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Sieg N, Naendrup JH, Gödel P, Balke-Want H, Simon F, Deckert M, Gillessen S, Kreissl S, Bröckelmann PJ, Borchmann P, von Tresckow B, Heger JM. Treatment patterns and disease course of previously untreated Primary Central Nervous System Lymphoma: Feasibility of MTX-based regimens in clinical routine. Eur J Haematol 2021; 107:202-210. [PMID: 33960535 DOI: 10.1111/ejh.13639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Primary central nervous system lymphoma (PCNSL) is a rare type of aggressive lymphoma of the central nervous system. Treatment strategies improved significantly over the past decades differ regionally but mainly consist of rituximab and high-dosed methotrexate (MTX)-based therapies. METHODS We assessed clinical outcomes of 100 patients with newly diagnosed PCNSL between 2010-2020 at the University Hospital of Cologne, Germany. RESULTS Patients were 23-88 years of age and either treated with MTX-based regimens (PRIMAIN, MARTA, MATRix), individual regimens, or best supportive care, respectively. Overall response rates were generally high (66,7-83,8%), but different organ toxicities required dose adjustments in most groups. Two-year overall survival rates were 57,9% (PRIMAIN), 63,6% (MARTA), 65,4% (MATRix), and 37,5% (Other), respectively. Out of 9 patients suffering from relapse >12 months from primary diagnosis, 7 patients (77,8%) received methotrexate-based salvage therapy with 2-year overall survival of 4/6 patients (66,7%). CONCLUSION Although a relevant proportion of patients are not eligible for clinical trials due to age, performance status, or comorbidities, these results prove feasibility of different MTX-based treatment strategies in clinical routine. Even elderly patients displayed surprisingly favorable outcomes. However, with compromising organ toxicities, reduction of intensity should be part of strategies in future clinical trials.
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Affiliation(s)
- Noëlle Sieg
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany.,Cologne Lymphoma Working Group, Cologne, Germany.,Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, California, USA
| | - Jan-Hendrik Naendrup
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany.,Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, California, USA
| | - Philipp Gödel
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany.,Cologne Lymphoma Working Group, Cologne, Germany.,Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, California, USA
| | - Hyatt Balke-Want
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany.,Cologne Lymphoma Working Group, Cologne, Germany.,Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, California, USA.,Institute of Neuropathology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Florian Simon
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany.,Cologne Lymphoma Working Group, Cologne, Germany.,Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, California, USA
| | - Martina Deckert
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, California, USA.,Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Sarah Gillessen
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany.,Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, California, USA
| | - Stefanie Kreissl
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany.,Cologne Lymphoma Working Group, Cologne, Germany.,Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, California, USA
| | - Paul J Bröckelmann
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany.,Cologne Lymphoma Working Group, Cologne, Germany.,Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, California, USA
| | - Peter Borchmann
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany.,Cologne Lymphoma Working Group, Cologne, Germany.,Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, California, USA
| | - Bastian von Tresckow
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, California, USA.,Cancer Center Cologne Essen (CCCE), Cologne and Essen, Germany
| | - Jan-Michel Heger
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany.,Cologne Lymphoma Working Group, Cologne, Germany.,Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, California, USA
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2
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Habot-Wilner Z, Frenkel S, Pe'er J. Efficacy and safety of intravitreal methotrexate for vitreo-retinal lymphoma - 20 years of experience. Br J Haematol 2021; 194:92-100. [PMID: 33900619 DOI: 10.1111/bjh.17451] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/12/2021] [Indexed: 02/05/2023]
Abstract
Vitreo-retinal lymphoma (VRL) is the most common intraocular lymphoma and is highly associated with central nervous system (CNS) lymphoma (CNSL), both posing a therapeutic challenge. We investigated patients' characteristics, efficacy and safety of intravitreal methotrexate (MTX) injections and their outcomes over 20 years. The records of 129 patients diagnosed between 1997 and 2018 were retrospectively reviewed. Lymphoma involved both the CNS and vitreo-retina (49%), solely the CNS (37%) or solely the vitreo-retina (14%). In all, 45·5% of the patients with CNSL either presented with VRL or developed it after a mean (±SE) of 85·7 (7·3) months. In all, 66·0% of the patients diagnosed with VRL either presented with CNSL or developed it after a mean (±SE) 42·6 (7·6) months. The 81 patients with VRL (134 eyes) received a mean (±SD) of 19 (7) injections; however, only 5 (4) injections were needed to reach complete remission. Local recurrence occurred in two of the 81 patients. Overall, 80·2% of eyes had an initial moderate-severe visual loss, and >50% of them improved. Reversible keratopathy was the most prevalent side-effect. A total of 18·5% developed intraocular pressure (IOP) elevation due to angle neovascularisation after 16 injections, which could be reversed with prompt intravitreal injection of bevacizumab. Intravitreal MTX injections are a safe and effective treatment for VRL. Fewer injections (15) may offer similar results with fewer side-effects.
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Affiliation(s)
- Zohar Habot-Wilner
- Uveitis Service, Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shahar Frenkel
- Ocular Oncology Service, Division of Ophthalmology, Hadassah Medical Center, Jerusalem, Israel.,Ocular Oncology and Ophthalmic Pathology Laboratory, The Wohl Institute for Translational Medicine, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Jacob Pe'er
- Ocular Oncology Service, Division of Ophthalmology, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
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3
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Jurenová D, Plesníková P, Lysková D, Babál P, Kobzová D, Furdová A. INTRAOCULAR LYMPHOMA WITH RETROBULBAR INFILTRATION. A CASE REPORT. CESKA A SLOVENSKA OFTALMOLOGIE : CASOPIS CESKE OFTALMOLOGICKE SPOLECNOSTI A SLOVENSKE OFTALMOLOGICKE SPOLECNOSTI 2021; 77:304-310. [PMID: 35081721 DOI: 10.31348/2021/37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Subjective and objective symptoms following intraocular lymphoma could lead to a misdiagnosis at the beginning of the disease, which is the cause for the delay in an effective treatment. The most common manifestation of lymphoma is an inflammatory disease affecting the uvea. A multidisciplinary approach to the diagnosis is required. Suspicion based on the ophthalmological examinations has to be verified by histology. We present a case report of a 78-year-old patient examined at our clinic, with progressive loss of vision in the left eye over 6 months, suspected of retinal detachment. Objectively the visual acuity was counting fingers in front of the left eye. Intraocular pressure changed from normotensive to hypertensive values during regular examinations. We realised imaging exams, ultrasonography and magnetic resonance, which proved an intraocular tumour with retrobulbar infiltration and retinal detachment. The patient was indicated for enucleation, which enabled assignment of a histological type of intraocular B-Non-Hodgkin lymphoma from marginal zone B-cells. We sent the patient to a haematologist-oncologist for management of the subsequent treatment and we prescribed an individual prosthesis to the patient after the enucleation. The patient remains under observation; no surgical treatment, chemotherapy or radiotherapy have been used for 15 months after the enucleation. The enucleation was both a diagnostic and treatment modality.
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4
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Farrall AL, Smith JR. Eye involvement in primary central nervous system lymphoma. Surv Ophthalmol 2020; 65:548-561. [PMID: 32057762 DOI: 10.1016/j.survophthal.2020.02.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 02/02/2020] [Accepted: 02/03/2020] [Indexed: 12/18/2022]
Abstract
Primary central nervous system lymphoma (PCNSL) may manifest initially in the eye (termed vitreoretinal lymphoma or VRL) or in non-ocular CNS compartments, or in both. The nature of the onset of PCNSL implies two clinical specialists - ophthalmologists and neuro-oncologists - independently may assess the primary presentation of this rare malignancy. Clinically relevant perspectives on expectations of PCNSL manifestation in both ocular and non-ocular CNS compartments would help inform management practices in each specialty, which should impact clinical outcomes. A recent increase in the number of published PCNSL cohort studies provides new opportunity to review the current prevalence rates of ocular involvement, and the timing of this involvement over the course of disease. In PCNSL cohorts defined by non-ocular CNS compartment involvement, with or without ocular involvement (termed "PCNSL ± ocular involvement" cohorts), mean rates of concomitant VRL at diagnosis, or at any time during the course, are 10% and 16%, respectively. Only a few individuals within this cohort group present with exclusive eye disease (<5%), and the rate of secondary ocular involvement is only 5-9%. In PCNSL cohorts defined by the involvement of the ocular compartment, with or without non-ocular CNS involvement (termed "VRL ± non-ocular CNS involvement" cohorts), 58% of persons have a primary ocular diagnosis, which carries a 50% risk of secondary involvement in the CNS beyond the eye. Rates of non-ocular CNS involvement with VRL at diagnosis or over the course of disease are 41% and 69%, respectively.
