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Lin T, Wang K, Yang D, Li Z, Zheng C, Chen X, Zhai L. Age-related differences in primary central nervous system lymphomas based on the SEER database. Front Med (Lausanne) 2025; 12:1534956. [PMID: 40206483 PMCID: PMC11979127 DOI: 10.3389/fmed.2025.1534956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2024] [Accepted: 03/11/2025] [Indexed: 04/11/2025] Open
Abstract
Objective The aim of this study was to compare prognostic factors and survival outcomes in patients with primary central nervous system lymphoma (PCNSL). Methods The Surveillance, Epidemiology, and End Results (SEER) database was queried for patients diagnosed with PCNSL between 2000 and 2019. Results Between 2000 and 2019, a total of 5,812 patients were diagnosed with PCNSL, of whom 2,175 (37%) were ≤ 60 years old and 3,637 (63%) were >60 years old. The younger patients had a higher rate of being diagnosed with stage I-II, a higher rate of receiving chemotherapy and radiotherapy, a similar rate of receiving surgery, and a longer survival time. The most common histological subtype among PCNSL patients was diffuse large B-cell lymphoma (PCNS-DLBCL). Younger PCNS-DLBCL patients who received surgery and chemotherapy exhibited significantly improved overall survival (OS) and disease-specific mortality (DSM) and that African American patients were associated with poorer OS and DSM. Older patients receiving surgery, chemotherapy, and radiotherapy exhibited significantly improved OS and DSM, male and higher Ann Arbor stage were associated with poorer OS and DSM. We created a nomogram for PCNS-DLBCL to predict OS, with a C-index of 0.6749 in the younger cohort and 0.6676 in the older cohort. In the combined therapy analysis, chemotherapy combined with surgical resection had better OS and DSM in all patients. Conclusions The two age-stratified cohorts significantly differed in terms of OS and independent influences on OS and DSM. Our constructed nomogram exhibited high accuracy in predicting OS in PCNS-DLBCL patients.
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Affiliation(s)
- Tengjiao Lin
- Cancer Center, Departments of Radiation Oncology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ke Wang
- Guangzhou University of Chinese Medicine, Guangzhou, China
- Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Deyu Yang
- Guangzhou University of Chinese Medicine, Guangzhou, China
- Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhichao Li
- Guangzhou University of Chinese Medicine, Guangzhou, China
- Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | | | - Xinrong Chen
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Linzhu Zhai
- Cancer Center, Departments of Radiation Oncology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Puhakka IK, Sunela KL, Rönkä AL, Rajamäki AM, Arkko UM, Klaavuniemi TM, Kuusisto MEL, Jäkälä PA, Selander TA, Kuitunen HK, Kantanen AM, Kuittinen OM. Defining MRI-based follow-up protocol for primary central nervous system lymphoma. Ann Hematol 2025; 104:627-634. [PMID: 39699653 PMCID: PMC11868308 DOI: 10.1007/s00277-024-06145-5] [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: 09/09/2024] [Accepted: 12/12/2024] [Indexed: 12/20/2024]
Abstract
BACKGROUND The optimal follow-up protocol for primary central nervous system lymphoma (PCNSL) is unclear. This is the first study to evaluate the benefit of structured follow-up imaging of PCNSL with respect to the timing of relapse. METHODS A total of 198 PCNSL patients (57.1% males) diagnosed between 2003 and 2020 were included. The data were collected retrospectively from 8 hospitals in Finland. Relapse detection details included structured follow-up imaging (sMRI) studies, additional imaging (aMRI) studies based on patients' new symptoms, and all outpatient and emergency visits. Overall survival (OS) with respect to the relapse detection method, sMRI versus aMRI, was also evaluated. RESULTS Relapse was diagnosed in 71 patients (35.9%), 66.1% of whom experienced relapse during the first 2 years after diagnosis. During the first year, 48.3% (14/29) of the relapses were detected via sMRI, and 51.7% (15/29) via aMRI. During the second year, the percentages were 33.3% and 66.7%, respectively. More than 5 years after the diagnosis, all the relapses were detected via aMRI. To observe one relapse during the first year, 9.4 sMRI studies were needed. Overall survival after relapse (OS2) was 4.0 months for the patients whose first relapse was detected via sMRI and 3.0 months for those whose first relapse was detected via aMRI (P = 0.203). CONCLUSIONS We found that structured imaging was beneficial for relapse detection during the first year after PCNSL diagnosis. A minor trend towards better survival after relapse was observed for patients who experienced relapse according to structured imaging.
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Affiliation(s)
- Inka K Puhakka
- Department of Neurology, Kuopio University Hospital, Puijonlaaksontie 2, 70210, Kuopio, Finland.
| | - Kaisa L Sunela
- Department of Oncology, Tampere University Hospital, Tampere, Finland
- Finnish Medicines Agency, Tampere, Finland
| | - Aino L Rönkä
- Department of Oncology, Kuopio University Hospital, Kuopio, Finland
- Oncology, Institute of Medical Medicine, Faculty of Health Medicine, University of Eastern Finland, Kuopio, Finland
| | - Aino M Rajamäki
- Department of Oncology, Hospital Nova of Central Finland, Jyväskylä, Finland
| | - Ulla-Mari Arkko
- Department of Oncology, North Karelia Central Hospital, Joensuu, Finland
| | - Tuula M Klaavuniemi
- Department of Oncology, Mikkeli Central Hospital, Mikkeli, Finland
- Oncology, Institute of Medical Medicine, Faculty of Health Medicine, University of Eastern Finland, Kuopio, Finland
| | - Milla E L Kuusisto
- Biomedicine and Internal Medicine Research Unit, University of Oulu, Oulu, Finland
- Medical Reseach Unit, Oulu University Hospital, Oulu, Finland
- Department of Internal Medicine, Länsi-Pohja Central Hospital, Kemi, Finland
| | - Pekka A Jäkälä
- Department of Neurology, Kuopio University Hospital, Puijonlaaksontie 2, 70210, Kuopio, Finland
- Neurology, Institute of Medical Medicine, Faculty of Health Medicine, University of Eastern Finland, Kuopio, Finland
| | | | | | - Anne-Mari Kantanen
- Department of Neurology, Kuopio University Hospital, Puijonlaaksontie 2, 70210, Kuopio, Finland
| | - Outi M Kuittinen
- Department of Oncology, Kuopio University Hospital, Kuopio, Finland
- Oncology, Institute of Medical Medicine, Faculty of Health Medicine, University of Eastern Finland, Kuopio, Finland
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3
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Duan L, Guo W, Yin S, Dong G, Li W, Chen F. Clinicopathological risk factors for prognosis and therapeutic response of primary central nervous system lymphoma in China: a single-center retrospective analysis of 118 cases. Ann Hematol 2025; 104:389-399. [PMID: 39692782 DOI: 10.1007/s00277-024-06147-3] [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: 03/20/2024] [Accepted: 12/12/2024] [Indexed: 12/19/2024]
Abstract
To investigate the prognostic significance of clinicopathological factors in patients with primary central nervous system lymphoma (PCNSL) in a single center. Patients newly diagnosed with PCNSL at our center were recruited between January 2019 and March 2023. Baseline demographic and clinicopathological data were collected retrospectively. The Kaplan-Meier method and Cox regression analysis were performed for survival analyses. A total of 118 patients were enrolled. The median age was 64 (IQR, 54-68). The median progression-free survival (PFS) and overall survival (OS) were 12.70 (95%CI, 9.73-23.30) months and 36.87 (95%CI, 25.57-NR) months, respectively. KPS < 70 and ECOG ≥ 3 were significantly associated with worse PFS and OS. High International Extranodal Lymphoma Study Group (IELSG) score (IELSG 4-5) and high-risk Memorial Sloan-Kettering Cancer Center (MSKCC) score were also adverse factors for PFS and OS. BTK inhibitors (BTKi) therapy (HR 0.39, 95% CI, 0.18-0.86, p = 0.020) and consolidation therapy (HR 0.19, 95% CI, 0.06-0.64, p = 0.007) were confirmed as independent favorable factors for OS. A high NK lymphocyte proportion was associated with worse OS (p = 0.008). Patients in the high NK lymphocyte group experienced a higher rate of primary tumor resistance (57.14%) than the low NK lymphocyte group (33.33%). KPS < 70, ECOG ≥ 3, IELSG 4-5, and high-risk MSKCC score are adverse factors for PFS and OS. Importantly, BTKi therapy and consolidation therapy are independent favorable factors for OS. Peripheral lymphocyte immunophenotyping could be a potential predictive indicator for prognosis and therapeutic response in PCNSL.
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Affiliation(s)
- Ling Duan
- Department of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, No.119 West Nansihuan Road, Beijing, 100070, China
| | - Wenhui Guo
- Department of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, No.119 West Nansihuan Road, Beijing, 100070, China
| | - Shuo Yin
- Department of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, No.119 West Nansihuan Road, Beijing, 100070, China
| | - Gehong Dong
- Department of Pathology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Wenbin Li
- Department of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, No.119 West Nansihuan Road, Beijing, 100070, China.
| | - Feng Chen
- Department of Neuro-Oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, No.119 West Nansihuan Road, Beijing, 100070, China.
