Health Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
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41
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Calimeri T, Ferreri AJM. Prevention of CNS relapse in diffuse large B-cell lymphoma: common sense prevails where science fails. Br J Haematol 2020; 190:645-647. [PMID: 32394433 DOI: 10.1111/bjh.16719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/13/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Teresa Calimeri
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Andrés J M Ferreri
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milano, Italy
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42
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Hutchings M, Ladetto M, Buske C, de Nully Brown P, Ferreri AJM, Pfreundschuh M, Schmitz N, Balari AS, van Imhoff G, Walewski J. ESMO Consensus Conference on malignant lymphoma: management of 'ultra-high-risk' patients. Ann Oncol 2019; 29:1687-1700. [PMID: 29924296 DOI: 10.1093/annonc/mdy167] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The European Society for Medical Oncology (ESMO) consensus conference on malignant lymphoma was held on 20 June 2015 in Lugano, Switzerland, and included a multidisciplinary panel of 25 leading experts. The aim of the conference was to develop recommendations on critical subjects difficult to consider in detail in the ESMO Clinical Practice Guidelines. The following areas were identified: (1) the elderly patient, (2) prognostic factors suitable for clinical use and (3) the 'ultra-high-risk' group. Before the conference, the expert panel was divided into three working groups; each group focused on one of these areas in order to address clinically relevant questions relating to that topic. All relevant scientific literature, as identified by the experts, was reviewed in advance. During the consensus conference, each working group developed recommendations to address each of the questions devised by their group. These recommendations were then presented to the entire multidisciplinary panel and a consensus was reached. This manuscript presents recommendations regarding the management of the following 'ultra-high-risk' situations: (1) early central nervous system relapse of diffuse large B-cell lymphoma, (2) primary refractory Hodgkin lymphoma and (3) plasmablastic lymphoma. Results, including a summary of evidence supporting each recommendation, are detailed in this manuscript. All expert panel members approved this final article.
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Affiliation(s)
- M Hutchings
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark.
| | - M Ladetto
- Hematology Division, Azienda Ospedaliera Santi Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - C Buske
- Comprehensive Cancer Center Ulm and Department of Internal Medicine III, Institute of Experimental Cancer Research University Hospital, Ulm, Germany
| | | | - A J M Ferreri
- Department of Onco-Hematology Medicine, Unit of Lymphoid Malignancies, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - M Pfreundschuh
- Innere Medizin I, University Klinik des Saarlandes, Hamburg, Germany
| | - N Schmitz
- Department of Hematology, Oncology and Stem Cell Transplantation, Asklepios Klinik St. Georg, Hamburg, Germany
| | - A Sureda Balari
- Servei d'Hematologia, Institut Català d'Oncologia - Hospital Duran i Reynals, Barcelona, Spain
| | - G van Imhoff
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - J Walewski
- Department of Lymphoid Malignancies, Maria Sklodowska-Curie Institute - Oncology Center, Warsaw, Poland
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43
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Garwood MJ, Hawkes EA, Churilov L, Chong G. Patient selection and tolerability of high-dose methotrexate as central nervous system prophylaxis in diffuse large B-cell lymphoma. Cancer Chemother Pharmacol 2019; 85:133-140. [PMID: 31848681 DOI: 10.1007/s00280-019-04007-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 12/04/2019] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Central nervous system (CNS) relapse in diffuse large B-cell lymphoma (DLBCL) is usually fatal. Risk stratification of patients has historically been poorly defined, and CNS prophylaxis with high-dose methotrexate (HDMTX) can be associated with multiple toxicities. The CNS International Prognostic Index (IPI) defines three patient risk groups for CNS disease. The aims of this study were to evaluate the toxicity of HDMTX and describe outcomes in HDMTX and non-HDMTX patients according to the CNS-IPI. METHODS 205 patients diagnosed with DLBCL between 2004 and 2014, initially treated with RCHOP-like chemotherapy and considered for HDMTX CNS prophylaxis were identified by pharmacy records at two teaching hospitals. Patient records were retrospectively reviewed for HDMTX toxicity, CNS-IPI calculation and CNS relapse. RESULTS 28 patients with DLBCL were selected for two doses of HDMTX. Two of 28 patients received only one dose, and three had their second dose reduced due to renal impairment. 28% of patients experienced nephrotoxicity. 24 HDMTX and 122 non-HDMTX patients were evaluable for the CNS-IPI. No significant difference in the CNS-IPI distribution between the two groups was identified (p = 0.695). Five patients had CNS relapse, two who received HDMTX and three who did not. No significant difference in CNS relapse rate was identified between 24 HDMTX patients propensity-matched to 24 non-HDMTX patients. CONCLUSIONS HDMTX was well-tolerated by patients. Application of the CNS-IPI identifies a different population of candidates for CNS prophylaxis compared to traditional criteria.
