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Ferreri AJM, Calimeri T, Cwynarski K, Dietrich J, Grommes C, Hoang-Xuan K, Hu LS, Illerhaus G, Nayak L, Ponzoni M, Batchelor TT. Primary central nervous system lymphoma. Nat Rev Dis Primers 2023; 9:29. [PMID: 37322012 PMCID: PMC10637780 DOI: 10.1038/s41572-023-00439-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2023] [Indexed: 06/17/2023]
Abstract
Primary central nervous system lymphoma (PCNSL) is a diffuse large B cell lymphoma in which the brain, spinal cord, leptomeninges and/or eyes are exclusive sites of disease. Pathophysiology is incompletely understood, although a central role seems to comprise immunoglobulins binding to self-proteins expressed in the central nervous system (CNS) and alterations of genes involved in B cell receptor, Toll-like receptor and NF-κB signalling. Other factors such as T cells, macrophages or microglia, endothelial cells, chemokines, and interleukins, probably also have important roles. Clinical presentation varies depending on the involved regions of the CNS. Standard of care includes methotrexate-based polychemotherapy followed by age-tailored thiotepa-based conditioned autologous stem cell transplantation and, in patients unsuitable for such treatment, consolidation with whole-brain radiotherapy or single-drug maintenance. Personalized treatment, primary radiotherapy and only supportive care should be considered in unfit, frail patients. Despite available treatments, 15-25% of patients do not respond to chemotherapy and 25-50% relapse after initial response. Relapse rates are higher in older patients, although the prognosis of patients experiencing relapse is poor independent of age. Further research is needed to identify diagnostic biomarkers, treatments with higher efficacy and less neurotoxicity, strategies to improve the penetration of drugs into the CNS, and roles of other therapies such as immunotherapies and adoptive cell therapies.
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Affiliation(s)
| | - Teresa Calimeri
- Lymphoma Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Kate Cwynarski
- Department of Haematology, University College Hospital, London, UK
| | - Jorg Dietrich
- Cancer and Neurotoxicity Clinic and Brain Repair Research Program, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Christian Grommes
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Khê Hoang-Xuan
- APHP, Groupe Hospitalier Salpêtrière, Sorbonne Université, IHU, ICM, Service de Neurologie 2, Paris, France
| | - Leland S Hu
- Department of Radiology, Neuroradiology Division, Mayo Clinic, Phoenix, AZ, USA
| | - Gerald Illerhaus
- Clinic of Hematology, Oncology and Palliative Care, Klinikum Stuttgart, Stuttgart, Germany
| | - Lakshmi Nayak
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Maurilio Ponzoni
- Pathology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Ateneo Vita-Salute San Raffaele, Milan, Italy
| | - Tracy T Batchelor
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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2
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Bravetti C, Degaud M, Armand M, Sourdeau E, Mokhtari K, Maloum K, Osman J, Verrier P, Houillier C, Roos-Weil D, Soussain C, Choquet S, Hoang-Xuan K, Le Garff-Tavernier M, Denis JA, Davi F. Combining MYD88 L265P mutation detection and clonality determination on CSF cellular and cell-free DNA improves diagnosis of primary CNS lymphoma. Br J Haematol 2023. [PMID: 36941788 DOI: 10.1111/bjh.18758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/22/2023] [Accepted: 03/07/2023] [Indexed: 03/23/2023]
Abstract
Diagnosis of primary central nervous system lymphoma (PCNSL) is challenging, and although brain biopsy remains the gold standard, cerebrospinal fluid (CSF) constitutes a less invasive source of lymphomatous biomarkers. In a retrospective cohort of 54 PCNSL cases tested at diagnosis or relapse, we evaluated the contribution of immunoglobulin heavy chain (IGH) gene clonality and MYD88 L265P detection on both CSF cell pellets and supernatants, in comparison with cytology, flow cytometry, interleukin (IL)-10 and IL-6 quantification. Clonality assessment included a new assay to detect partial IGH-DJ rearrangements. Clonal IGH rearrangements and/or MYD88 L265P mutation were detected in 27 (50%) cell pellets and 24 (44%) supernatant cell-free (cf) DNA. Combining analyses on both compartments, 36 (66%) cases had at least one detectable molecular marker, present only in cfDNA for 9 (16%) of them. While cytology and flow cytometry were positive in only 7 (13.0%) and 9 (17.3%) cases respectively, high IL-10 levels were observed in 36 (66.7%) cases. Overall, taking into account molecular and cytokine results, 46/54 (85%) cases had at least one lymphomatous biomarker detectable in the CSF. These results show that this combination of biomarkers evaluated on both cell pellet and supernatant CSF fractions improves significantly the biological diagnosis of PCNSL.