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Garaba A, Aslam N, Ponzio F, Panciani PP, Brinjikji W, Fontanella M, De Maria L. Radiomics for differentiation of gliomas from primary central nervous system lymphomas: a systematic review and meta-analysis. Front Oncol 2024; 14:1291861. [PMID: 38420015 PMCID: PMC10899458 DOI: 10.3389/fonc.2024.1291861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
Background and objective Numerous radiomics-based models have been proposed to discriminate between central nervous system (CNS) gliomas and primary central nervous system lymphomas (PCNSLs). Given the heterogeneity of the existing models, we aimed to define their overall performance and identify the most critical variables to pilot future algorithms. Methods A systematic review of the literature and a meta-analysis were conducted, encompassing 12 studies and a total of 1779 patients, focusing on radiomics to differentiate gliomas from PCNSLs. A comprehensive literature search was performed through PubMed, Ovid MEDLINE, Ovid EMBASE, Web of Science, and Scopus databases. Overall sensitivity (SEN) and specificity (SPE) were estimated. Event rates were pooled using a random-effects meta-analysis, and the heterogeneity was assessed using the χ2 test. Results The overall SEN and SPE for differentiation between CNS gliomas and PCNSLs were 88% (95% CI = 0.83 - 0.91) and 87% (95% CI = 0.83 - 0.91), respectively. The best-performing features were the ones extracted from the Gray Level Run Length Matrix (GLRLM; ACC 97%), followed by those obtained from the Neighboring Gray Tone Difference Matrix (NGTDM; ACC 93%), and shape-based features (ACC 91%). The 18F-FDG-PET/CT was the best-performing imaging modality (ACC 97%), followed by the MRI CE-T1W (ACC 87% - 95%). Most studies applied a cross-validation analysis (92%). Conclusion The current SEN and SPE of radiomics to discriminate CNS gliomas from PCNSLs are high, making radiomics a helpful method to differentiate these tumor types. The best-performing features are the GLRLM, NGTDM, and shape-based features. The 18F-FDG-PET/CT imaging modality is the best-performing, while the MRI CE-T1W is the most used.
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Affiliation(s)
- Alexandru Garaba
- Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Nummra Aslam
- Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Francesco Ponzio
- Interuniversity Department of Regional and Urban Studies and Planning, Politecnico di Torino, Torino, Italy
| | - Pier Paolo Panciani
- Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Waleed Brinjikji
- Department of Neurosurgery and Interventional Neuroradiology, Mayo Clinic, Rochester, MN, United States
| | - Marco Fontanella
- Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Lucio De Maria
- Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
- Department of Clinical Neuroscience, Geneva University Hospitals (HUG), Geneva, Switzerland
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5
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Nizic A, Ibricevic-Balic L, Ceric T, Omerhodzic I, Burazerovic L, Saric V, Mameledzija E, Hasanefendic B. Primary Central Nervous System Lymphoma, Treatment Outcomes - 10 Year Experience. Single Center Study. Mater Sociomed 2024; 36:23-25. [PMID: 38590596 PMCID: PMC10999144 DOI: 10.5455/msm.2024.36.23-25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 02/25/2024] [Indexed: 04/10/2024] Open
Abstract
Background Primary central nervous system lymphoma(PCNSL) is an aggressive, rare form of Non-Hodgkin lymphoma, characterized by the absence of systemic disease. There are limited data and no strictly defined guidelines for management of PCNSL. Objective The aim of this study was to report a 10 year experience of PCNSL treatment, to evaluate treatment outcomes and asses Progression Free and Overall Survival of these patients. Methods Study was conducted on the Haematology Clinic, Clinical center University of Sarajevo, BH, in the period from January 2012.-December 2022. Total sample of 24 patients were enrolled. All have undergone diagnostic surgery. Patients were treated with regimens based on High dose Methotrexate, with/without whole brain radiotherapy as consolidation. Treatment response was captured by imaging techniques. Patients who have relapsed were evaluated with imaging techniques and treated according to Methotrexate-based treatment protocols. Results We have captured equal gender distribution. The median age of patients was 59.5 years (range 20-79). Pathohistological analysis confirmed DLBCL diagnosis in 22 patients, T cell lymphoma and anaplastic large cell lymphoma, each in 1 patient. Chemotherapy, chemotherapy combined with WBRT and radiotherapy were given to 5, 18 and 1 patients, respectively. The overall complete response rate (CR) was 87,15%. Those receiving combined modality-treatment had higher CR than those receiving chemotherapy (94,4% versus 60%). Out of 24 patients, 11 of them relapsed. The median time to relapse was 29 months (from 1 to 105). After second line of the treatment, CR was 54,5%, while 45,45% of patients died during the treatment. 4 patients relapsed for the second time with median time to relapse of 9 months (from 2 to 77). 2 year OS rate was 67%, and the median OS rate was 45,9 months. 2 year PFS rate was 31%. Conclusion The OS and PFS rates indicate the usage of new drugs and consolidation with autologous stem cell transplantation in patients with PCNSL in order to achieve better treatment outcomes.
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Affiliation(s)
- Ajla Nizic
- Primary Health Care Center "JU Dom zdravlja Kantona Sarajevo"
| | | | - Timur Ceric
- Oncology Clinic, Clinical Center University of Sarajevo
| | | | | | - Vasvija Saric
- Haematology Clinic, Clinical center University of Sarajevo
| | | | - Berina Hasanefendic
- Clinical Biochemistry and Immunology, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
- Faculty of Health Studies, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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Rice ML, Barreto EF, Rule AD, Martin CE, Truong HL, Mara KC, Kashani KB, Thompson CA, Witzig TE, Barreto JN. Development and validation of a model to predict acute kidney injury following high-dose methotrexate in patients with lymphoma. Pharmacotherapy 2024; 44:4-12. [PMID: 37926860 DOI: 10.1002/phar.2889] [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: 06/21/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 11/07/2023]
Abstract
STUDY OBJECTIVE To develop and validate a model for predicting acute kidney injury (AKI) after high-dose methotrexate (HDMTX) exposure. DESIGN Retrospective analysis. SETTING Multisite integrated health system throughout Minnesota and Wisconsin. PATIENTS Adult patients with lymphoma who received HDMTX as a 4-h infusion. MEASUREMENTS AND MAIN RESULTS LASSO methodology was used to identify factors available at the outset of therapy that predicted incident AKI within 7 days following HDMTX. The model was then validated in an independent cohort. The incidence of AKI within 7 days following HDMTX was 21.6% (95% confidence interval (CI) 18.4%-24.8%) in the derivation cohort (435 unique patients who received a total of 1642 doses of HDMTX) and 15.6% (95% CI 5.3%-24.8%) in the validation cohort (55 unique patients who received a total of 247 doses of HDMTX). Factors significantly associated with AKI after HDMTX in the multivariable model included age ≥ 55 years, male sex, and lower HDMTX dose number. Other factors that were not found to be significantly associated with AKI on multivariable analysis, but were included in the final model, were body surface area, Charlson Comorbidity Index, and estimated glomerular filtration rate. The c-statistic of the model was 0.72 (95% CI 0.69-0.75) in the derivation cohort and 0.72 (95% CI 0.60-0.84) in the validation cohort. CONCLUSION This model utilizing identified sociodemographic and clinical factors is predictive of AKI following HDMTX administration in adult patients with lymphoma.
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Affiliation(s)
- Mikhaila L Rice
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew D Rule
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Huong L Truong
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Carrie A Thompson
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas E Witzig
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason N Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
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7
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Xia Y, Li X, Jiang N, Wei X. A novel Bruton's tyrosine kinase inhibitor JDB175 shows potent efficacy to suppress central nervous system lymphoma. MedComm (Beijing) 2023; 4:e424. [PMID: 37929016 PMCID: PMC10625055 DOI: 10.1002/mco2.424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/13/2023] [Accepted: 10/23/2023] [Indexed: 11/07/2023] Open
Abstract
Patients with central nervous system (CNS) lymphoma face limited treatment options and poor treatment outcomes, emphasizing the urgent need for effective therapeutic strategies. One limiting factor contributing to the suboptimal efficacy is the inadequate penetration of most treatment drugs across the blood-brain barrier (BBB). Recent insights into the pathophysiology of CNS lymphoma have identified the Bruton's tyrosine kinase (BTK) signaling pathway as a potential target. Some clinical trials have shown impressive responses to BTK inhibitors in CNS lymphoma. However, currently approved BTK inhibitors have low BBB penetration rates, limiting their efficacy. In this study, we discovered that JDB175, a novel and highly selective BTK inhibitor, exhibits excellent BBB penetration capabilities and demonstrates favorable activity in a mouse model of CNS lymphoma while showing no significant signs of toxicity. JDB175 effectively inhibits the BTK signaling pathway in human lymphoma cells, suppressing their proliferation, inducing cell cycle arrest, and promoting apoptosis. The significance of this study lies in addressing the critical unmet medical need for effective treatments for CNS lymphoma. This finding indicates a promising avenue for improved treatments in CNS lymphoma, potentially opening doors for further clinical investigation and therapeutic advancements.
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Affiliation(s)
- Yong Xia
- Laboratory of Aging Research and Cancer Drug TargetState Key Laboratory of Biotherapy and Cancer CenterNational Clinical Research Center for GeriatricsWest China HospitalSichuan UniversityChengduChina
| | - Xue Li
- Laboratory of Aging Research and Cancer Drug TargetState Key Laboratory of Biotherapy and Cancer CenterNational Clinical Research Center for GeriatricsWest China HospitalSichuan UniversityChengduChina
| | - Ning Jiang
- Jumbo Drug Bank Co., Ltd., High‐Tech ZoneChengduChina
| | - Xiawei Wei
- Laboratory of Aging Research and Cancer Drug TargetState Key Laboratory of Biotherapy and Cancer CenterNational Clinical Research Center for GeriatricsWest China HospitalSichuan UniversityChengduChina
- Jumbo Drug Bank Co., Ltd., High‐Tech ZoneChengduChina
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8
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Zhou Y, Wang X, Lin X, Wang J, Yan X, Wen Y. Sustained response following BTK inhibitors based treatment in HIV-related primary central nervous system lymphoma: case report. AIDS Res Ther 2023; 20:63. [PMID: 37644480 PMCID: PMC10466696 DOI: 10.1186/s12981-023-00554-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 08/11/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Despite increasing effort for treating primary central nervous system lymphoma (PCNSL), the prognosis of human immunodeficiency virus (HIV) -related PCNSL was still unsatisfactory. There is currently a lack of clinical evidence for the application of Bruton tyrosine kinase (BTK) inhibitor in HIV-related PCNSL. We reported two HIV-related PCNSL patients, who achieved sustained remission by application of BTK inhibitor based treatment. This protocol had not been previously reported for the treatment of HIV-related PCNSL. CASE PRESENTATION The two cases were characterized by the treatment choice of Bruton tyrosine kinase (BTK) inhibitor. Rituximab was not recommended for them due to their very low CD4+ T cell counts. They both took MTX as the first-line therapy and got a relief in initial phase. For the first case, ibrutinib was kept both in the first-line therapy and in the maintenance therapy. When the second case underwent a progressive disease, we continued to use orelabrutinib as one of the salvage treatment, in combination with programmed cell death-1 (PD-1) inhibitor plus lenalidomide. They both achieved a continuous response of up to 20 months without opportunistic infection. CONCLUSIONS This report highlights the safety and effectiveness of BTK inhibitors, as well as lenalidomide and PD-1 inhibitor in HIV-related PCNSL patients. Both the new therapeutic approaches and a multidisciplinary team authentically contributed to improved survival outcome among HIV-positive PCNSL patients.