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Affiliation(s)
- Alexandra L Farrall
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia.
| | - Justine R Smith
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia.
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5
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Kinslow CJ, Rae AI, Neugut AI, Adams CM, Cheng SK, Sheth SA, McKhann GM, Sisti MB, Bruce JN, Iwamoto FM, Sonabend AM, Wang TJC. Surgery plus adjuvant radiotherapy for primary central nervous system lymphoma. Br J Neurosurg 2020; 34:690-696. [PMID: 31931632 DOI: 10.1080/02688697.2019.1710820] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Objective: Recent studies of primary central nervous system lymphoma (PCNSL) have found a positive association between cytoreductive surgery and survival, challenging the traditional notion that surgery is not beneficial and potentially harmful. However, no studies have examined the potential added benefits of adjuvant treatment in the post-operative setting. Here, we investigate survival in PCNSL patients treated with surgery plus radiation therapy (RT).Methods: The Surveillance, Epidemiology, and End-Results Program was used to identify patients with PCNSL from 1995-2013. We retrospectively analyzed the relationship between treatment, prognostic factors, and survival using case-control design. Treatment categories were compared to biopsy alone.Results: We identified 5417 cases. Median survival times for biopsy alone (n = 1824, 34%), biopsy + RT (n = 1460, 27%), surgery alone (n = 1222, 27%), and surgery + RT (n = 911, 17%) were 7, 8, 20, and 27 months, respectively. On multivariable analysis, surgery + RT was associated with improved survival over surgery alone (hazard ratio [HR] = 0.58 [95% confidence interval = 0.53-0.64] vs. HR = 0.71 [0.65-0.77]). Adjuvant RT was associated with improved survival, regardless of the extent of resection. HR's for subtotal resection, gross-total resection, subtotal resection + RT, and gross-total resection + RT were 0.77 (0.66-0.89), 0.66 (0.57-0.76), 0.62 (0.52-0.72), and 0.54 (0.46-0.63), respectively. Survival improved after adjuvant RT in patients under and over 60 years old. All findings were confirmed by multivariable analysis of cause-specific survival.Conclusion: Adjuvant RT was associated with improved survival in PCNSL patients who underwent surgery. Although these data are hypothesis-generating, additional information on neurotoxicity, dosing, and concurrent chemotherapy will be necessary to validate these findings. Cytoreductive surgery for PCNSL is common in the general population, and more studies are needed to assess optimal treatment in the post-operative setting.
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Affiliation(s)
- Connor J Kinslow
- Department of Radiation Oncology, College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA
| | - Ali I Rae
- Department of Neurological Surgery, Oregon Health & Sciences University, Portland, OR, USA
| | - Alfred I Neugut
- Department of Epidemiology, Mailman School of Public Health, and Department of Medicine, College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA.,Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA
| | - Christopher M Adams
- Division of Biostatistics, New York State Psychiatric Institute, Columbia University Irving Medical Center, New York, NY, USA
| | - Simon K Cheng
- Department of Radiation Oncology, College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA.,Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA
| | - Sameer A Sheth
- Department of Neurological Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Guy M McKhann
- Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA.,Department of Neurological Surgery, College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA
| | - Michael B Sisti
- Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA.,Department of Neurological Surgery, College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA
| | - Jeffrey N Bruce
- Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA.,Department of Neurological Surgery, College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA
| | - Fabio M Iwamoto
- Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA.,Department of Neurology, College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA
| | - Adam M Sonabend
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Tony J C Wang
- Department of Radiation Oncology, College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA.,Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA
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6
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Wu Q, Yang Z, Xu Y. Nomograms Predict Survival Outcome of Primary Intramedullary Spinal Cord Lymphoma Patients. Med Sci Monit 2019; 25:7418-7429. [PMID: 31579048 PMCID: PMC6791184 DOI: 10.12659/msm.919628] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Primary intramedullary spinal cord lymphoma (PISCL) is a rare cause of myelopathies. Considering its poor prognosis, it is essential to determine the appropriate treatment strategies and to develop nomograms to predict survival outcome for PISCL patients. Material/Methods Data were collected from the Surveillance, Epidemiology and End Results (SEER) database. We used 364 patients to investigate overall survival (OS) and 289 patients for cancer-specific survival (CSS). Kaplan-Meier method was to evaluate correlations of survival with different treatment strategies and clinicopathologic factors. Univariate and multivariable analyses were conducted to assess OS and CSS based on different variables. Risk factors were integrated to build nomograms. Results Most of the 414 PISCL patients diagnosed with positive histology had diffuse B cell lymphoma, were under 60 years old, were male, were of white race, had 1 primary tumor, were married, were low stage, and had previously undergone chemotherapy. We found that radiation therapy had no effect on patient OS and CSS, and patients receiving chemotherapy alone tended to have better OS and CSS in comparison with other groups. In addition, we showed that clinicopathologic factors, including histologic type, age, stage, and marital status, could serve as independent prognostic factors for PISCL patient OS and CSS. These factors were utilized to construct nomograms. The calibration curves demonstrated good agreement. The concordance indexes for OS and CSS were 0.672 (P=0.024) and 0.683 (P=0.029), respectively. Conclusions Practical nomograms were established for patients’ OS and CSS. Besides, this study can guild clinician to make the right decision for appropriate treatment of PISCL patients.
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Affiliation(s)
- Qiong Wu
- Department of Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China (mainland)
| | - Zuyi Yang
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China (mainland)
| | - Yuan Xu
- Department of Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China (mainland)
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7
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Royer-Perron L, Hoang-Xuan K. Management of primary central nervous system lymphoma. Presse Med 2018; 47:e213-e244. [PMID: 30416008 DOI: 10.1016/j.lpm.2018.04.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 03/21/2018] [Accepted: 04/09/2018] [Indexed: 12/28/2022] Open
Abstract
A rare tumor, primary central nervous system lymphoma can affect immunocompetent and immunocompromised patients. While sensitive to radiotherapy or chemotherapy crossing the blood-brain barrier, it often recurs. Modern treatment consists of high-dose methotrexate-based induction chemotherapy, often followed by consolidation with either radiotherapy or further chemotherapy. Neurotoxicity is however a concern with radiotherapy, especially for patients older than 60 years. The benefit of the addition of rituximab to chemotherapy is unclear. Targeted therapies and immunotherapy have been effective in some patients and are tested on a larger scale. Survival has improved in the last decade, but remains poor in older patients.