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Affiliation(s)
- Clotilde Bravetti
- Department of Biological Hematology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) and Sorbonne Université, Paris, France
| | - Michaël Degaud
- Department of Biological Hematology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) and Sorbonne Université, Paris, France
| | - Marine Armand
- Department of Biological Hematology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) and Sorbonne Université, Paris, France
| | - Elise Sourdeau
- Department of Biological Hematology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) and Sorbonne Université, Paris, France
| | - Karima Mokhtari
- Department of Neuropathology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Karim Maloum
- Department of Biological Hematology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) and Sorbonne Université, Paris, France
| | - Jennifer Osman
- Department of Biological Hematology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) and Sorbonne Université, Paris, France
| | - Patricia Verrier
- Department of Biological Hematology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) and Sorbonne Université, Paris, France
| | - Caroline Houillier
- Department of Neurology-2, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), IHU, ICM, Sorbonne Université, Paris, France
| | - Damien Roos-Weil
- Department of Clinical Hematology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) and Sorbonne Université, Paris, France
| | - Carole Soussain
- Division of Hematology, Institut Curie, Site Saint-Cloud, and INSERM U932, PSL Research University, Paris, France
| | - Sylvain Choquet
- Department of Clinical Hematology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) and Sorbonne Université, Paris, France
| | - Khe Hoang-Xuan
- Department of Neurology-2, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), IHU, ICM, Sorbonne Université, Paris, France
| | - Magali Le Garff-Tavernier
- Department of Biological Hematology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) and Sorbonne Université, Paris, France
| | - Jérôme Alexandre Denis
- Department of Endocrine and Oncological Biochemistry, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) and Sorbonne Université, Centre de recherche Saint-Antoine (UMR_S 938), Biologie et thérapeutiques du cancer, Paris, France
| | - Frédéric Davi
- Department of Biological Hematology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) and Sorbonne Université, Paris, France
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3
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Nguyen-Them L, Alentorn A, Ahle G, Soussain C, Mathon B, Le Garff Tavernier M, Houillier C, Hoang-Xuan K. CSF biomarkers in primary CNS lymphoma. Rev Neurol (Paris) 2023; 179:141-149. [PMID: 36336490 DOI: 10.1016/j.neurol.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/04/2022] [Accepted: 06/10/2022] [Indexed: 11/06/2022]
Abstract
PCNSL is a non-Hodgkin lymphoma (NHL) affecting brain, spinal cord, eyes and leptomeninges. In the past two decades, its prognosis significantly improved due to therapeutic advances but it remains a highly aggressive tumor and early diagnosis is necessary for optimal management. Diagnosis relies on the identification of lymphoma cells in brain tissue obtained by stereotactic biopsy. Alternatively, lymphoma cells may be found in CSF through lumbar puncture (LP) or by a vitrectomy. For several reasons, the diagnosis of PCNSL may be challenging. Misleading radiological presentations are frequent. Dramatic response to steroids may bias histological analysis and deep brain location or frail health status can contraindicate brain biopsy. In the follow-up of patients who have been previously treated, differential diagnosis between tumor relapse and post-treatment may be also difficult. Therefore, the development of complementary reliable diagnostic tools is needed. This review will summarize several diagnostic or prognostic CSF biomarkers which have been proposed in PCNSL, their interests and limits.
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Affiliation(s)
- L Nguyen-Them
- Centre Hospitalier Saint Jean, 20 Avenue du Languedoc, 66000 Perpignan, France; Hôpital Pitié Salpêtrière, APHP, Sorbonne Université, 47-83 Boulevard de l'Hôpital, 75013 Paris, France.
| | - A Alentorn
- Hôpital Pitié Salpêtrière, APHP, Sorbonne Université, 47-83 Boulevard de l'Hôpital, 75013 Paris, France
| | - G Ahle
- Hôpitaux Civils de Colmar, 39 Avenue Liberté, 68024 Colmar, France
| | - C Soussain
- Institut Curie - site de Saint Cloud, 35 Rue Dailly, 92210 Saint-Cloud, France
| | - B Mathon
- Hôpital Pitié Salpêtrière, APHP, Sorbonne Université, 47-83 Boulevard de l'Hôpital, 75013 Paris, France
| | - M Le Garff Tavernier
- Hôpital Pitié Salpêtrière, APHP, Sorbonne Université, 47-83 Boulevard de l'Hôpital, 75013 Paris, France
| | - C Houillier
- Hôpital Pitié Salpêtrière, APHP, Sorbonne Université, 47-83 Boulevard de l'Hôpital, 75013 Paris, France
| | - K Hoang-Xuan
- Hôpital Pitié Salpêtrière, APHP, Sorbonne Université, 47-83 Boulevard de l'Hôpital, 75013 Paris, France
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4
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Kizek DJ, Goethe EA, Karas PJ, Treiber JM, Jalali A, Gopinath SP, Kass JS. Neurolymphomatosis of the brachial plexus from atypical primary central nervous system lymphoma lesions: A case report and review of the literature. Surg Neurol Int 2022; 13:464. [DOI: 10.25259/sni_421_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 08/30/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Primary central nervous system lymphoma (PCNSL) is an aggressive and extranodal non-Hodgkin lymphoma limited to the neuroaxis. In immunocompetent individuals, PCNSL is more common in older adults and lacks the association with the Epstein–Barr virus found in individuals with AIDS-associated PCNSL. Because the clinical presentation and radiographic findings of PCNSL are highly variable, stereotactic brain biopsy is typically required for definitive diagnosis. High-dose methotrexate, in combination with other chemotherapeutic agents with or without whole brain radiation, is the mainstay of treatment.