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Affiliation(s)
- Ying Zhou
- Department of Infectious Diseases II, The First Affiliated Hospital of China Medical University, No. 155, Nanjing North Street, Heping District, Shenyang, 110001, Liaoning Province, China
| | - Xiaoxue Wang
- Department of hematology, The First Affiliated Hospital of China Medical University, No. 155, Nanjing North Street, Heping District, Shenyang, 110001, Liaoning Province, China
| | - Xuyong Lin
- Department of pathology, The First Affiliated Hospital of China Medical University, No. 155, Nanjing North Street, Heping District, Shenyang, Liaoning Province, China
| | - Jun Wang
- Department of neurosurgery, The First Affiliated Hospital of China Medical University, No. 155, Nanjing North Street, Heping District, Shenyang, Liaoning Province, China
| | - Xiaojing Yan
- Department of hematology, The First Affiliated Hospital of China Medical University, No. 155, Nanjing North Street, Heping District, Shenyang, 110001, Liaoning Province, China.
| | - Ying Wen
- Department of Infectious Diseases II, The First Affiliated Hospital of China Medical University, No. 155, Nanjing North Street, Heping District, Shenyang, 110001, Liaoning Province, China.
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9
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Foerster AK, Lauer EM, Scherer F. Clinical applications of circulating tumor DNA in central nervous system lymphoma. Semin Hematol 2023; 60:150-156. [PMID: 37442670 DOI: 10.1053/j.seminhematol.2023.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023]
Abstract
Detection and characterization of circulating tumor DNA (ctDNA) in body fluids have the potential to revolutionize management of patients with lymphoma. Minimal access to malignant DNA through a simple blood draw or lumbar puncture is particularly appealing for CNS lymphomas (CNSL), which cannot be easily or repeatedly sampled without invasive surgeries. Profiling of ctDNA provides a real-time snapshot of the genetic composition in patients with CNSL and enables ultrasensitive quantification of lymphoma burden at any given time point during the course of the disease. Here, we broadly review technical challenges of ctDNA identification in CNSL, recent advances of innovative liquid biopsy technologies, potential clinical applications of ctDNA and how it may improve CNSL risk stratification, outcome prediction, and monitoring of measurable residual disease. Finally, we discuss clinical trials and scenarios in which ctDNA could be implemented to guide risk-adapted and personalized treatment decisions.
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Affiliation(s)
- Anna Katharina Foerster
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Eliza M Lauer
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Florian Scherer
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK) partner site Freiburg and German Cancer Research Center (DKFZ), Heidelberg, Germany.
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10
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David KA, Sundaram S, Kim SH, Vaca R, Lin Y, Singer S, Malecek MK, Carter J, Zayac A, Kim MS, Reddy N, Ney D, Habib A, Strouse C, Graber J, Bachanova V, Salman S, Vendiola JA, Hossain N, Tsang M, Major A, Bond DA, Agrawal P, Mier-Hicks A, Torka P, Rajakumar P, Venugopal P, Berg S, Glantz M, Goldlust SA, Folstad M, Kumar P, Ollila TA, Cai J, Spurgeon S, Sieg A, Cleveland J, Chang J, Epperla N, Karmali R, Naik S, Martin P, Smith SM, Rubenstein J, Kahl B, Evens AM. Older patients with primary central nervous system lymphoma: Survival and prognostication across 20 U.S. cancer centers. Am J Hematol 2023; 98:900-912. [PMID: 36965007 PMCID: PMC10979647 DOI: 10.1002/ajh.26919] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 03/21/2023] [Indexed: 03/27/2023]
Abstract
There is a paucity of large-scale data delineating outcomes and prognostication of older patients with primary central nervous system lymphoma (PCNSL). We retrospectively analyzed 539 newly-diagnosed PCNSL patients ages ≥60 years across 20 U.S. academic centers. The median age was 70 years (range 60-88); at least one geriatric syndrome was present in 46%; the median Cumulative Index Ratings Scale-Geriatrics (CIRS-G) score was 6 (range, 0-27); and 36% had impairment in activities of daily living (ADL). The most common induction regimens were high-dose methotrexate (HD-MTX) ± rituximab; methotrexate, temozolomide, rituximab (MTR); and rituximab, methotrexate, procarbazine, vincristine (R-MPV). Overall, 70% of patients achieved remission, with 14% undergoing consolidative autologous stem cell transplant (ASCT) and 24% receiving maintenance. With 58-month median follow-up, median progression-free survival (PFS) and overall survival (OS) were 17 months (95% CI 13-22 months) and 43 months (95% CI 31-56 months), respectively. Three-year PFS and OS were highest with MTR (55% and 74%, respectively). With single-agent methotrexate ± rituximab, 3-year PFS and OS were 30% (p = .0002) and 47% (p = .0072). On multivariate analysis, increasing age at diagnosis and Cooperative Oncology Group (ECOG) performance status (PS) was associated with inferior PFS; age, hypoalbuminemia, higher CIRS-G score, and ECOG PS adversely affected OS. Among patients receiving maintenance, 3-year PFS was 65% versus 45% without maintenance (p = 0.02), with 3-year OS of 84% versus 61%, respectively (p = .0003). Altogether, outcomes in older PCNSL patients appeared optimized with HD-MTX combination induction regimens and maintenance therapy. Furthermore, several prognostic factors, including geriatric measures, were associated with inferior outcomes.
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Affiliation(s)
- Kevin A. David
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | | | - Seo-Hyun Kim
- Rush University Medical Center, Chicago, Illinois, USA
| | - Ryan Vaca
- Penn State Cancer Institute, Hershey, Pennsylvania, USA
| | - Yong Lin
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | - Samuel Singer
- John Theurer Cancer Center, Hackensack, New Jersey, USA
| | | | - Jordan Carter
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | - Adam Zayac
- Brown University, Providence, Rhode Island, USA
| | - Myung Sun Kim
- Oregon Health & Science University, Portland, Oregon, USA
| | | | - Douglas Ney
- University of Colorado, Aurora, Colorado, USA
| | - Alma Habib
- University of Minnesota, Minneapolis, Minnesota, USA
| | | | | | | | - Sidra Salman
- Loyola University Medical Center, Maywood, Illinois, USA
| | | | | | - Mazie Tsang
- University of California, San Francisco, California, USA
| | - Ajay Major
- University of Chicago, Chicago, Illinois, USA
| | - David A. Bond
- Division of Hematology, Ohio State University, Columbus, Ohio, USA
| | | | | | - Pallawi Torka
- Roswell Park Cancer Institute, Buffalo, New York, USA
| | | | | | - Stephanie Berg
- Loyola University Medical Center, Maywood, Illinois, USA
| | | | | | | | - Pallavi Kumar
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | | | - Johnny Cai
- Oregon Health & Science University, Portland, Oregon, USA
| | | | - Alex Sieg
- University of Iowa, Iowa City, Iowa, USA
| | | | - Julie Chang
- University of Wisconsin, Madison, Wisconsin, USA
| | | | | | - Seema Naik
- Penn State Cancer Institute, Hershey, Pennsylvania, USA
| | - Peter Martin
- Weill Cornell Medical College, New York City, New York, USA
| | | | | | - Brad Kahl
- Washington University in St. Louis, St. Louis, Missouri, USA
| | - Andrew M. Evens
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
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11
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Radiomics-Based Machine Learning Model for Predicting Overall and Progression-Free Survival in Rare Cancer: A Case Study for Primary CNS Lymphoma Patients. Bioengineering (Basel) 2023; 10:bioengineering10030285. [PMID: 36978676 PMCID: PMC10045100 DOI: 10.3390/bioengineering10030285] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/15/2023] [Accepted: 02/20/2023] [Indexed: 02/24/2023] Open
Abstract
Primary Central Nervous System Lymphoma (PCNSL) is an aggressive neoplasm with a poor prognosis. Although therapeutic progresses have significantly improved Overall Survival (OS), a number of patients do not respond to HD–MTX-based chemotherapy (15–25%) or experience relapse (25–50%) after an initial response. The reasons underlying this poor response to therapy are unknown. Thus, there is an urgent need to develop improved predictive models for PCNSL. In this study, we investigated whether radiomics features can improve outcome prediction in patients with PCNSL. A total of 80 patients diagnosed with PCNSL were enrolled. A patient sub-group, with complete Magnetic Resonance Imaging (MRI) series, were selected for the stratification analysis. Following radiomics feature extraction and selection, different Machine Learning (ML) models were tested for OS and Progression-free Survival (PFS) prediction. To assess the stability of the selected features, images from 23 patients scanned at three different time points were used to compute the Interclass Correlation Coefficient (ICC) and to evaluate the reproducibility of each feature for both original and normalized images. Features extracted from Z-score normalized images were significantly more stable than those extracted from non-normalized images with an improvement of about 38% on average (p-value < 10−12). The area under the ROC curve (AUC) showed that radiomics-based prediction overcame prediction based on current clinical prognostic factors with an improvement of 23% for OS and 50% for PFS, respectively. These results indicate that radiomics features extracted from normalized MR images can improve prognosis stratification of PCNSL patients and pave the way for further study on its potential role to drive treatment choice.