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Affiliation(s)
- Louis Royer-Perron
- Hôpital Pierre-Boucher, Longueuil, Canada; AP-HP, Sorbonne universités, UPMC université Paris 06, hôpitaux Universitaires La Pitié Salpêtrière, Charles Foix, service de neurologie, 2, Mazarin, 75013, Paris, France; LOC network, 75561 Paris cedex 13, France.
| | - Khê Hoang-Xuan
- Institut du Cerveau et de la Moelle épinière (ICM), Inserm U 1127, CNRS UMR 7225, Paris, France; AP-HP, Sorbonne universités, UPMC université Paris 06, hôpitaux Universitaires La Pitié Salpêtrière, Charles Foix, service de neurologie, 2, Mazarin, 75013, Paris, France; LOC network, 75561 Paris cedex 13, France
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8
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Qian L, Tomuleasa C, Florian IA, Shen J, Florian IS, Zdrenghea M, Dima D. Advances in the treatment of newly diagnosed primary central nervous system lymphomas. Blood Res 2017; 52:159-166. [PMID: 29043230 PMCID: PMC5641507 DOI: 10.5045/br.2017.52.3.159] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 08/29/2017] [Indexed: 12/18/2022] Open
Abstract
Primary central nervous system lymphoma (PCNSL) is a type of highly invasive non-Hodgkin lymphoma. With a growing number of organ transplantation and immunosuppressant therapy, the incidence of PCNSL has been growing rapidly in recent years, which is attributed to the increased incidence of HIV/AIDS, a prominent risk factor for developing PCNSL. The rising rate of PCNSL incidence is the highest among the intracranial tumors. In the past 20 years, dozens of clinical trials related to PCNSL have been registered, but adequate therapeutics are still challenging. Currently, the chemotherapy regimens based on high-dose methotrexate and whole-brain radiotherapy are the two main therapeutic options; however, the toxicity associated with those is the main problem that challenges medical researchers. Novel agents and therapeutic strategies have been developed in recent years. In the current review, we describe advances in the treatment of PCNSL and discuss novel therapeutic approaches currently in development, such as the use of rituximab, disruption of the blood-brain barrier, and state-of-the-art radiotherapy.
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Affiliation(s)
- Liren Qian
- Department of Hematology, Navy General Hospital of PLA, Beijing, China
| | - Ciprian Tomuleasa
- Department of Hematology, Iuliu Hatieganu University, Cluj Napoca, Romania.,Department of Hematology, Ion Chiricuta Oncology Institute, Cluj Napoca, Romania
| | | | - Jianliang Shen
- Department of Hematology, Navy General Hospital of PLA, Beijing, China
| | - Ioan-Stefan Florian
- Department of Neurosurgery, Emergency University Hospital, Cluj Napoca, Romania
| | - Mihnea Zdrenghea
- Department of Hematology, Iuliu Hatieganu University, Cluj Napoca, Romania.,Department of Hematology, Ion Chiricuta Oncology Institute, Cluj Napoca, Romania
| | - Delia Dima
- Department of Hematology, Ion Chiricuta Oncology Institute, Cluj Napoca, Romania
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9
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Primary central nervous system lymphoma: essential points in diagnosis and management. Med Oncol 2017; 34:61. [PMID: 28315229 DOI: 10.1007/s12032-017-0920-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 03/14/2017] [Indexed: 12/19/2022]
Abstract
Primary central nervous system lymphoma (PCNSL) is an extra-nodal non-Hodgkin lymphoma. PCNSL is defined as lymphoma involving the brain, leptomeninges, eyes, or spinal cord without evidence of lymphoma outside the CNS. Treatment includes induction with chemotherapy and consolidation with whole-brain radiotherapy or high-dose chemotherapy supported by autologous stem cell transplantation. High-dose methotrexate is the most important drug in cases with PCNSL, and this drug will be used in combination with small molecules, BTK inhibitors, new monoclonal antibodies, and checkpoint blockers.
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10
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Kerbauy MN, Moraes FY, Lok BH, Ma J, Kerbauy LN, Spratt DE, Santos FPS, Perini GF, Berlin A, Chung C, Hamerschlak N, Yahalom J. Challenges and opportunities in primary CNS lymphoma: A systematic review. Radiother Oncol 2017; 122:352-361. [PMID: 28104300 DOI: 10.1016/j.radonc.2016.12.033] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 12/29/2016] [Accepted: 12/29/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Historically, high-dose methotrexate (HD-MTX) plus consolidation chemotherapy and/or whole brain radiotherapy (WBRT) has been the gold standard on Primary Central Nervous System Lymphoma (PCNSL) management. We sought to examine and summarize the data, on clinical trial (CT) setting, investigating multi-modality treatment to PCNSL. METHODS We performed a systematic review of electronic databases (Medline, EMBASE, Cochrane Database and clinicaltrials.gov) and a manual search to identify original PCNSL phase 2 and phase 3 CT from the last 10years. After a 4stage Prisma based selection process, 32 published (3 Randomized CT and 29 phases 2 CT) studies ultimately were selected for review. Four ongoing clinical trials found on clinicaltrial.gov were reviewed. Two investigators reviewed titles, abstracts, and articles independently. Two investigators abstracted data sequentially and evaluated each study independently. FINDINGS Treatment of PCNSL requires a multidisciplinary approach. HD-MTX represents the most accepted standard of care induction therapy for newly diagnosed PCNSL. When HD-MTX is given with WBRT for consolidation delayed neurotoxicity can be an important complication, particularly in elderly patients. Studies have suggested that WBRT may be deferred until relapse without compromising survival and deferring WBRT may be the best approach in elderly patients. Results from dose-reduced WBRT and consolidative HD-Ara-C are encouraging. High-dose chemotherapy in combination with autologous stem cell transplantation (HDC-ASCT) as chemotherapy alone has emerged as an important consolidative treatment for selected population. The optimal salvage therapy is still to be defined. CONCLUSION WBRT for consolidation is a well-studied modality; however emerging options to selected population such as HDC-ASCT, dose-reduced WBRT or chemotherapy alone are associated with similar survival outcome and less neurotoxicity in selected series. Ongoing and future clinical trials will better define the best approach on this rare disease.
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Affiliation(s)
- Mariana N Kerbauy
- Department of Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Fabio Y Moraes
- Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo, Brazil; Department of Radiation Oncology, University of Toronto, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.
| | - Benjamin H Lok
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Jennifer Ma
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Lucila N Kerbauy
- Department of Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan Medical Center, Ann Arbor, USA
| | - Fabio P S Santos
- Department of Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Guilherme F Perini
- Department of Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Caroline Chung
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, USA
| | - Nelson Hamerschlak
- Department of Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Joachim Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
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Abstract
BACKGROUND The prognosis for patients with primary vitreoretinal is dismal. The close association of primary vitreoretinal lymphoma with primary central nervous system lymphoma is responsible for high rates of mortality. Traditional treatments consist of systemic chemotherapy and whole-brain radiotherapy. The optimal approach for the treatment of isolated primary vitreoretinal lymphoma is unclear. METHODS A review of the relevant medical and scientific literature was performed, focusing on the clinical features of primary vitreoretinal lymphoma and the progress made in the management of isolated ocular disease. RESULTS Ocular treatment options for primary vitreoretinal lymphoma have recently expanded with the addition of intravitreal chemotherapeutic agents and localized radiation. Based on several retrospective reports, a general shift has been made toward local therapy (eg, orbital radiotherapy, intravitreal chemotherapy) for ocular disease. No prospective, randomized clinical trials yet exist to guide therapy. CONCLUSIONS Optimal treatment regimens for isolated primary vitreoretinal lymphoma continue to evolve. Further investigations into novel therapies and protocols are needed to decrease recurrence rates, reduce or prevent central nervous system involvement, and improve rates of overall survival.