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Affiliation(s)
| | - Eliza A Hawkes
- Departments of Haematology and Oncology, Olivia Newton John Cancer, Wellness and Research Centre, Austin Hospital, Heidelberg, VIC, Australia
- Department of Medical Oncology, Eastern Health, Box Hill, VIC, Australia
| | - Leonid Churilov
- Florey Institute of Neuroscience and Mental Health, Melbourne, Australia
| | - Geoffrey Chong
- The University of Melbourne, Parkville, VIC, Australia.
- Departments of Haematology and Oncology, Olivia Newton John Cancer, Wellness and Research Centre, Austin Hospital, Heidelberg, VIC, Australia.
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44
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Renal involvement in diffuse large B-cell lymphoma: A case report. MARMARA MEDICAL JOURNAL 2019. [DOI: 10.5472/marumj.638192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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45
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Nachmias B, Sandler V, Slyusarevsky E, Pogrebijski G, Kritchevsky S, Ben-Yehuda D, Goldschmidt N, Gatt ME. Evaluation of cerebrospinal clonal gene rearrangement in newly diagnosed non-Hodgkin's lymphoma patients. Ann Hematol 2019; 98:2561-2567. [PMID: 31515574 DOI: 10.1007/s00277-019-03798-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 09/08/2019] [Indexed: 11/24/2022]
Abstract
Overt central nervous system (CNS) involvement in aggressive non-Hodgkin's lymphoma (NHL) is rare at diagnosis. Much effort is put to identify risk factors for occult CNS involvement, and the risk assessment of CNS relapse. Prophylactic treatment carries risk of adverse events and its efficacy is not clear. Detection of cerebrospinal fluid molecular gene rearrangement (GRR) as a method to detect occult disease has been studied in acute leukemia and primary CNS lymphoma. To date, the capacity of a positive GRR in newly diagnosed NHL patients to predict CNS relapse has not been addressed. We retrospectively studied the prognostic value of GRR in cerebrospinal fluid samples of 148 newly diagnosed patients with high grade NHL. We demonstrate that positive GRR at diagnosis does not affect PFS or OS and did not predict CNS relapse. However, although numbers were small, repeated positive samples (≥ 2) correlated with a higher risk for CNS relapse (p = 0.048), possibly stressing the need for an aggressive preventive approach.
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Affiliation(s)
- Boaz Nachmias
- Hematology Department, Hadassah Hebrew University Medical Center, POB 12000, Jerusalem, Israel.
| | - Veronica Sandler
- Hematology Department, Hadassah Hebrew University Medical Center, POB 12000, Jerusalem, Israel
| | - Elena Slyusarevsky
- Hematology Department, Hadassah Hebrew University Medical Center, POB 12000, Jerusalem, Israel
| | - Galina Pogrebijski
- Hematology Department, Hadassah Hebrew University Medical Center, POB 12000, Jerusalem, Israel
| | - Svetlana Kritchevsky
- Hematology Department, Hadassah Hebrew University Medical Center, POB 12000, Jerusalem, Israel
| | - Dina Ben-Yehuda
- Hematology Department, Hadassah Hebrew University Medical Center, POB 12000, Jerusalem, Israel
| | - Neta Goldschmidt
- Hematology Department, Hadassah Hebrew University Medical Center, POB 12000, Jerusalem, Israel
| | - Moshe E Gatt
- Hematology Department, Hadassah Hebrew University Medical Center, POB 12000, Jerusalem, Israel
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46
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Eyre TA, Djebbari F, Kirkwood AA, Collins GP. Efficacy of central nervous system prophylaxis with stand-alone intrathecal chemotherapy in diffuse large B-cell lymphoma patients treated with anthracycline-based chemotherapy in the rituximab era: a systematic review. Haematologica 2019; 105:1914-1924. [PMID: 31488560 PMCID: PMC7327624 DOI: 10.3324/haematol.2019.229948] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/02/2019] [Indexed: 11/19/2022] Open
Abstract
Central nervous system (CNS) relapse of diffuse large B-cell lymphoma remains uncommon but catastrophic. The benefit of standalone intrathecal prophylaxis in reducing CNS recurrence is unclear and remains controversial. No systematic review analysing the evidence for stand-alone intrathecal prophylaxis has been performed in the era of anti-CD20 monoclonal antibody therapy. A comprehensive search (01/2002-01/2019) was systematically performed using Ovid MEDLINE®, Ovid EMBASE® and Cochrane. Studies were selected from a total of 804, screened based on predefined inclusion/exclusion criteria, and were critically appraised. Three post hoc analyses (RICOVER-60, RCHOP-14/21, GOYA), one prospective database and 10 retrospective series were included. 7,357 rituximab/obinutuzumab-exposed patients were analysed. The median percentage receiving intrathecal prophylaxis was 11.9%. Cumulative CNS relapse incidence ranged from 1.9% at 6.5 years to 8.4% at 5 years. Median time (of medians) to CNS relapse was 10 months. 73% developed isolated CNS relapses, 24% concurrent CNS/systemic relapse, and 3% post-systemic relapse. Reported CNS relapse sites were: parenchymal (58%), leptomeningeal (27%), and both (12%). Event rates were low resulting in limited power within each study to provide robust univariable/multivariable analysis. Intrathecal prophylaxis was not a univariable or multivariable factor associated with a reduction in CNS relapse in any study. We found no strong evidence for the benefit, or indeed genuine lack of benefit, of stand-alone intrathecal prophylaxis in preventing CNS relapse in diffuse large B-cell lymphoma-treated patients using anthracycline-based immunochemotherapy. Current published study designs limit the strength of such conclusions.