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12
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Kuitunen HK, Rönkä ALK, Sonkajärvi EM, Isokangas JM, Pyörälä M, Palosaari KAA, Jokimäki AS, Partanen AE, Littow HJ, Vakkala MA, Jantunen EJ, Huttunen ME, Marin KJ, Aromaa-Häyhä AMK, Auvinen PK, Selander T, Puhakka IK, Kuittinen OM. Blood-Brain Barrier Disruption (BBBD)-Based Immunochemotherapy for Primary Central Nervous System Lymphoma (PCNSL), Early Results of a Phase II Study. Cancers (Basel) 2023; 15:cancers15041341. [PMID: 36831682 PMCID: PMC9953868 DOI: 10.3390/cancers15041341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 02/07/2023] [Accepted: 02/17/2023] [Indexed: 02/22/2023] Open
Abstract
Primary central nervous system lymphoma is a rare but aggressive brain malignancy. It is associated with poor prognosis even with the current standard of care. The aim of this study was to evaluate the effect and tolerability of blood-brain barrier disruption treatment combined with high-dose treatment with autologous stem cell transplantation as consolidation on primary central nervous system lymphoma patients. We performed a prospective phase II study for 25 patients with previously untreated primary central nervous system lymphoma. The blood-brain barrier disruption treatment was initiated 3-4 weeks after the MATRix regimen using the previously optimized therapy protocol. Briefly, each chemotherapy cycle included two subsequent intra-arterial blood-brain barrier disruption treatments on days 1 and 2 via either one of the internal carotid arteries or vertebral arteries. Patients received the therapy in 3-week intervals. The treatment was continued for two more courses after achieving a maximal radiological response to the maximum of six courses. The complete treatment response was observed in 88.0% of the patients. At the median follow-up time of 30 months, median progression-free and overall survivals were not reached. The 2-year overall and progression-free survival rates were 67.1% and 70.3%, respectively. Blood-brain barrier disruption treatment is a promising option for primary central nervous system lymphoma with an acceptable toxicity profile.
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Affiliation(s)
- Hanne K. Kuitunen
- Cancer Center, Oulu University Hospital, 90220 Oulu, Finland
- Correspondence: ; Tel.: +358-503561799
| | - Aino L. K. Rönkä
- Department of Oncology and Radiotherapy, Kuopio University Hospital, 70210 Kuopio, Finland
| | - Eila M. Sonkajärvi
- Surgery and Anaesthesia Center, Oulu University Hospital, 90220 Oulu, Finland
| | - Juha-Matti Isokangas
- Service for Medical Care, Oulu University Hospital Diagnostics, 90220 Oulu, Finland
| | - Marja Pyörälä
- Department of Medicine, Kuopio University Hospital, 70210 Kuopio, Finland
| | - Kari A. A. Palosaari
- Service for Medical Care, Oulu University Hospital Diagnostics, 90220 Oulu, Finland
| | | | - Anu E. Partanen
- Department of Medicine, Kuopio University Hospital, 70210 Kuopio, Finland
| | - Harri J. Littow
- Service for Medical Care, Oulu University Hospital Diagnostics, 90220 Oulu, Finland
| | - Merja A. Vakkala
- Surgery and Anaesthesia Center, Oulu University Hospital, 90220 Oulu, Finland
- Medical Research Center Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, 90220 Oulu, Finland
| | - Esa J. Jantunen
- Department of Medicine, Kuopio University Hospital, 70210 Kuopio, Finland
- Institute of Clinical Medicine, University of Eastern Finland and Department of Medicine, 70210 Kuopio, Finland
- Hospital District of North Carelia, Joensuu Central Hospital, 80210 Joensuu, Finland
| | - Mirja E. Huttunen
- Surgery and Anaesthesia Center, Oulu University Hospital, 90220 Oulu, Finland
| | - Katja J. Marin
- Department of Oncology and Radiotherapy, Kuopio University Hospital, 70210 Kuopio, Finland
| | | | - Päivi K. Auvinen
- Department of Oncology and Radiotherapy, Kuopio University Hospital, 70210 Kuopio, Finland
| | - Tuomas Selander
- Science Service Center, Kuopio University Hospital, 70210 Kuopio, Finland
| | - Inka K. Puhakka
- Department of Neurology, Kuopio University Hospital, 70210 Kuopio, Finland
| | - Outi M. Kuittinen
- Department of Oncology and Radiotherapy, Kuopio University Hospital, 70210 Kuopio, Finland
- School of Medicine, Institute of Clinical Medicine, Oncology, Faculty of Medicine, University of Eastern Finland, 70210 Kuopio, Finland
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13
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Foreman BE, Mullikin TC, Floyd SR, Kelsey CR, Patel MP, Peters KB, Kirkpatrick JP, Reitman ZJ, Vaios EJ. Long-term outcomes with reduced-dose whole-brain radiotherapy and a stereotactic radiosurgery boost for primary central nervous system lymphoma. Neurooncol Adv 2023; 5:vdad097. [PMID: 37706200 PMCID: PMC10496939 DOI: 10.1093/noajnl/vdad097] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023] Open
Abstract
Background Primary central nervous system lymphoma (PCNSL) is an aggressive diffuse large B-cell lymphoma. Treatment approaches are historically associated with neurotoxicity, particularly with high-dose whole-brain radiotherapy (WBRT). We hypothesized that reduced dose-WBRT (rd-WBRT) followed by a stereotactic radiosurgery (SRS) boost could provide durable disease control without significant adverse effects. Methods We retrospectively reviewed PCNSL patients treated with rd-WBRT plus an SRS boost at Duke University between 2008 and 2021. Progression-free survival and overall survival (OS) were estimated using competing risk and Kaplan-Meier methods. Results We identified 23 patients with pathologically confirmed PCNSL. Median age at diagnosis was 69 years (Q1Q3: 52-74) and median Karnofsky Performance Scale (KPS) was 80 (Q1Q3: 70-80). Median follow-up was 21 months. Median doses for rd-WBRT and SRS were 23.4 Gy (Q1Q3: 23.4-23.4) and 12 Gy (Q1Q3: 12-12.5), respectively. The cumulative incidence of intracranial progression at 2 years was 23% (95% CI: 8-42). Six patients (26%) developed distant radiographic progression while 2 patients (9%) developed both distant and local progression. Ten patients (44%) were alive without progression at last follow-up. By Kaplan-Meier estimate, the 2-year OS was 69% (95% CI: 46-84). There were no reported grade 3 + radiation-induced toxicities. Conclusions The combination of rd-WBRT with an SRS boost appears well-tolerated with durable intracranial control. This approach may represent a treatment option for select patients, such as those with progressive or refractory disease. Further prospective studies are needed to validate these findings and determine whether this approach could be incorporated into consolidation strategies.
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Affiliation(s)
| | - Trey C Mullikin
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Scott R Floyd
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Chris R Kelsey
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | - Mallika P Patel
- Department of Pharmacy, Duke University Medical Center, Durham, NC, USA
- The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA
| | - Katherine B Peters
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - John P Kirkpatrick
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
- The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA
| | - Zachary J Reitman
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
- Department of Pathology, Duke University Medical Center, Durham, NC, USA
- The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA
| | - Eugene J Vaios
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
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14
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Cheng C, Yao C, Huang P, Yu C, Fang W, Chuang W, Wu S, Lin Y, Hung Y, Tsai C, Yu S, Chou W, Tien H. Cerebrospinal fluid soluble programmed death‐ligand 1 is a useful prognostic biomarker in primary central nervous system lymphoma. Br J Haematol 2022; 201:75-85. [PMID: 36480431 DOI: 10.1111/bjh.18598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 11/13/2022] [Accepted: 11/27/2022] [Indexed: 12/13/2022]
Abstract
The increased expression of programmed death-ligands 1 and 2 (PD-L1 and PD-L2, respectively) on tumour cells contributes to immune evasion, suggesting that these proteins are attractive therapeutic targets. This study aimed to evaluate the validity of cerebrospinal fluid (CSF) soluble PD-L1 (sPD-L1) and soluble PD-L2 (sPD-L2) as biomarkers for primary central nervous system lymphoma (PCNSL). We determined the CSF concentrations of sPD-L1 and sPD-L2 in 46 patients with PCNSL using enzyme-linked immunosorbent assays (ELISAs). A control group comprised 153 patients with other brain tumours, inflammatory/infectious status, or neurodegenerative diseases. Only CSF sPD-L1 levels were significantly higher in patients with PCNSL relative to the controls. CSF sPD-L1 also exhibited superior overall discrimination performance compared to CSF sPD-L2 in diagnosing PCNSL. Compared with patients with PCNSL with low CSF sPD-L1 levels, more patients with high levels had high serum lactate dehydrogenase levels, leptomeningeal involvement, and deep-brain involvement. Furthermore, CSF sPD-L1 could predict poor survival in PCNSL but CSF sPD-L2 could not. Intriguingly, CSF sPD-L1 levels were correlated with disease status and their dynamic changes post treatment could predict time to relapse. In conclusion, this study identified CSF sPD-L1 as a promising prognostic biomarker, indicating a therapeutic potential of PD-L1 blockade in PCNSL.