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12
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Ma WL, Hou HA, Hsu YJ, Chen YK, Tang JL, Tsay W, Yeh PT, Yang CM, Lin CP, Tien HF. Clinical outcomes of primary intraocular lymphoma patients treated with front-line systemic high-dose methotrexate and intravitreal methotrexate injection. Ann Hematol 2016; 95:593-601. [DOI: 10.1007/s00277-015-2582-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 12/16/2015] [Indexed: 12/17/2022]
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13
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Hoang-Xuan K, Bessell E, Bromberg J, Hottinger AF, Preusser M, Rudà R, Schlegel U, Siegal T, Soussain C, Abacioglu U, Cassoux N, Deckert M, Dirven CMF, Ferreri AJM, Graus F, Henriksson R, Herrlinger U, Taphoorn M, Soffietti R, Weller M. Diagnosis and treatment of primary CNS lymphoma in immunocompetent patients: guidelines from the European Association for Neuro-Oncology. Lancet Oncol 2015; 16:e322-32. [DOI: 10.1016/s1470-2045(15)00076-5] [Citation(s) in RCA: 221] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 01/17/2015] [Accepted: 01/23/2015] [Indexed: 10/23/2022]
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14
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Hämatologische Spezialdiagnostik und Therapieoptionen bei okulären Lymphomen unter Berücksichtigung einer ZNS-Beteiligung. Ophthalmologe 2015; 112:231-6. [DOI: 10.1007/s00347-014-3207-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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15
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Reduced neurotoxicity with combined treatment of high-dose methotrexate, cyclophosphamide, doxorubicin, vincristine and prednisolone (M-CHOP) and deferred radiotherapy for primary central nervous system lymphoma. Clin Neurol Neurosurg 2014; 127:106-11. [DOI: 10.1016/j.clineuro.2014.10.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 10/05/2014] [Accepted: 10/10/2014] [Indexed: 11/21/2022]
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16
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Wiggans KT, Skorupski KA, Reilly CM, Frazier SA, Dubielzig RR, Maggs DJ. Presumed solitary intraocular or conjunctival lymphoma in dogs and cats: 9 cases (1985–2013). J Am Vet Med Assoc 2014; 244:460-70. [DOI: 10.2460/javma.244.4.460] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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17
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Pilot study of gamma-knife surgery-incorporated systemic chemotherapy omitting whole brain radiotherapy for the treatment of elderly primary central nervous system lymphoma patients with poor prognostic scores. Med Oncol 2014; 31:863. [PMID: 24496562 DOI: 10.1007/s12032-014-0863-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 01/23/2014] [Indexed: 10/25/2022]
Abstract
Systemic chemotherapy followed by whole brain radiotherapy (WBRT) is a widely used treatment strategy for patients with primary central nervous system lymphoma (PCNSL). However, the outcome of this treatment strategy in elderly patients, particularly with a poor prognostic score, was disappointing compared with younger patients, and the deterioration of cognitive function after WBRT is more problematic in these patients. To avoid this debilitating complication of WBRT and increase treatment efficacy in elderly patients, we designed systemic chemotherapy that incorporated interim gamma-knife surgery (GKS) treatment for elderly PCNSL patients (age≥65 years), omitting WBRT in this pilot trial. A total of four elderly patients with a poor prognostic score based on an International Extranodal Lymphoma Study Group were enrolled in this pilot clinical trial. All study patients acquired complete response and showed stable or improved neuropsychological function during the disease-free state. The median progression-free survival was 9.5 months (range 8.6-22.5 months), and the median overall survival was 15.8 months (range 13.3-25.1 months), which were likely to be similar to those of the chemotherapy followed by WBRT for those patients. This pilot study demonstrated that GKS-incorporated systemic chemotherapy can obtain complete response with high probability and considerably long survival, which suggests that this treatment strategy is efficient and neuropsychologically safe for elderly PCNSL patients with a poor prognostic score.
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Lake W, Chang JE, Kennedy T, Morgan A, Salamat S, Başkaya MK. A case series of primary central nervous system posttransplantation lymphoproliferative disorder: imaging and clinical characteristics. Neurosurgery 2014; 72:960-70; discussion 970. [PMID: 23685504 DOI: 10.1227/neu.0b013e31828cf619] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Primary central nervous system posttransplantation lymphoproliferative disorder (PCNS-PTLD) is a rare complication after solid organ transplantation (SOT). With increasing rates of SOT, PCNS-PTLD incidence is increasing. OBJECTIVE To describe the characteristics of PCNS-PTLD patients requiring neurosurgical intervention. METHODS From 2000 to 2011, 10 patients with prior SOT underwent biopsy for evaluation of brain lesions and were diagnosed with PCNS-PTLD. Data collected included imaging characteristics, pathology, treatments administered, and survival outcomes. RESULTS All patients had kidney transplantation, and 3 had concurrent pancreas transplantation. Median age at diagnosis was 49 years, with a median of 4.5 years from SOT to diagnosis (range, 1.8-11.4 years). Presenting symptoms most often included focal neurological deficits (n = 6), although several patients had nonspecific symptoms of headache and altered mental status. Brain lesions were generally multiple (n = 7), supratentorial (n = 8), and lobar or periventricular in distribution with ring enhancement. Diagnosis was established by stereotactic (n = 4) and open surgical (n = 6) biopsy. Treatments most frequently administered included reduction of immunosuppression (n = 10), dexamethasone (n = 10), rituximab (n = 8), high-dose methotrexate (n = 3), and whole-brain radiotherapy (n = 6). Six patients remain alive without PCNS-PTLD relapse, including 4 patients who have sustained remissions beyond 2 years from diagnosis of PCNS-PTLD. Of 4 observed deaths, 1 was related to progressive PCNS-PTLD. CONCLUSION PCNS-PTLD must be considered in the differential diagnosis of any patient with prior SOT presenting with an intracranial lesion. Histological diagnosis with brain biopsy is imperative, given the risk for opportunistic infections that may have similar imaging findings and presentation. Prognosis is variable, although long-term survival has been reported.
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Affiliation(s)
- Wendell Lake
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin 53792, USA
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19
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Abstract
Primary CNS lymphoma is a non-Hodgkin's lymphoma confined to the CNS: the brain, eyes and cerebrospinal fluid. Unlike other primary brain tumors, primary CNS lymphoma is uniquely chemo- and radiosensitive. However, the outcome of primary CNS lymphoma patients is significantly inferior to similar non-Hodgkin's lymphoma patients. Multiple prospective studies using high-dose methotrexate, with or without whole-brain radiotherapy, have reported improved primary CNS lymphoma outcome, but numerous questions remain regarding the optimal care of a given patient.
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Affiliation(s)
- Lauren E Abrey
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, NY 10021, USA.
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20
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Abstract
Neuro-oncology is a rapidly growing field of study. The understanding of brain tumors has expanded in pace with advances in the field of molecular biology and genetics. Diagnoses are more accurate, biopsy and surgical intervention safer, radiotherapy more focused and chemotherapy safer and better tolerated. Novel strategies based on the understanding of brain tumor biology are emerging as targeted approaches to therapy. Despite all this, only a minority of patients with certain subsets of brain tumors have experienced prolonged survival. This review focuses on the standard and emerging therapies for the two most common categories of brain tumors: gliomas and meningiomas. Primary CNS lymphoma, while a relatively rare tumor, is also included as a topic of discussion as the achievements in its treatment represent the principal strides in the evolution of neuro-oncology.
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Affiliation(s)
- Enrico C Lallana
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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21
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Jahnke K, Thiel E. Treatment options for central nervous system lymphomas in immunocompetent patients. Expert Rev Neurother 2014; 9:1497-509. [DOI: 10.1586/ern.09.100] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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22
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Sagoo MS, Mehta H, Swampillai AJ, Cohen VML, Amin SZ, Plowman PN, Lightman S. Primary intraocular lymphoma. Surv Ophthalmol 2013; 59:503-16. [PMID: 24560125 DOI: 10.1016/j.survophthal.2013.12.001] [Citation(s) in RCA: 145] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2012] [Revised: 12/10/2013] [Accepted: 12/10/2013] [Indexed: 01/25/2023]
Abstract
Primary intraocular lymphoma (PIOL) is an ocular malignancy that is a subset of primary central system lymphoma (PCNSL). Approximately one-third of PIOL patients will have concurrent PCNSL at presentation, and 42-92% will develop PCNSL within a mean of 8-29 months. Although rare, the incidence has been rising in both immunocompromised and immunocompetent populations. The majority of PIOL is diffuse large B-cell lymphoma, though rare T-cell variants are described. Recently, PIOL has been classified by main site of involvement in the eye, with vitreoretinal lymphoma as the most common type of ocular lymphoma related to PCNSL. Diagnosis remains challenging for ophthalmologists and pathologists. PIOL can masquerade as noninfectious or infectious uveitis, white dot syndromes, or occasionally as other neoplasms such as metastatic cancers. Laboratory diagnosis by cytology has been much aided by the use of immunocytochemistry, flow cytometry, biochemical finding of interleukin changes (IL10:IL6 ratio > 1), and cellular microdissection with polymerase chain reaction amplification for clonality. Use of several tests improves the diagnostic yield. Approaches to treatment have centered on systemic methotrexate-based chemotherapy, often with cytarabine (Ara-C) and radiotherapy. Use of intravitreal chemotherapy with methotrexate (0.4 mg/0.1 mL) is promising in controlling ocular disease, and intravitreal rituximab (anti-CD20 monoclonal antibody) has also been tried. Despite these advances, prognosis remains poor.