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Affiliation(s)
- Toby A Eyre
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford
| | - Faouzi Djebbari
- Department of Pharmacy, Oxford University Hospitals NHS Foundation Trust, Oxford
| | - Amy A Kirkwood
- Cancer Research UK & UCL Cancer Trials Centre, UCL Cancer Institute, London, UK
| | - Graham P Collins
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford
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Ong SY, Phipps C, Nagarajan C, Tang T, Lim ST, Goh YT, Lee YS. Cell-of-origin and bone marrow involvement increase specificity of defining patients with diffuse large B-cell lymphoma at high risk of CNS relapse: a study of 793 patients treated with chemoimmunotherapy in Asia. Leuk Lymphoma 2019; 61:225-227. [PMID: 31379229 DOI: 10.1080/10428194.2019.1648805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Shin Yeu Ong
- Department of Haematology, Singapore General Hospital, Singapore
| | | | | | | | | | - Yeow Tee Goh
- Department of Haematology, Singapore General Hospital, Singapore
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48
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Magomedova AU, Misyurina AE, Mangasarova JK, Gorenkova LG, Margolin OV, Fastova EA, Kravchenko SK. [CNS involvement and the feasibility of intratecal chemotherapy administration in patients with a nodal form of diffuse large B-cell lymphoma not otherwise specified. Data of prospective study]. TERAPEVT ARKH 2019; 91:35-40. [PMID: 32598734 DOI: 10.26442/00403660.2019.07.000323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Indexed: 11/22/2022]
Abstract
Aim of the issue was to determine indications for intratecal chemotherapy drugs administration to prevent relapse of diffuse large B-cell lymphoma (DLBCL) with central nervous system (CNS) involvement. MATERIALS AND METHODS Since January 2009 to December 2018 102 patients with primary nodal DLBCL over 18 years old were treated in the National Research Center for Hematology, Moscow, Russian Federation. Diagnosis were established in all cases according to histological and immunohistochemical studies which made it possible to exclude the transformation of mature B-cell lymphoma into DLBCL. RESULTS Isolated leptomeningeal involvement of CNS in the debut of the disease was detected in 1 (0.98%) out of 102 patients with DLBCL. Focal brain tissue involvement was not detected in any patient. More than half of the patients (54%) had a high risk of disease recurrence or progression with CNS involvement: in 8 (7.8%) patients had kidney/adrenal involvement, in the same proportion - bone marrow involvement, paranasal sinuses involvement - in 5 (4.9 %), epidural space - in 7 (6.9%) and breast - in 5 (4.9%) of patients. In 82 (80%) patients, a non-GCB (postgerminal differentiation of B-cell analog) molecular subtype of DLBCL was determined. CONCLUSION The introduction of chemotherapy drugs into the spinal canal is recommended in isolated cases of leptomeningeal involvement of CNS at the time of DLBCL onset and is carried out according to standard recommendations. Prevention of relapse with involvement of central nervous system using intratecal chemotherapy in patients with nodal form of DLBCL is not indicated due to the absence of cases with disease progression or recurrence into CNS when patients were treated with R-m-NHL-BFM-90, R-DA-EPOCH and R-CHOP protocol.