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Affiliation(s)
- Chieh‐Lung Cheng
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine National Taiwan University Taipei Taiwan
| | - Chi‐Yuan Yao
- Department of Laboratory Medicine, National Taiwan University Hospital, College of Medicine National Taiwan University Taipei Taiwan
| | - Po‐Hao Huang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, College of Medicine National Taiwan University Taipei Taiwan
| | - Chih‐Wei Yu
- Department of Radiology and Medical Imaging, National Taiwan University Hospital, College of Medicine National Taiwan University Taipei Taiwan
| | - Wei‐Quan Fang
- Division of New Drug Center for Drug Evaluation Taipei Taiwan
| | - Wen‐Hui Chuang
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine National Taiwan University Taipei Taiwan
| | - Shang‐Ju Wu
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine National Taiwan University Taipei Taiwan
| | - Yu‐Jen Lin
- Department of Hematological Oncology National Taiwan University Cancer Center Taipei Taiwan
| | - Yu‐Chin Hung
- Division of Hematology and Oncology, Department of Internal Medicine National Taiwan University Hospital Yunlin Taiwan
| | - Cheng‐Hong Tsai
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine National Taiwan University Taipei Taiwan
| | - Shan‐Chi Yu
- Department of Pathology, National Taiwan University Hospital, College of Medicine National Taiwan University Taipei Taiwan
| | - Wen‐Chien Chou
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine National Taiwan University Taipei Taiwan
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, College of Medicine National Taiwan University Taipei Taiwan
| | - Hwei‐Fang Tien
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine National Taiwan University Taipei Taiwan
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15
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Lukas RV, Mrugala MM, Lesniak MS, Chandler JP. Challenging Cases in Neuro-Oncology. Semin Neurol 2022; 42:752-757. [PMID: 36417993 DOI: 10.1055/a-1985-7157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Neuro-oncology encompasses a broad field focusing on an array of neoplasms, many of which can mimic several diseases. Neurologists will often be involved in the initial diagnostic evaluation and management of these patients. Their insight is central to optimizing the diagnostic yield and providing high-level clinical care. Several neuro-oncologic cases are reviewed with a goal of increasing the understanding of these diseases in a clinically relevant manner and providing updates on the contemporary thinking in the subspecialty.
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Affiliation(s)
- Rimas V Lukas
- Department of Neurology, Northwestern University, Chicago, Illinois.,Lou and Jean Malnati Brain Tumor Institute, Chicago, Illinois
| | - Maciej M Mrugala
- Department of Neurology, Mayo Clinic-Scottsdale, Scottsdale, Arizona
| | - Maciej S Lesniak
- Lou and Jean Malnati Brain Tumor Institute, Chicago, Illinois.,Department of Neurological Surgery, Northwestern University, Chicago, Illinois
| | - James P Chandler
- Lou and Jean Malnati Brain Tumor Institute, Chicago, Illinois.,Department of Neurological Surgery, Northwestern University, Chicago, Illinois
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16
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DeAtkine AB, Abdelrashid M, Tucker Z, Mehta A, Markert JM, Kim J, Fiveash JB, Oster RA, Lobbous M, Nabors LB. High-dose methotrexate and rituximab induction regimen in immunocompetent patients with primary CNS lymphoma: a retrospective single-center study of survival predictors. J Neurooncol 2022; 158:33-40. [PMID: 35441948 DOI: 10.1007/s11060-022-04004-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/20/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Primary Central Nervous System Lymphoma (PCNSL) is an aggressive tumor that is confined to the CNS. Although the provision of high-dose methotrexate (HD-MTX) has remarkably improved outcomes in PCNSL patients, the optimal treatment regimens and standard MTX dose for induction therapy have been largely controversial. Herein, we sought to explore the impact of adjuvant rituximab and different dosages of induction HD-MTX on survival outcomes of immunocompetent patients with PCNSL. METHODS In this study, we examined patients with PCNSL treated at a single NCI-designated comprehensive cancer center to evaluate their survival outcomes. We conducted a retrospective analysis of 51 immunocompetent patients with PCNSL who received their induction chemotherapy at the University of Alabama at Birmingham (UAB) between 2001 and 2019. Only adult patients with a confirmed diagnosis of PCNSL who had either HD-MTX alone or in combination with rituximab were included. Patients' demographics, clinical characteristics, and survival data were collected and analyzed. RESULTS There is no significant difference in survival among patients who received MTX alone versus MTX plus rituximab (HR = 0.996 (95% CI: 0.398-2.493), p = 0.994). Lower doses of MTX were associated with worse survival outcomes (HR = 0.680 (95% CI: 0.530-0.872), p = 0.002); however, this difference in survival was not significant when adjusted to age (HR = 0.797 (95% CI: 0.584-1.088), p = 0.153). CONCLUSION Our experience challenges the role of rituximab in PCNSL during induction therapy. Our study also highlights the shorter survival in elderly patients with PCNSL which can be related, to some extent, to the relatively lower doses of HD-MTX. There is an unmet need to establish a consensus on the most effective upfront regimen in PCNSL through prospective studies.
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Affiliation(s)
- Andrew B DeAtkine
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Moaaz Abdelrashid
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Zach Tucker
- Division of Neuro-Oncology, Department of Neurology, University of Alabama at Birmingham, FOT 1020
- 510 20th Street South, Birmingham, AL, 35233, USA
| | - Amitkumar Mehta
- Division of Hematology and Oncology, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - James M Markert
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA.,O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jinsuh Kim
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John B Fiveash
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert A Oster
- O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA.,Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mina Lobbous
- Division of Neuro-Oncology, Department of Neurology, University of Alabama at Birmingham, FOT 1020
- 510 20th Street South, Birmingham, AL, 35233, USA.,O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - L Burt Nabors
- Division of Neuro-Oncology, Department of Neurology, University of Alabama at Birmingham, FOT 1020
- 510 20th Street South, Birmingham, AL, 35233, USA. .,O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA.
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17
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Kutuk T, Grass GD, Oliver D, Mokhtari S, Sahebjam S, Kim S, Penagaricano J, Yu HHM, Tran N, Etame A, Peterson JL, Forsyth P, Robinson T. Revisiting the concept of recurrence of primary CNS lymphomas after complete response to methotrexate-based therapy: Periventricular reseeding as the predominant mechanism of recurrence. Adv Radiat Oncol 2022; 7:100940. [PMID: 35814853 PMCID: PMC9260129 DOI: 10.1016/j.adro.2022.100940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/28/2022] [Indexed: 11/08/2022] Open
Abstract
Purpose Understanding patterns of relapse for primary central nervous system lymphoma (PCNSL) may inform mechanisms of recurrence and optimal consolidation strategies. In this study, we report patterns of relapse among patients with PCNSL who achieved a complete response to high-dose methotrexate (HD-MTX)-based chemotherapy with or without consolidation radiation therapy (RT). Methods and Materials We conducted an institutional retrospective analysis of patients with PCNSL who received HD-MTX-based chemotherapy between November 2001 and May 2019. Relapses were characterized as in-field (within original T1 contrasted lesion), marginal (within T2 fluid-attenuated inversion recovery but not T1), local (in-field or marginal), distant brain (no overlap), or distant (distant brain, cerebrospinal fluid, vitreous or extra-axial) and further characterized with respect to periventricular location (≤10 mm of ventricles). Results Seventy-eight patients with PCNSL met inclusion criteria, of whom 29 (37%) underwent consolidation RT. Median progression-free survival and overall survival were 57.0 and 66.7 months, respectively. After a median follow-up of 38.9 months, a total of 32 patients (41%) experienced recurrence. Most patients (21 [65.6%]) had a periventricular failure. Surprisingly, local recurrences (n = 11) were exclusively observed within periventricular lesions, whereas distant recurrences (n = 21) were seen in both periventricular and nonperiventricular locations (P = .009). The median time to progression was shorter for locally recurrent lesions compared with distant recurrences (13.8 vs 26.1 months; P = .03). Conclusions After complete response to HD-MTX, few failures occurred within initial T1 contrast-enhancing lesions and many of these may have been alternatively classified as periventricular failures. These observations argue against the use of purely focal RT consolidation for patients who achieve a complete response after HD-MTX-based chemotherapy and suggest that periventricular reseeding may have a central role in PCNSL recurrence.
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18
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Patel AM, Ali O, Kainthla R, Rizvi SM, Awan FT, Patel T, Pan E, Maher E, Desai NB, Timmerman R, Kumar KA, Ramakrishnan Geethakumari P. Primary central nervous system lymphoma: a real-world comparison of therapy access and outcomes by hospital setting. Neurooncol Pract 2022; 9:183-192. [PMID: 35601974 PMCID: PMC9113306 DOI: 10.1093/nop/npab066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background This study analyzes sociodemographic barriers for primary CNS lymphoma (PCNSL) treatment and outcomes at a public safety-net hospital versus a private tertiary academic institution. We hypothesized that these barriers would lead to access disparities and poorer outcomes in the safety-net population. Methods We reviewed records of PCNSL patients from 2007-2020 (n = 95) at a public safety-net hospital (n = 33) and a private academic center (n = 62) staffed by the same university. Demographics, treatment patterns, and outcomes were analyzed. Results Patients at the safety-net hospital were significantly younger, more commonly Black or Hispanic, and had a higher prevalence of HIV/AIDS. They were significantly less likely to receive induction chemotherapy (67% vs 86%, P = .003) or consolidation autologous stem cell transplantation (0% vs. 47%, P = .001), but received more whole-brain radiation therapy (35% vs 16%, P = .001). Younger age and receiving any consolidation therapy were associated with improved progression-free (PFS, P = .001) and overall survival (OS, P = .001). Hospital location had no statistical impact on PFS (P = .725) or OS (P = .226) on an age-adjusted analysis. Conclusions Our study shows significant differences in treatment patterns for PCNSL between a public safety-net hospital and an academic cancer center. A significant survival difference was not demonstrated, which is likely multifactorial, but likely was positively impacted by the shared multidisciplinary care delivery between the institutions. As personalized therapies for PCNSL are being developed, equitable access including clinical trials should be advocated for resource-limited settings.