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Affiliation(s)
- Mandeep S Sagoo
- UCL Institute of Ophthalmology, London, UK; Moorfields Eye Hospital, London, UK; Department of Ophthalmology, St Bartholomew's Hospital, London, UK.
| | | | | | - Victoria M L Cohen
- Moorfields Eye Hospital, London, UK; Department of Ophthalmology, St Bartholomew's Hospital, London, UK
| | | | | | - Sue Lightman
- UCL Institute of Ophthalmology, London, UK; Moorfields Eye Hospital, London, UK
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Fernandes BF, Nikolitch K, Coates J, Novais G, Odashiro A, Odashiro PP, Belfort RN, Burnier MN. Local chemotherapeutic agents for the treatment of ocular malignancies. Surv Ophthalmol 2013; 59:97-114. [PMID: 24112549 DOI: 10.1016/j.survophthal.2013.01.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Revised: 01/24/2013] [Accepted: 01/29/2013] [Indexed: 11/30/2022]
Abstract
We critically analyze available peer-reviewed literature, including clinical trials and case reports, on local ocular cancer treatments. Recent innovations in many areas of ocular oncology have introduced promising new therapies, but, for the most part, the optimal treatment of ocular malignancies remains elusive.
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Affiliation(s)
- Bruno F Fernandes
- Department of Ophthalmology and Pathology, The McGill University Health Center, and Henry C. Witelson Ocular Pathology Laboratory, Montreal, Canada.
| | - Katerina Nikolitch
- Department of Ophthalmology and Pathology, The McGill University Health Center, and Henry C. Witelson Ocular Pathology Laboratory, Montreal, Canada
| | - James Coates
- Department of Ophthalmology and Pathology, The McGill University Health Center, and Henry C. Witelson Ocular Pathology Laboratory, Montreal, Canada
| | - Gustavo Novais
- Department of Ophthalmology and Pathology, The McGill University Health Center, and Henry C. Witelson Ocular Pathology Laboratory, Montreal, Canada
| | - Alexandre Odashiro
- Department of Ophthalmology and Pathology, The McGill University Health Center, and Henry C. Witelson Ocular Pathology Laboratory, Montreal, Canada
| | - Patricia P Odashiro
- Department of Ophthalmology and Pathology, The McGill University Health Center, and Henry C. Witelson Ocular Pathology Laboratory, Montreal, Canada
| | - Rubens N Belfort
- Department of Ophthalmology and Pathology, The McGill University Health Center, and Henry C. Witelson Ocular Pathology Laboratory, Montreal, Canada
| | - Miguel N Burnier
- Department of Ophthalmology and Pathology, The McGill University Health Center, and Henry C. Witelson Ocular Pathology Laboratory, Montreal, Canada
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Salamoon M, Hussein T, Kenj M, Bachour M. High-dose methotrexate, high-dose cytarabine and temozolomide for the treatment of primary central nervous system lymphoma (PCNSL). Med Oncol 2013; 30:690. [PMID: 23959450 DOI: 10.1007/s12032-013-0690-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 08/08/2013] [Indexed: 11/30/2022]
Abstract
Treatment of primary central nervous system lymphoma (PCNSL) associates with low response rates and poor survival using conventional radio and chemotherapy. Due to its favorable toxicity profile, temozolomide has emerged as a new option for treatment of PCNSL in young patients. In this study, we report a series of PCNSL patients treated with an innovative regimen combining high dose of both cytarabine and methotrexate with temozolomide without radiotherapy or intrathecal chemotherapy. To evaluate a new intensive chemotherapy with temozolomide, trying to assess response and progression-free survival rates and if the results are promising, we are aiming at evaluating the overall survival (OS) taking into consideration the toxicity profile. The study was performed at Al Mowassa Charity Hospital in Damascus (Syria). Forty patients with histologically confirmed PCNSL median age 52 years (range 20-65) years were included. Biopsies were cultured, and a karyotyping was made in 32 patients. An induction chemotherapy was started, and methotrexate 3 gr/m² over 12 h on day 1, cytarabine 3 gr/m² every 12 h on day 1 and temozolomide 150 mg/m² from day 2 through day 6 with a total of 6 cycles were given on a monthly basis. Among the 40 patients included in the study, a complete response was observed in 34 patients (85%) and a partial response in the remaining 6 patients (15%). Disease progressed in 8 out of 40 patients (20%) while 32 patients are still living at 5 years making the OS reaching 77%. Grade II nephrotoxicity was observed in 2 patients while grade III and IV hematotoxicity was observed in 5 patients. High dose of both Ara-C and MTX combined with temozolomide appears to be a good choice in the treatment of PCNSL, in the light of good response and OS rates, taking into consideration the acceptable toxicity profile. However, a larger trial is needed to make it an acceptable new combination as a first line for PCNSL patients.
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Affiliation(s)
- Maher Salamoon
- Department of Hematology and Medical Oncology, Al Bairouni University Hospital, Damascus University, Damascus, Syria,
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25
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Management of Elderly Patients with Primary Central Nervous System Lymphoma. Curr Neurol Neurosci Rep 2013; 13:344. [DOI: 10.1007/s11910-013-0344-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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26
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Mikami R, Nakayama H, Goto H, Kimura K, Usui Y, Nogi S, Tajima Y, Okubo M, Kanesaka N, Sugahara S, Tokuuye K. Preliminary results of radiotherapy for primary intraocular non-Hodgkin lymphoma. Leuk Lymphoma 2013; 54:2181-4. [DOI: 10.3109/10428194.2013.769216] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Brastianos PK, Batchelor TT. Primary Central Nervous System Lymphoma. Hematol Oncol Clin North Am 2012; 26:897-916. [DOI: 10.1016/j.hoc.2012.05.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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28
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Prodduturi P, Bierman PJ. Current and emerging pharmacotherapies for primary CNS lymphoma. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2012; 6:219-31. [PMID: 22654527 PMCID: PMC3362327 DOI: 10.4137/cmo.s7752] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Primary central nervous system lymphoma (PCNSL) constitutes a rare group of extranodal non-Hodgkin's lymphoma (NHL) primarily of B cell origin. It occurs in both immuno-competent and immune-compromised patients. High dose m ethotrexate (HD-MTX) based chemotherapy is the standard therapy. Chemotherapy with whole brain radiation therapy (WBRT) improves response rates and survival compared with WBRT alone. However, due to the increased risk for neurotoxicity with WBRT, recent studies have focused on using chemotherapy alone. Methotrexate based multi-agent chemotherapy without WBRT is associated with similar t reatment rates and survival compared with regimens that include WBRT although controlled trials have not been performed. Because of the low incidence of this disease, it is difficult to conduct randomized controlled trials. In this article we have discussed about the past, present and emerging treatment options in patients with PCNSL.