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Affiliation(s)
- A U Magomedova
- National Research Center for Hematology, Department of Intensive High-Dose Chemotherapy with Round-the-Clock and Day Hospital (IVHT with CS and DS)
| | - A E Misyurina
- National Research Center for Hematology, Department of Intensive High-Dose Chemotherapy with Round-the-Clock and Day Hospital (IVHT with CS and DS)
| | - J K Mangasarova
- National Research Center for Hematology, Department of Intensive High-Dose Chemotherapy with Round-the-Clock and Day Hospital (IVHT with CS and DS)
| | - L G Gorenkova
- National Research Center for Hematology, Department of Intensive High-Dose Chemotherapy with Round-the-Clock and Day Hospital (IVHT with CS and DS)
| | - O V Margolin
- National Research Center for Hematology, Department of Intensive High-Dose Chemotherapy with Round-the-Clock and Day Hospital (IVHT with CS and DS)
| | - E A Fastova
- National Research Center for Hematology, Department of Intensive High-Dose Chemotherapy with Round-the-Clock and Day Hospital (IVHT with CS and DS)
| | - S K Kravchenko
- National Research Center for Hematology, Department of Intensive High-Dose Chemotherapy with Round-the-Clock and Day Hospital (IVHT with CS and DS)
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49
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Eyre TA, Kirkwood AA, Wolf J, Hildyard C, Mercer C, Plaschkes H, Griffith J, Fields P, Gunawan A, Oliver R, Booth S, Martinez‐Calle N, McMillan A, Bishton M, Fox CP, Collins GP, Hatton CSR. Stand‐alone intrathecal central nervous system (CNS) prophylaxis provide unclear benefit in reducing CNS relapse risk in elderly DLBCL patients treated with R‐CHOP and is associated increased infection‐related toxicity. Br J Haematol 2019; 187:185-194. [DOI: 10.1111/bjh.16070] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 05/11/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Toby A. Eyre
- Department of Haematology Churchill Hospital, Oxford University Hospitals NHS Foundation Trust Oxford UK
| | - Amy A. Kirkwood
- Cancer Research UK & UCL Cancer Trials Centre UCL Cancer Institute, UCL London UK
| | - Julia Wolf
- Department of Haematology Great Western Hospital Swindon UK
| | | | - Carolyn Mercer
- Department of Haematology Churchill Hospital, Oxford University Hospitals NHS Foundation Trust Oxford UK
| | | | - John Griffith
- Department of Haematology Great Western Hospital Swindon UK
| | - Paul Fields
- Department of Haematology Guys and St Thomas’ Hospitals NHS Foundation Trust London UK
| | - Arief Gunawan
- Department of Haematology Guys and St Thomas’ Hospitals NHS Foundation Trust London UK
| | - Rebecca Oliver
- Department of Haematology University Hospitals Bristol NHS Foundation Trust Bristol UK
| | - Stephen Booth
- Department of Haematology Royal Berkshire Hospital NHS Foundation Trust Reading UK
| | - Nicolas Martinez‐Calle
- Department of Clinical Haematology Nottingham University Hospitals NHS Trust Nottingham UK
| | - Andrew McMillan
- Department of Clinical Haematology Nottingham University Hospitals NHS Trust Nottingham UK
| | - Mark Bishton
- Department of Clinical Haematology Nottingham University Hospitals NHS Trust Nottingham UK
| | - Christopher P. Fox
- Department of Clinical Haematology Nottingham University Hospitals NHS Trust Nottingham UK
| | - Graham P. Collins
- Department of Haematology Churchill Hospital, Oxford University Hospitals NHS Foundation Trust Oxford UK
| | - Chris S. R. Hatton
- Department of Haematology Churchill Hospital, Oxford University Hospitals NHS Foundation Trust Oxford UK
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50
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El-Galaly TC, Cheah CY, Villa D. Real world data as a key element in precision medicine for lymphoid malignancies: potentials and pitfalls. Br J Haematol 2019; 186:409-419. [PMID: 31140600 DOI: 10.1111/bjh.15965] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Molecular genetic studies of lymphoma have led to refinements in disease classification in the most recent World Health Organization update. Nevertheless, a 'one-size-fits-most' treatment strategy based on morphology remains widely used for lymphoma despite significant molecular heterogeneity within histopathologically-defined subtypes. Precision medicine aims to improve patient outcomes by leveraging disease- and patient-specific information to optimise treatment strategies, but implementation of precision medicine strategies is challenged by the biological diversity and rarity of lymphomas. In this review, we explore existing and emerging real-world data sources that can be used to facilitate the development of precision medicine strategies in lymphoma. We provide illustrative examples of the use of real-world analyses to refine treatment strategies, provide comparators for clinical trials, improve risk-stratification to identify patients with unmet clinical needs and describe long-term and rare toxicities.
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Affiliation(s)
- Tarec C El-Galaly
- Department of Haematology, Clinical Cancer Research Centre, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Chan Y Cheah
- Department of Haematology, Sir Charles Gairdner Hospital and Pathwest Laboratory Medicine, Nedlands, WA, Australia
| | - Diego Villa
- Division of Medical Oncology and Centre for Lymphoid Cancer, BC Cancer, Vancouver, BC, Canada
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