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Affiliation(s)
- Akshat M Patel
- Division of Hematologic Malignancies and Stem Cell Transplantation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Omer Ali
- Division of Hematologic Malignancies and Stem Cell Transplantation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Radhika Kainthla
- Division of Hematology/Oncology, Parkland Health and Hospital System, Dallas, Texas, USA
| | - Syed M Rizvi
- Division of Hematologic Malignancies and Stem Cell Transplantation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Farrukh T Awan
- Division of Hematologic Malignancies and Stem Cell Transplantation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Toral Patel
- Department of Neurosurgery, Parkland Health and Hospital System, Dallas, Texas, USA
| | - Edward Pan
- Department of Neurology, Parkland Health and Hospital System, Dallas, Texas, USA
| | - Elizabeth Maher
- Department of Neurology, Parkland Health and Hospital System, Dallas, Texas, USA
| | - Neil B Desai
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Robert Timmerman
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Kiran A Kumar
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Praveen Ramakrishnan Geethakumari
- Division of Hematologic Malignancies and Stem Cell Transplantation, University of Texas Southwestern Medical Center, Dallas, Texas, USA,Corresponding Author: Praveen Ramakrishnan Geethakumari, MD, MS, Division of Hematologic Malignancies and Stem Cell Transplantation, University of Texas Southwestern Medical Center, 2201 Inwood Rd, Dallas, TX 75390, USA ()
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19
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Ibrutinib in Refractory or Relapsing Primary Central Nervous System Lymphoma: A Systematic Review. Neurol Int 2022; 14:99-108. [PMID: 35076567 PMCID: PMC8788490 DOI: 10.3390/neurolint14010009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/09/2022] [Accepted: 01/10/2022] [Indexed: 01/05/2023] Open
Abstract
Primary Central Nervous System Lymphoma (PCNSL) is a rare variant of Non-Hodgkin Lymphoma (NHL) representing 1–2% of all NHL cases. PCNSL is defined as a lymphoma that occurs in the brain, spinal cord, leptomeninges, or eyes. Efforts to treat PCNSL by traditional chemotherapy and radiotherapy have generally been unsuccessful as a significant proportion of patients have frequent relapses or are refractory to treatment. The prognosis of patients with Refractory or Relapsed (R/R) PCNSL is abysmal. The optimal treatment for R/R PCNSL is poorly defined as there are only a limited number of studies in this setting. Several studies have recently shown that ibrutinib, a Bruton tyrosine kinase (BTK) inhibitor, has promising results in the treatment of R/R PCNSL. However, these are preliminary studies with a limited sample size. In this systematic review, we explored and critically appraised the evidence about the efficacy of the novel agent ibrutinib in treating R/R PCNSL.
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20
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Steffanoni S, Calimeri T, Anzalone N, Mastaglio S, Bernardi M, Ferreri AJ. A narrative review of consolidation strategies for young and fit patients with newly-diagnosed primary central nervous system lymphoma. Expert Rev Hematol 2021; 15:33-43. [PMID: 34904506 DOI: 10.1080/17474086.2022.2018297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION The modern treatment of patients with primary central nervous system lymphoma (PCNSL) consists of two phases: induction, currently represented by a high-dose-methotrexate-based polychemotherapy, and consolidation. The optimal consolidation therapy has not been defined yet, but several strategies, such as whole-brain radiotherapy (WBRT), high-dose chemotherapy supported by autologous stem cell transplantation (HDC/ASCT) or non-myeloablative chemotherapy, have been addressed in important randomized trials. AREAS COVERED This review provides an overview of the current role of consolidation strategies in young and fit patients with newly-diagnosed PCNSL. Publications in English language, peer-reviewed, from high-quality international journals, edited from 2003 to 2021 were identified on PubMed. EXPERT OPINION Consolidation treatment significantly improved outcomes of PCNSL. Radiotherapy had represented for years the only choice in the consolidation therapy, but large randomized trials have demonstrated that HDC/ASCT is equally effective and associated with lower neurotoxicity risk in patients younger than 65-70 years. Encouraging results have been obtained using reduced-dose WBRT, while a recent randomized trial failed to demonstrate that consolidation with non-myeloablative chemotherapy is more effective than HDC/ASCT in PCNSL patients. A personalized consolidation treatment, driven also by a response prediction model based on radiological and molecular details, may improve the management of PCNSL patients.
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Affiliation(s)
- Sara Steffanoni
- Department of Medicine, Division of Hematology, Valduce Hospital, Como, Italy
| | - Teresa Calimeri
- Lymphoma Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicoletta Anzalone
- Neuroradiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Sara Mastaglio
- Hematology and BMT Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Bernardi
- Hematology and BMT Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrés Jm Ferreri
- Lymphoma Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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21
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Verdu-Bou M, Tapia G, Hernandez-Rodriguez A, Navarro JT. Clinical and Therapeutic Implications of Epstein-Barr Virus in HIV-Related Lymphomas. Cancers (Basel) 2021; 13:5534. [PMID: 34771697 PMCID: PMC8583310 DOI: 10.3390/cancers13215534] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 10/29/2021] [Indexed: 12/26/2022] Open
Abstract
The incidence of lymphomas is increased in people living with HIV (PLWH). Aggressive B-cell non-Hodgkin lymphomas (NHLs) are the most common and are considered an AIDS-defining cancer (ADC). Although Hodgkin lymphoma (HL) is not considered an ADC, its incidence is also increased in PLWH. Among all HIV-related lymphomas (HRL), the prevalence of Epstein-Barr virus (EBV) is high. It has been shown that EBV is involved in different lymphomagenic mechanisms mediated by some of its proteins, contributing to the development of different lymphoma subtypes. Additionally, cooperation between both HIV and EBV can lead to the proliferation of aberrant B-cells, thereby being an additional lymphomagenic mechanism in EBV-associated HRL. Despite the close relationship between EBV and HRL, the impact of EBV on clinical aspects has not been extensively studied. These lymphomas are treated with the same therapeutic regimens as the general population in combination with cART. Nevertheless, new therapeutic strategies targeting EBV are promising for these lymphomas. In this article, the different types of HRL are extensively reviewed, focusing on the influence of EBV on the epidemiology, pathogenesis, clinical presentation, and pathological characteristics of each lymphoma subtype. Moreover, novel therapies targeting EBV and future strategies to treat HRL harboring EBV are discussed.
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Affiliation(s)
- Miriam Verdu-Bou
- Lymphoid Neoplasms Group, Josep Carreras Leukaemia Research Institute, Can Ruti Campus, 08916 Badalona, Spain;
| | - Gustavo Tapia
- Department of Pathology, Germans Trias i Pujol Hospital, Universitat Autònoma de Barcelona, 08916 Badalona, Spain;
| | - Agueda Hernandez-Rodriguez
- Department of Microbiology, Germans Trias i Pujol Hospital, Universitat Autònoma de Barcelona, 08916 Badalona, Spain;
| | - Jose-Tomas Navarro
- Lymphoid Neoplasms Group, Josep Carreras Leukaemia Research Institute, Can Ruti Campus, 08916 Badalona, Spain;
- Department of Hematology, Institut Català d’Oncologia-Germans Trias i Pujol Hospital, 08916 Badalona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, 08916 Badalona, Spain
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22
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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: 1.0] [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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23
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Calimeri T, Steffanoni S, Foppoli M, Ponzoni M, Ferreri AJM. Implications of recent molecular achievements in early diagnosis and precision treatments for primary CNS lymphoma. Expert Opin Ther Targets 2021; 25:749-760. [PMID: 34606736 DOI: 10.1080/14728222.2021.1988927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: Primary diffuse large B-cell lymphoma (DLBCL) of the central nervous system (PCNSL) represents a relevant challenge in onco-hematology. PCNSL has specific molecular profile and biological characteristics that distinguish it from systemic DLBCL. Several translational studies have allowed for significant improvement in the knowledge about its genomic and molecular profile. High-dose-methotrexate-based chemotherapy followed whole-brain irradiation or autologous stem cell transplantation is the most commonly used therapeutic approach in PCNSL patients.Areas covered: This work provides an overview of the new biomarkers of PCNSL, focusing on their potential diagnostic, predictive and prognostic role. Publications in English language, peer-reviewed, high-quality international journals, were identified on PubMed.Expert opinion: Early diagnosis, a better antitumor response definition and recognition of new effective treatments are important research fields aiming to improve PCNSL outcome and management. The acquisition of new molecular and genomic knowledge in PCNSL has allowed for the attainment of promising diagnostic and prognostic tools as well as the development of clinical trials with new therapeutic approaches beyond chemotherapy agents, which have demonstrated activity in refractory/relapsed PCNSL and deserve to be investigated in first-line therapy.