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Affiliation(s)
- Prathima Prodduturi
- University of Nebraska Medical Center, Division of Hematology and Oncology, Omaha, NE, USA 68198-7680
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29
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Abrey LE. The impact of chemotherapy on cognitive outcomes in adults with primary brain tumors. J Neurooncol 2012; 108:285-90. [DOI: 10.1007/s11060-012-0807-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 01/26/2012] [Indexed: 12/19/2022]
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30
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Wieduwilt MJ, Valles F, Issa S, Behler CM, Hwang J, McDermott M, Treseler P, O'Brien J, Shuman MA, Cha S, Damon LE, Rubenstein JL. Immunochemotherapy with intensive consolidation for primary CNS lymphoma: a pilot study and prognostic assessment by diffusion-weighted MRI. Clin Cancer Res 2012; 18:1146-55. [PMID: 22228634 PMCID: PMC3288204 DOI: 10.1158/1078-0432.ccr-11-0625] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE We evaluated a novel therapy for primary central nervous system lymphoma (PCNSL) with induction immunochemotherapy with high-dose methotrexate, temozolomide, and rituximab (MT-R) followed by intensive consolidation with infusional etoposide and high-dose cytarabine (EA). In addition, we evaluated the prognostic value of the minimum apparent diffusion coefficient (ADC(min)) derived from diffusion-weighted MRI (DW-MRI) in patients treated with this regimen. EXPERIMENTAL DESIGN Thirty-one patients (median age, 61 years; median Karnofsky performance score, 60) received induction with methotrexate every 14 days for 8 planned cycles. Rituximab was administered the first 6 cycles and temozolomide administered on odd-numbered cycles. Patients with responsive or stable central nervous system (CNS) disease received EA consolidation. Pretreatment DW-MRI was used to calculate the ADC(min) of contrast-enhancing lesions. RESULTS The complete response rate for MT-R induction was 52%. At a median follow-up of 79 months, the 2-year progression-free and overall survival were 45% and 58%, respectively. For patients receiving EA consolidation, the 2-year progression-free and overall survival were 78% and 93%, respectively. EA consolidation was also effective in an additional 3 patients who presented with synchronous CNS and systemic lymphoma. Tumor ADC(min) less than 384 × 10(-6) mm(2)/s was significantly associated with shorter progression-free and overall survival. CONCLUSIONS MT-R induction was effective and well tolerated. MT-R followed by EA consolidation yielded progression-free and overall survival outcomes comparable to regimens with chemotherapy followed by whole-brain radiotherapy consolidation but without evidence of neurotoxicity. Tumor ADC(min) derived from DW-MRI provided better prognostic information for PCNSL patients treated with the MTR-EA regimen than established clinical risk scores.
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Affiliation(s)
- Matthew J Wieduwilt
- Division of Hematology/Oncology, University of California San Francisco, Box 1270, 505 Parnassus Avenue, San Francisco, CA 94143, USA.
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Chan CC, Rubenstein JL, Coupland SE, Davis JL, Harbour JW, Johnston PB, Cassoux N, Touitou V, Smith JR, Batchelor TT, Pulido JS. Primary vitreoretinal lymphoma: a report from an International Primary Central Nervous System Lymphoma Collaborative Group symposium. Oncologist 2011. [PMID: 22045784 DOI: 10.1634/theoncologist.2011-2010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Primary vitreoretinal lymphoma (PVRL), also known as primary intraocular lymphoma, is a rare malignancy typically classified as a diffuse large B-cell lymphoma and most frequently develops in elderly populations. PVRL commonly masquerades as posterior uveitis and has a unique tropism for the retina and central nervous system (CNS). Over 15% of primary CNS lymphoma patients develop intraocular lymphoma, usually occurring in the retina and/or vitreous. Conversely, 65%-90% of PVRL patients develop CNS lymphoma. Consequently, PVRL is often fatal because of ultimate CNS association. Current PVRL animal models are limited and require further development. Typical clinical findings include vitreous cellular infiltration (lymphoma and inflammatory cells) and subretinal tumor infiltration as determined using dilated fundoscopy, fluorescent angiography, and optical coherent tomography. Currently, PVRL is most often diagnosed using both histology to identify lymphoma cells in the vitreous or retina and immunohistochemistry to indicate monoclonality. Additional adjuncts in diagnosing PVRL exist, including elevation of interleukin-10 levels in ocular fluids and detection of Ig(H) or T-cell receptor gene rearrangements in malignant cells. The optimal therapy for PVRL is not defined and requires the combined effort of oncologists and ophthalmologists. PVRL is sensitive to radiation therapy and exhibits high responsiveness to intravitreal methotrexate or rituximab. Although systemic chemotherapy alone can result in high response rates in patients with PVRL, there is a high relapse rate. Because of the disease rarity, international, multicenter, collaborative efforts are required to better understand the biology and pathogenesis of PVRL as well as to define both diagnostic markers and optimal therapies.
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Affiliation(s)
- Chi-Chao Chan
- Immunopathology Section, Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bethesda, Maryland 20892-1857, USA.
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Chan CC, Rubenstein JL, Coupland SE, Davis JL, Harbour JW, Johnston PB, Cassoux N, Touitou V, Smith JR, Batchelor TT, Pulido JS. Primary vitreoretinal lymphoma: a report from an International Primary Central Nervous System Lymphoma Collaborative Group symposium. Oncologist 2011; 16:1589-99. [PMID: 22045784 DOI: 10.1634/theoncologist.2011-0210] [Citation(s) in RCA: 293] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Primary vitreoretinal lymphoma (PVRL), also known as primary intraocular lymphoma, is a rare malignancy typically classified as a diffuse large B-cell lymphoma and most frequently develops in elderly populations. PVRL commonly masquerades as posterior uveitis and has a unique tropism for the retina and central nervous system (CNS). Over 15% of primary CNS lymphoma patients develop intraocular lymphoma, usually occurring in the retina and/or vitreous. Conversely, 65%-90% of PVRL patients develop CNS lymphoma. Consequently, PVRL is often fatal because of ultimate CNS association. Current PVRL animal models are limited and require further development. Typical clinical findings include vitreous cellular infiltration (lymphoma and inflammatory cells) and subretinal tumor infiltration as determined using dilated fundoscopy, fluorescent angiography, and optical coherent tomography. Currently, PVRL is most often diagnosed using both histology to identify lymphoma cells in the vitreous or retina and immunohistochemistry to indicate monoclonality. Additional adjuncts in diagnosing PVRL exist, including elevation of interleukin-10 levels in ocular fluids and detection of Ig(H) or T-cell receptor gene rearrangements in malignant cells. The optimal therapy for PVRL is not defined and requires the combined effort of oncologists and ophthalmologists. PVRL is sensitive to radiation therapy and exhibits high responsiveness to intravitreal methotrexate or rituximab. Although systemic chemotherapy alone can result in high response rates in patients with PVRL, there is a high relapse rate. Because of the disease rarity, international, multicenter, collaborative efforts are required to better understand the biology and pathogenesis of PVRL as well as to define both diagnostic markers and optimal therapies.
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Affiliation(s)
- Chi-Chao Chan
- Immunopathology Section, Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bethesda, Maryland 20892-1857, USA.
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Gonzalez-Aguilar A, Houillier C, Soussain C, Hoang-Xuan K. [Management of primary central nervous system lymphoma]. Rev Neurol (Paris) 2011; 167:721-8. [PMID: 21906768 DOI: 10.1016/j.neurol.2011.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 08/02/2011] [Indexed: 11/18/2022]
Abstract
Primary CNS lymphoma is the malignant brain tumor whose prognosis has improved the most the two past decades. The majority of the patients achieve a complete remission with treatment and a substantial minority may hope to be cured. The treatment includes high-dose methotrexate polychemotherapy combined or not with whole brain radiotherapy (WBRT). Elderly patients who are exposed to a high risk of treatment induced neurotoxicity need a specific management avoiding or defering WBRT. In young patients, the main questions concerning the treatment are the role of consolidation WBRT and intensive chemotherapy with peripheral blood stem cell rescue in the initial treatment of PCNSL. As recently shown, national and international collaborative efforts make now possible randomized trials for this rare disease, which would contribute to better define the treatment strategy. New insights in PCNSL tumorigenesis would help to better understand the heterogeneity of outcome and to develop efficient targeted therapies.