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Affiliation(s)
- Teresa Calimeri
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sara Steffanoni
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Foppoli
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maurilio Ponzoni
- Universita' di Medicina e Chirurgia, Vita -Salute San Raffaele, Milano, Italy.,Department of Pathology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrés J M Ferreri
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
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24
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Leone R, Sferruzza G, Calimeri T, Steffanoni S, Conte GM, De Cobelli F, Falini A, Ferreri AJM, Anzalone N. Quantitative muscle mass biomarkers are independent prognosis factors in primary central nervous system lymphoma: The role of L3-skeletal muscle index and temporal muscle thickness. Eur J Radiol 2021; 143:109945. [PMID: 34492625 DOI: 10.1016/j.ejrad.2021.109945] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/03/2021] [Accepted: 08/29/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To investigate the role of quantitative muscle biomarkers assessed with skeletal muscle index at the third lumbar vertebra (L3-SMI) and temporal muscle thickness (TMT) in predicting progression-free and overall survival in patients with primary central nervous system lymphoma (PCNSL) undergoing first-line high-dose methotrexate-based chemotherapy. METHODS L3-SMI and TMT were calculated on abdominal CT and brain high-resolution 3D-T1-weighted MR images, respectively, using predefined validated methods. Standardized sex-specific cut-off values were used to divide patients in different risk categories. Kaplan-Meier plots were calculated, and survival analysis was performed using log-rank tests, univariate, and multivariable Cox-regression models, calculating hazard ratios (HR) and 95% confidence intervals (CI), also adjusting for potential confounders (age, sex, and performance status). RESULTS Forty-three patients were included in this study. Median follow-up was 23 months (interquartile range 12-40); at median follow-up, rates of progression-free and overall survival for the cohort were 46% and 57%, respectively. Thirteen (30%) and 11 (26%) patients showed L3-SMI or TMT values below the predefined cut-offs. In Cox-regression multivariable analysis patients with low L3-SMI or TMT showed significantly worse progression-free (HR 4.40, 95% CI 1.66-11.61, p = 0.003; HR 4.40, 95% CI 1.68-11.49, p = 0.003, respectively) and overall survival (HR 3.16, 95% CI 1.09-9.11, p = 0.034; HR 4.93, 95% CI 1.78-13.65, p = 0.002, respectively) compared to patients with high L3-SMI or TMT. CONCLUSIONS Quantitative muscle mass evaluation assessed by both L3-SMI and TMT is a promising tool to identify PCNSL patients at high risk of negative outcome. Confirmatory studies on larger independent series are warranted.
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Affiliation(s)
- R Leone
- Department of Neuroradiology, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - G Sferruzza
- Department of Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan and Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - T Calimeri
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - S Steffanoni
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - G M Conte
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - F De Cobelli
- Department of Radiology, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, via Olgettina 60, 20132 Milan, Italy
| | - A Falini
- Department of Neuroradiology, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - A J M Ferreri
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - N Anzalone
- Department of Neuroradiology, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy.
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25
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Shao L, Xu C, Wu H, Jamal M, Pan S, Li S, Chen F, Yu D, Liu K, Wei Y. Recent Progress on Primary Central Nervous System Lymphoma-From Bench to Bedside. Front Oncol 2021; 11:689843. [PMID: 34485125 PMCID: PMC8416460 DOI: 10.3389/fonc.2021.689843] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 07/27/2021] [Indexed: 02/03/2023] Open
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare subtype of extra-nodal lymphoma. The high relapse rate of PCNSL remains a major challenge to the hematologists, even though patients exhibit high sensitivity to the methotrexate-based chemotherapeutic regimens. Recently, the advent of Bruton's tyrosine kinase inhibitor (BTKi) and CAR T treatment has made more treatment options available to a proportion of patients. However, whether BTKi monotherapy should be given alone or in combination with conventional chemotherapy is still a clinical question. The status of CAR T therapy for PCNSLs also needs to be elucidated. In this review, we summarized the latest progress on the epidemiology, pathology, clinical manifestation, diagnosis, and treatment options for PCNSLs.
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Affiliation(s)
- Liang Shao
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Chengshi Xu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Huijing Wu
- Department of Lymphoma Medicine, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Muhammad Jamal
- Department of Immunology, School of Basic Medical Science, Wuhan University, Wuhan, China
| | - Shan Pan
- School of Medicine, Wuhan University of Science and Technology, Wuhan, China
| | - Sirui Li
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Fei Chen
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Ding Yu
- Department of Lymphoma Medicine, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kui Liu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yongchang Wei
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, China
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26
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Scordo M, Wang TP, Ahn KW, Chen Y, Ahmed S, Awan FT, Beitinjaneh A, Chen A, Chow VA, Dholaria B, Epperla N, Farooq U, Ghosh N, Grover N, Hamad N, Hildebrandt GC, Holmberg L, Hong S, Inwards DJ, Jimenez-Jimenez A, Karmali R, Kenkre VP, Khimani F, Klyuchnikov E, Krem MM, Munshi PN, Nieto Y, Prestidge T, Ramakrishnan Geethakumari P, Rezvani AR, Riedell PA, Seo S, Shah NN, Solh M, Yared JA, Kharfan-Dabaja MA, Herrera A, Hamadani M, Sauter CS. Outcomes Associated With Thiotepa-Based Conditioning in Patients With Primary Central Nervous System Lymphoma After Autologous Hematopoietic Cell Transplant. JAMA Oncol 2021; 7:993-1003. [PMID: 33956047 DOI: 10.1001/jamaoncol.2021.1074] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Importance Primary central nervous system lymphoma (PCNSL) requires induction and consolidation to achieve potential cure. High-dose therapy and autologous hematopoietic cell transplant (AHCT) is an accepted and effective consolidation strategy for PCNSL, but no consensus exists on the optimal conditioning regimens. Objective To assess the outcomes in patients with PCNSL undergoing AHCT with the 3 most commonly used conditioning regimens: thiotepa/busulfan/cyclophosphamide (TBC), thiotepa/carmustine (TT-BCNU), and carmustine/etoposide/cytarabine/melphalan (BEAM). Design, Setting, and Participants This observational cohort study used registry data from the Center for International Blood and Marrow Transplant Research registry. The Center is a working group of more than 380 transplantation centers worldwide that contributed detailed data on HCT to a statistical center at the Medical College of Wisconsin, Milwaukee. The participant data were from 603 adult patients with PCNSL who underwent AHCT as initial, or subsequent, consolidation between January 2010 and December 2018. Patients were excluded if they had a non-Hodgkin lymphoma subtype other than diffuse large B-cell lymphoma, systemic non-Hodgkin lymphoma, or HIV; received an uncommon conditioning regimen; or were not in partial remission or complete remission prior to AHCT. Statistical analysis was performed from July 5, 2020, to March 1, 2021. Interventions Patients received 1 of 3 conditioning regimens: TBC (n = 263), TT-BCNU (n = 275), and BEAM (n = 65). Main Outcomes and Measures The primary outcome was progression-free survival. Secondary outcomes included hematopoietic recovery, incidence of relapse, nonrelapse mortality, and overall survival. Results Of 603 patients, the mean age was 57 (range, 19-77) years and 318 (53%) were male. The 3-year adjusted progression-free survival rates were higher in the TBC cohort (75%) and TT-BCNU cohort (76%) compared with the BEAM cohort (58%) (P = .03) owing to a higher relapse risk in the BEAM cohort (hazard ratio [HR], 4.34; 95% CI, 2.45-7.70; P < .001). In a multivariable regression analysis, compared with the TBC cohort, patients who received TT-BCNU had a higher relapse risk (HR, 1.79; 95% CI, 1.07-2.98; P = .03), lower risk of nonrelapse mortality (NRM) (HR, 0.50; 95% CI, 0.29-0.87; P = .01), and similar risk of all-cause mortality more than 6 months after HCT (HR, 1.54; 95% CI, 0.93-2.55; P = .10). Age of 60 years or older, Karnofsky performance status less than 90, and an HCT-comorbidity index greater than or equal to 3 were associated with lower rates of survival across all 3 cohorts. Subgroup analyses demonstrated that patients aged 60 years and older had considerably higher NRM with TBC. Conclusions and Relevance In this cohort study, thiotepa-based conditioning regimen was associated with higher rates of survival compared with BEAM, despite higher rates of early toxic effects and NRM; these findings may assist clinicians in choosing between TBC or TT-BCNU based on patient and disease characteristics.