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Affiliation(s)
- A Gonzalez-Aguilar
- UPMC, Service de neurologie Mazarin, groupe hospitalier Pitié-Salpêtrière, 47 boulevard de l'Hôpital, Paris cedex 13, France
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Gerard LM, Imrie KR, Mangel J, Buckstein R, Doherty M, Mackenzie R, Cheung MC. High-dose methotrexate based chemotherapy with deferred radiation for treatment of newly diagnosed primary central nervous system lymphoma. Leuk Lymphoma 2011; 52:1882-90. [DOI: 10.3109/10428194.2011.584004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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35
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Primary intraocular lymphoma: a review. J Neurooncol 2011; 105:127-34. [DOI: 10.1007/s11060-011-0618-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Accepted: 05/23/2011] [Indexed: 10/18/2022]
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36
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Primary CNS lymphoma in patients younger than 60: can whole-brain radiotherapy be deferred? J Neurooncol 2010; 104:323-30. [DOI: 10.1007/s11060-010-0497-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Accepted: 12/03/2010] [Indexed: 11/26/2022]
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Ney DE, Reiner AS, Panageas KS, Brown HS, DeAngelis LM, Abrey LE. Characteristics and outcomes of elderly patients with primary central nervous system lymphoma: the Memorial Sloan-Kettering Cancer Center experience. Cancer 2010; 116:4605-12. [PMID: 20572045 DOI: 10.1002/cncr.25363] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Approximately 50% of all patients with primary central nervous system lymphoma (PCNSL) are aged ≥65 years; however, this group is relatively understudied, and to the authors's knowledge, optimal treatment for older patients is not well defined. METHODS This was a retrospective review of PCNSL patients aged ≥65 years who were treated at Memorial Sloan-Kettering Cancer Center between 1986 and 2008. A multivariate analysis of demographic and clinical variables on prognosis and receipt of treatment was performed. RESULTS One hundred seventy-four patients between the ages of 65 and 89 years were identified; there was a slight predominance of women (52.9%). One hundred forty-eight patients were treated with chemotherapy at the time of diagnosis (98% with methotrexate-based therapy) and 31 of these patients also received whole-brain radiotherapy (WBRT). Sixteen patients received WBRT alone. A radiographic response to chemotherapy was noted in 76% of patients. Ninety patients developed disease progression after initial treatment; 74 received salvage therapy and 48% of these patients responded to salvage treatment. The median overall survival was 25 months (range, 18-33 months), and the 3-year survival rate was 36%. Approximately 20.1% of patients were alive for ≥11 years. WBRT was delivered more frequently before 1998, and patients with a history of prior malignancy were less likely to receive WBRT. Age and performance status were identified as the most important predictors of survival. Treatment-related neurotoxicity at 2 years was strongly associated with receipt of WBRT (P=.0002). CONCLUSIONS PCNSL in the elderly remains sensitive to methotrexate-based chemotherapy and aggressive treatment may be warranted both at the time of diagnosis and disease recurrence.
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Affiliation(s)
- Douglas E Ney
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA
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Hashemi-Sadraei N, Peereboom DM. Chemotherapy in newly diagnosed primary central nervous system lymphoma. Ther Adv Med Oncol 2010; 2:273-92. [PMID: 21789140 PMCID: PMC3126018 DOI: 10.1177/1758834010365330] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Primary central nervous system lymphoma (PCNSL) accounts for only 3% of brain tumors. It can involve the brain parenchyma, leptomeninges, eyes and the spinal cord. Unlike systemic lymphoma, durable remissions remain uncommon. Although phase III trials in this rare disease are difficult to perform, many phase II trials have attempted to define standards of care. Treatment modalities for patients with newly diagnosed PCNSL include radiation and/or chemotherapy. While the role of radiation therapy for initial management of PCNSL is controversial, clinical trials will attempt to improve the therapeutic index of this modality. Routes of chemotherapy administration include intravenous, intraocular, intraventricular or intra-arterial. Multiple trials have outlined different methotrexate-based chemotherapy regimens and have used local techniques to improve drug delivery. A major challenge in the management of patients with PCNSL remains the delivery of aggressive treatment with preservation of neurocognitive function. Because PCNSL is rare, it is important to perform multicenter clinical trials and to incorporate detailed measurements of long-term toxicities. In this review we focus on different chemotherapeutic approaches for immunocompetent patients with newly diagnosed PCNSL and discuss the role of local drug delivery in addition to systemic therapy. We also address the neurocognitive toxicity of treatment.
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Franklin JL, Finlay J. Leukemias and lymphomas: treatment and prophylaxis of the central nervous system. Curr Treat Options Neurol 2010; 8:335-45. [PMID: 16942676 DOI: 10.1007/s11940-006-0023-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Central nervous system (CNS)-directed therapy is required for many acute leukemia patients and for nearly all aggressive or high-grade non-Hodgkin's lymphoma patients as part of an overall chemotherapy plan for disease eradication. The CNS therapy decisions differ for overt disease treatment versus prophylactic treatment and take into consideration the type of leukemia or lymphoma, the age of the patient, and other prognostic factors. A variety of CNS-directed therapies are used for prevention or treatment of CNS disease in acute leukemias or aggressive lymphomas: intrathecal medications (cytosine arabinoside, methotrexate, or both in combination with hydrocortisone) with or without cranial or craniospinal irradiation, intrathecal medication only with intensive systemic chemotherapy, or high-dose chemotherapy specifically chosen for CNS penetrance. Any type of CNS-directed therapy, whether intrathecal chemotherapy, high-dose systemic chemotherapy, or irradiation, may cause acute or delayed (late) toxicity. Ongoing clinical trial research aims to reduce the risk of toxicity from CNS-directed therapy while preserving or improving treatment efficacy.
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Affiliation(s)
- Janet L Franklin
- Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA.
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Carrabba MG, Reni M, Foppoli M, Chiara A, Franzin A, Politi LS, Villa E, Ciceri F, Ferreri AJM. Treatment approaches for primary CNS lymphomas. Expert Opin Pharmacother 2010; 11:1263-76. [DOI: 10.1517/14656561003767456] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Matteo G Carrabba
- San Raffaele Scientific Institute, Haematology and Bone Marrow Transplantation Unit, Department of Oncology, Milan, Italy
- San Raffaele Scientific Institute, Unit of Lymphoid Malignancies, Medical Oncology Unit, Department of Oncology, Milan, Italy
| | - Michele Reni
- San Raffaele Scientific Institute, Medical Oncology Unit, Department of Oncology, Milan, Italy
| | - Marco Foppoli
- San Raffaele Scientific Institute, Unit of Lymphoid Malignancies, Medical Oncology Unit, Department of Oncology, Milan, Italy
| | - Anna Chiara
- San Raffaele Scientific Institute, Radiotherapy Unit, Department of Oncology, Milan, Italy
| | - Alberto Franzin
- San Raffaele Scientific Institute, Neurosurgery Unit, Department of Head and Neck, Milan, Italy
| | | | - Eugenio Villa
- San Raffaele Scientific Institute, Medical Oncology Unit, Department of Oncology, Milan, Italy
| | - Fabio Ciceri
- San Raffaele Scientific Institute, Haematology and Bone Marrow Transplantation Unit, Department of Oncology, Milan, Italy
| | - Andrés JM Ferreri
- San Raffaele Scientific Institute, Unit of Lymphoid Malignancies, Medical Oncology Unit, Department of Oncology, Milan, Italy
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41
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Current Management of Primary Central Nervous System Lymphoma. Int J Radiat Oncol Biol Phys 2010; 76:666-78. [DOI: 10.1016/j.ijrobp.2009.10.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Revised: 09/22/2009] [Accepted: 10/21/2009] [Indexed: 11/18/2022]
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Kiewe P, Fischer L, Martus P, Thiel E, Korfel A. Meningeal dissemination in primary CNS lymphoma: diagnosis, treatment, and survival in a large monocenter cohort. Neuro Oncol 2010; 12:409-17. [PMID: 20308318 DOI: 10.1093/neuonc/nop053] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The frequency of meningeal dissemination (MD) in primary CNS lymphoma (PCNSL), its prognostic impact, and optimal management have not been defined thus far. In 69 of 92 (75%) immunocompetent patients, primarily diagnosed with PCNSL at our institution between January 1994 and February 2007, cerebrospinal fluid was analyzed for MD. MD was found by cytomorphology in 7/63 (11%), by immunophenotyping in 1/32 (3%), and by PCR of the IgH CDR III region in 6/37 (16%). Neuroradiologic examination revealed MD in 3 of 69 patients (4%). Median event-free survival (EFS) of patients with MD diagnosed by any of the methods was 26 months, of those without MD 34.1 months (P = .24); median overall survival (OAS) of these two patients' groups was 45.5 and 42.5 months, respectively (P = .34). Patients with cytomorphologic proof of MD had a median EFS of 15.4 months and OAS of 18.5 months, those without MD 34.3 and 45 months (P = .018 and .017, respectively). We found a low frequency of MD despite the use of putatively sensitive diagnostic methods. No impact on outcome was seen for MD, diagnosed by any of the methods used; however, patients with cytomorphologic proof of MD had a significantly shorter median EFS and OAS.