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Affiliation(s)
- Michael Scordo
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Trent P Wang
- Division of Transplantation and Cellular Therapy, University of Miami Miller School of Medicine, Miami, Florida
| | - Kwang W Ahn
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee.,Institute for Health and Equity, Division of Biostatistics, Medical College of Wisconsin, Milwaukee
| | - Yue Chen
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Sairah Ahmed
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Farrukh T Awan
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Amer Beitinjaneh
- Division of Transplantation and Cellular Therapy, University of Miami Miller School of Medicine, Miami, Florida
| | - Andy Chen
- Department of Medicine, Oregon Health and Science University, Portland
| | - Victor A Chow
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Narendranath Epperla
- The James Cancer Hospital and Solove Research Institute, Division of Hematology, Department of Medicine, The Ohio State University, Columbus
| | - Umar Farooq
- Division of Hematology, Oncology and Blood & Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City
| | - Nilanjan Ghosh
- Levine Cancer Institute, Department of Hematologic Oncology and Blood Disorders, Atrium Health, Charlotte, North Carolina
| | - Natalie Grover
- Department of Medicine, University of North Carolina Hospitals, Chapel Hill
| | - Nada Hamad
- St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | | | - Leona Holmberg
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Sanghee Hong
- Blood and Marrow Transplant Program, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | | | - Antonio Jimenez-Jimenez
- Division of Transplantation and Cellular Therapy, University of Miami Miller School of Medicine, Miami, Florida
| | - Reem Karmali
- Department of Medicine, Northwestern University, Chicago, Illinois
| | | | - Farhad Khimani
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Evgeny Klyuchnikov
- Department for Stem Cell Transplantation, University Cancer Center, Hamburg, Germany
| | | | - Pashna N Munshi
- Department of Medicine, Georgetown University Hospital, Washington, DC
| | - Yago Nieto
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston
| | - Tim Prestidge
- Blood and Cancer Centre, Starship Children's Hospital, Auckland, New Zealand
| | | | - Andrew R Rezvani
- Division of Blood & Marrow Transplantation, Stanford University, Stanford, California
| | - Peter A Riedell
- Department of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Sachiko Seo
- Department of Hematology and Oncology, Dokkyo Medical University, Tochigi, Japan
| | - Nirav N Shah
- Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Melhem Solh
- The Blood and Marrow Transplant Group of Georgia, Northside Hospital, Atlanta
| | - Jean A Yared
- Blood & Marrow Transplantation Program, Greenebaum Comprehensive Cancer Center, Division of Hematology/Oncology, Department of Medicine, University of Maryland, Baltimore
| | - Mohamed A Kharfan-Dabaja
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, Florida
| | - Alex Herrera
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Mehdi Hamadani
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Craig S Sauter
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medical College, New York, New York
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27
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Improving the antitumor activity of R-CHOP with NGR-hTNF in primary CNS lymphoma: final results of a phase 2 trial. Blood Adv 2021; 4:3648-3658. [PMID: 32766857 DOI: 10.1182/bloodadvances.2020002270] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 06/20/2020] [Indexed: 01/01/2023] Open
Abstract
Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) is the standard treatment of diffuse large B-cell lymphoma (DLBCL). Primary DLBCL of the central nervous system (CNS) (primary central nervous system lymphoma [PCNSL]) is an exception because of the low CNS bioavailability of related drugs. NGR-human tumor necrosis factor (NGR-hTNF) targets CD13+ vessels, enhances vascular permeability and CNS access of anticancer drugs, and provides the rationale for the treatment of PCNSL with R-CHOP. Herein, we report activity and safety of R-CHOP preceded by NGR-hTNF in patients with PCNSL relapsed/refractory to high-dose methotrexate-based chemotherapy enrolled in a phase 2 trial. Overall response rate (ORR) was the primary endpoint. A sample size of 28 patients was considered necessary to demonstrate improvement from 30% to 50% ORR. NGR-hTNF/R-CHOP would be declared active if ≥12 responses were recorded. Treatment was well tolerated; there were no cases of unexpected toxicities, dose reductions or interruptions. NGR-hTNF/R-CHOP was active, with confirmed tumor response in 21 patients (75%; 95% confidence interval, 59%-91%), which was complete in 11. Seventeen of the 21 patients with response to treatment received consolidation (ASCT, WBRT, and/or lenalidomide maintenance). At a median follow-up of 21 (range, 14-31) months, 5 patients remained relapse-free and 6 were alive. The activity of NGR-hTNF/R-CHOP is in line with the expression of CD13 in both pericytes and endothelial cells of tumor vessels. High plasma levels of chromogranin A, an NGR-hTNF inhibitor, were associated with proton pump inhibitor use and a lower remission rate, suggesting that these drugs should be avoided during TNF-based therapy. Further research on this innovative approach to CNS lymphomas is warranted. The trial was registered as EudraCT: 2014-001532-11.
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Margold M, Seidel S, Kowalski T, Ladigan S, Baraniskin A, Schroers R, Frey AV, Schmidt-Wolf IGH, Herrlinger U, Korfel A, Schlegel U. The value of bone marrow biopsy for staging of patients with primary CNS lymphoma. Neuro Oncol 2021; 23:2076-2084. [PMID: 33984138 PMCID: PMC8643483 DOI: 10.1093/neuonc/noab109] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND In patients with presumed primary CNS lymphoma (PCNSL) a systemic manifestation is found only in a small minority. Although bone marrow biopsy (BMB) is recommended for staging, its diagnostic value is unclear. METHODS A retrospective analysis of 392 patients with presumed PCNSL from three university hospitals and 33 patients with secondary CNS lymphoma (SCNSL) and initial CNS involvement from a multicentre Germany-wide prospective registry was performed. RESULTS A BMB was performed and documented in 320/392 patients with presumed PCNSL; 23 had pathologic results. One harboured the same lymphoma in the brain and bone marrow (BM), 22 showed findings in BM discordant to the histology of brain lymphoma; n=12 harboured a low grade lymphoma in the bone marrow, the other showed B-cell proliferation but no proof of lymphoma (n=5), monoclonal B-cells (n=3) or abnormalities not B-cell associated (n=2). In the group of SCNSL with initial CNS manifestation 32/33 patients underwent BMB; seven were documented with bone marrow involvement (BMI); one had concordant results in the brain and bone marrow with no other systemic manifestation. Six had additional systemic lymphoma manifestations apart from the brain and bone marrow. CONCLUSIONS In only two out of 352 (0.6%) patients with CNS lymphoma (320 presumed PCNSL and 32 SCNSL) BMB had an impact on diagnosis and treatment. While collected in a selected cohort these findings challenge the value of BMB as part of routine staging in presumed PCNSL.
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Affiliation(s)
- Michelle Margold
- Department of Neurology, Knappschaftskrankenhaus University of Bochum, In der Schornau 23-25, 44892 Bochum, Germany
| | - Sabine Seidel
- Department of Neurology, Knappschaftskrankenhaus University of Bochum, In der Schornau 23-25, 44892 Bochum, Germany
| | - Thomas Kowalski
- Department of Neurology, Knappschaftskrankenhaus University of Bochum, In der Schornau 23-25, 44892 Bochum, Germany
| | - Swetlana Ladigan
- Department of Internal Medicine, Knappschaftskrankenhaus University of Bochum, In der Schornau 23-25, 44892 Bochum, Germany
| | - Alexander Baraniskin
- Department of Internal Medicine, Knappschaftskrankenhaus University of Bochum, In der Schornau 23-25, 44892 Bochum, Germany
| | - Roland Schroers
- Department of Internal Medicine, Knappschaftskrankenhaus University of Bochum, In der Schornau 23-25, 44892 Bochum, Germany
| | - Anna Verena Frey
- Department of Pathology, University of Freiburg, Breisacherstr. 115a 70106 Freiburg, Germany
| | - Ingo G H Schmidt-Wolf
- Department of Integrated Oncology, University of Bonn, Venusberg - Campus 1, 53127 Bonn, Germany
| | - Ulrich Herrlinger
- Department of Neurology, University of Bonn, Venusberg - Campus 1, 53127 Bonn, Germany
| | - Agnieszka Korfel
- Department of Hemato-Oncology, Charité University of Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin.,Lilly Pharma Germany GmbH, Werner-Reimers-Str. 2-4, 61352 Bad Homburg vor der Höhe, Germany
| | - Uwe Schlegel
- Department of Neurology, Knappschaftskrankenhaus University of Bochum, In der Schornau 23-25, 44892 Bochum, Germany
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Holdhoff M, Wagner-Johnston N, Roschewski M. Systemic Approach to Recurrent Primary CNS Lymphoma: Perspective on Current and Emerging Treatment Strategies. Onco Targets Ther 2020; 13:8323-8335. [PMID: 32903865 PMCID: PMC7445492 DOI: 10.2147/ott.s192379] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/30/2020] [Indexed: 12/16/2022] Open
Abstract
There is no uniform standard of care for the treatment of refractory or recurrent primary central nervous lymphoma (r/r PCNSL). Many different systemic treatment regimens have been studied, but available data are based on small prospective or retrospective reports. There have been no randomized controlled trials in r/r PCNSL to date. Here, we provide an overview of published systemic regimens for the treatment of r/r PCNSL, as well as therapies that are under investigation. In addition, based on available data, we propose strategies of how to approach choice of therapy for different groups of patients in this disease setting. Patients can be mainly divided into three groups: 1) patients suitable for a re-challenge with high-dose methotrexate (HD-MTX)-based regimens and that may or may not be candidates for consolidation with high-dose chemotherapy with autologous stem cell transplant, 2) patients refractory to HD-MTX or that had early relapse, but suitable for an aggressive treatment strategy with re-induction with non-MTX-based therapy, possibly followed by high-dose chemotherapy with autologous transplant, and 3) patients not suitable for re-treatment with HD-MTX and that are not candidates for aggressive therapy. As PCNSL is a rare disease and as there is urgent need for better outcomes in r/r PCNSL, clinical trial participation is encouraged, especially in elderly or frail patients who are not candidates for high-dose chemotherapy and transplant.
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Affiliation(s)
- Matthias Holdhoff
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland, USA
| | - Nina Wagner-Johnston
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland, USA
| | - Mark Roschewski
- Lymphoid Malignancies Branch, National Cancer Institute, Bethesda, Maryland, USA
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Abstract
OPINION STATEMENT Primary central nervous system lymphoma is a complex disease with no agreed-upon standard-of-care therapy. Induction therapy involves multiagent chemotherapy based on high-dose methotrexate, with several regimens available. We have a preference for a regimen using rituximab, methotrexate (3.5 g/m2), procarbazine, and vincristine (R-MPV) for initial induction therapy, given the favorable balance between toxicities and very high response rates (80-90%), which allow for decreasing disease burden and increasing the effectiveness of consolidation treatments. However, in the absence of consolidation therapies, R-MPV is not an effective regimen to achieve long-term remission.Based on high rates of long-term remission, our first choice for consolidation therapy is high-dose chemotherapy with autologous stem-cell transplant using thiotepa, busulfan, and cyclophosphamide as a myeloablative regimen, with a curative intent. This typically applies to patients with a favorable performance status at the end of induction, typically with ECOG performance status of 2 or better, adequate organ function, and age younger than 70. Patients with a high transplant-related mortality risk may still be considered for milder myeloablative regimens such as carmustine/thiotepa.For patients who are not transplant candidates, we typically offer consolidation with reduced dose whole-brain radiation therapy (WBRT) (23.4 Gy), which seems to be associated with lower risks of neurotoxicity as compared with higher doses of radiation. For patients who are not transplant candidates and that do not accept the risk of cognitive decline from the radiotherapy, we typically offer consolidation high-dose cytarabine, provided the patient understands the high risk of relapse. For these patients, a clinical trial is strongly recommended.
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