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Affiliation(s)
- Philipp Kiewe
- Department of Hematology, Oncology and Transfusion Medicine, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30/31, 12200 Berlin, Germany.
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Pe'er J, Hochberg FH, Foster CS. Clinical review: treatment of vitreoretinal lymphoma. Ocul Immunol Inflamm 2010; 17:299-306. [PMID: 19831557 DOI: 10.3109/09273940903370755] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Vitreoretinal lymphoma is the most common type of intraocular lymphoma. It is mostly a high-grade B-cell malignancy with a poor prognosis, and is often associated with primary central nervous system lymphoma. Since intraocular lymphoma was first recognized almost 60 years ago, its treatment has gradually evolved. In the early years enucleation was often performed. Since that time, radiation therapy alone, systemic chemotherapy alone, or a combination of the two have been used extensively Because of the limited intraocular penetration of drugs administered systemically, the systemic and local toxicity of chemotherapy and radiation therapy and the high rate of recurrence, intravitreous chemotherapy, mainly using methotrexate, has become popular in the last decade, with encouraging results. More recently, biological treatment with intravitreal injections of rituximab has been investigated, with good results and minimal side effects. This review summarizes the present knowledge on vitreoretinal lymphoma therapy, with an eye to future molecular approaches.
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Affiliation(s)
- Jacob Pe'er
- Department of Ophthalmology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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Monotherapy with methotrexate for primary central nervous lymphoma has single agent activity in the absence of radiotherapy: a single institution cohort. J Neurooncol 2009; 98:385-93. [PMID: 20020180 PMCID: PMC2883931 DOI: 10.1007/s11060-009-0090-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2009] [Accepted: 11/30/2009] [Indexed: 01/09/2023]
Abstract
We have retrospectively reviewed toxicities and response of a cohort of primary central nervous system lymphoma (PCNSL) patients treated with high dose parenteral methotrexate (MTX) monotherapy without whole brain radiation. From The Massachusetts General Hospital (MGH) Cancer Registry, active since 1946, we selected all immunocompetent patients with histologic and/or radiographic PCNSL diagnosed between 1980 and 2007. We identified the recipients of MTX with leucovorin rescue as sole therapy. No patient received radiation therapy (XRT). We analyzed this cohort for toxicity, response and patterns of recurrence. The cohort of 121 patients received on average 11 cycles of intravenous MTX at a median dose of 8 g/m2. Median interval between cycles was 10 days. After 3 months of therapy, the overall response rate was 85% (58% CR, 27% PR). The overall survival (OS) for the cohort was 7 years and progression-free survival (PFS) was 3.14 years. A trend toward a higher PFS was seen in patients who continued to receive MTX (3.48 years) every three months as compared to patients who ceased MTX after one year (2.86 years). Of 68 patients who achieved initial CR, there were 40 recurrences. Twenty-six of the 40 were re-induced with MTX as above; Sixty-nine percent again achieved CR. Eighty-one treatment-related toxicities occurred in 1316 MTX cycles. These toxicities included MRI white matter changes (N = 8) and lead to MTX cessation in 16 patients. High-dose MTX monotherapy of PCNSL is well-tolerated and provides PFS of >3 years and OS >7 years.
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Herrlinger U, Glantz M, Schlegel U, Gisselbrecht C, Cavalli F. Should Intra-cerebrospinal Fluid Prophylaxis Be Part of Initial Therapy for Patients With Non-Hodgkin Lymphoma: What We Know, and How We Can Find Out More. Semin Oncol 2009; 36:S25-34. [DOI: 10.1053/j.seminoncol.2009.05.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Primary intraocular lymphoma (PIOL) is a type of primary central nervous system lymphoma (PCNSL). It is the most common neoplastic masquerade syndrome involving the eye. Its protean ocular manifestations, plus in many cases the initial positive response to corticosteroid therapy for presumed uveitis, delay accurate diagnosis. A high index of suspicion is essential, followed by tissue biopsy with cytology and ancillary studies. Current treatment is based on chemotherapy featuring high-dose methotrexate and radiation therapy. Prognosis is poor due to CNS involvement, but newer therapies have had some success in prolonging survival.
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Affiliation(s)
- John Y Choi
- Retina Specialists of Boston, Cambridge, MA, USA
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47
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Yamanaka R, Shinbo Y, Sano M, Homma J, Tsuchiya N, Yajima N, Tamura T, Hondoh H, Takahashi H, Morii K, Onda K, Tanaka R. Salvage therapy and late neurotoxicity in patients with recurrent primary CNS lymphoma treated with a modified ProMACE-MOPP hybrid regimen. Leuk Lymphoma 2009; 48:1119-26. [PMID: 17577775 DOI: 10.1080/10428190701299564] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We report the efficacy of salvage therapy with a modified ProMACE-MOPP combined with radiation in patients with primary central nervous system lymphoma (PCNSL). Thirty-two immunocompetent patients were treated with a regimen of pirarubicin, cyclophosphamide, etoposide, vincristin, and methotrexate (MTX: 500 mg/m(2)) administered in 21-day cycles. Patients received 20 Gy of whole-brain radiotherapy after three cycles of chemotherapy. A single cycle of chemotherapy was repeated every four months for two years. Nine patients with CNS relapse were retreated with additional cycles of the ProMACE-MOPP hybrid regimen with a 90% objective response rate. Median complete response (CR) duration was 13.2 months and median survival time (MST) for the nine patients treated after initial relapse was 30 months. One of 17 patients (5.8%) who had less than 20 Gy of whole brain irradiation developed dementia. In contrast, six of seven (85.7%) patients who had more than 30 Gy of whole brain radiotherapy became demented. Maintaining a moderate dose of MTX, while adding chemotherapeutic agents and 20 Gy of whole brain radiation therapy, improved disease control and overall survival and lowered the incidence of delayed neurologic toxicity in patients with PCNSL. Additional treatment with a ProMACE-MOPP hybrid regimen is still effective for relapsed disease.
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Affiliation(s)
- Ryuya Yamanaka
- Department of Neurosurgery, Brain Research Institute, Niigata University, Niigata.
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Abstract
Optimum treatment for patients with primary CNS lymphoma remains challenging because there have not been any large randomised clinical trials of this rare tumour. Drugs used in treating systemic non-Hodgkin lymphoma have mostly proven ineffective because of difficulties crossing the blood-brain barrier. The recognition of the efficacy of high-dose methotrexate was a substantial therapeutic breakthrough and further advances, such as the development of polychemotherapy regimens, have built on this. Whole-brain radiotherapy can consolidate response to chemotherapy, but the associated toxic effects of chemoradiation can be unacceptable. Other effective approaches include disruption of the blood-brain barrier and the use of high-dose chemotherapy. Recently, there have been attempts to optimise multi-drug chemotherapy regimens by focusing on improving survival and reducing toxic effects. A promising area of research is the incorporation of novel targeted drugs into standard treatment frameworks. In the future, greater cooperation between research groups should hopefully lead to further therapeutic advances.
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Affiliation(s)
- Patrick G Morris
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
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50
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Principes de traitement des lymphomes primitifs du système nerveux central chez l’immunocompétent. ONCOLOGIE 2009. [DOI: 10.1007/s10269-008-1026-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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