Case Description:
A 70-year-old HIV-negative woman presented with confusion, acute flaccid left arm weakness, and left hand numbness. Head computed tomography without contrast demonstrated a 1 cm hyperdense round lesion in the suprasellar cistern that prompted further evaluation. Gadolinium-enhanced brain magnetic resonance imaging demonstrated enhancing lesions with heterogeneous signal intensity in the suprasellar, pineal, and right periatrial regions that did not explain the limb weakness and numbness. Serum and cerebrospinal fluid (CSF) studies were unrevealing, and a diagnosis of PCNSL was made following stereotactic biopsy. The patient’s liver cirrhosis precluded chemotherapy, but treatment with whole-brain radiation was pursued.
Conclusion:
The myriad clinical presentations and insidious course of PCNSL contribute to diagnostic difficulties, delays in treatment, and poor outcomes. Stereotactic brain biopsy is the primary method of PCNSL diagnosis since malignant cells are typically not detected in CSF. PCNSL should be considered in the differential diagnosis when immunocompetent elderly patients present with multiple intracranial lesions, even in the presence of lower motor neuron findings.
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Affiliation(s)
- Dominic J. Kizek
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
| | - Eric A. Goethe
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
| | - Patrick J. Karas
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
| | - Jeffrey M. Treiber
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
| | - Ali Jalali
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
| | - Shankar P. Gopinath
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
| | - Joseph S. Kass
- Department of Neurology, Baylor College of Medicine, Houston, Texas, United States
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Nohira S, Shimato S, Yamanouchi T, Takeuchi K, Yamamoto T, Ito M, Kato K, Nishizawa T. A Case of Primary Leptomeningeal Lymphoma Presenting with Hydrocephalus Characterized by Disproportionately Large Fourth Ventricle. NMC Case Rep J 2022; 8:399-404. [PMID: 35079495 PMCID: PMC8769436 DOI: 10.2176/nmccrj.cr.2020-0215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/07/2020] [Indexed: 11/20/2022] Open
Abstract
Primary leptomeningeal malignant lymphoma (PLML) is a rare variant of primary central nerve system malignant lymphoma (PCNSL) which is restricted to leptomeninges. The lesions of PLML can often be detected as abnormal enhancement on the surface of central nervous system or the ventricular wall on magnetic resonance imaging (MRIs). Cerebrospinal fluid (CSF) evaluation together with such MRI findings provides the definitive diagnosis of PLML. Here, we present a 45-year-old female case of PLML in which hydrocephalus with disproportionately large fourth ventricle was observed at presentation with gait instability. Head MRI revealed no abnormal enhancement and CSF cytology was negative, leaving the cause of hydrocephalus undetermined. Endoscopic third ventriculostomy (ETV) was effectively performed for hydrocephalus and her symptoms disappeared. Nearly 2 years later, she was brought to emergent room due to unconsciousness with the recurrence of hydrocephalus. MRI showed expanded fourth ventricle and abnormal enhancement on the ventricular wall. The endoscopic surgery for improving CSF flow was successful and inflammatory change was endoscopically observed on the ventricular wall involving aqueduct. Pathological diagnosis of the specimen from the ventricular wall proved B-cell lymphoma. Because neither brain parenchymal masses nor systemic tumors were identified, she was diagnosed with PLML and treated by high-dose methotrexate. She was in a stable state 2 years after the diagnosis of PLML. We report and discuss the characteristics of this case.
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Affiliation(s)
- Shota Nohira
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Shinji Shimato
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Takashi Yamanouchi
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Kazuhito Takeuchi
- Department of Neurosurgery, Graduate School of Medicine, Nagoya University, Nagoya, Aichi, Japan
| | - Taiki Yamamoto
- Department of Neurosurgery, Graduate School of Medicine, Nagoya University, Nagoya, Aichi, Japan
| | - Makoto Ito
- Department of Pathology, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Kyozo Kato
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Toshihisa Nishizawa
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
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6
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Anand P. Neurologic Infections in Patients on Immunomodulatory and Immunosuppressive Therapies. ACTA ACUST UNITED AC 2021; 27:1066-1104. [PMID: 34623105 DOI: 10.1212/con.0000000000000985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Both broadly immunosuppressive medications and selective immunomodulatory agents that act on particular components of the immune system are increasingly used in the treatment of neurologic and non-neurologic diseases. These therapies predispose patients to particular infections, some of which may affect the nervous system. Therefore, familiarity with the clinical and radiologic features of neurologic infections associated with specific immunomodulatory therapies is of importance for the practicing neurologist. This article reviews these neuroinfectious conditions, as well as other neurologic complications unique to transplant recipients and other patients who are immunocompromised. RECENT FINDINGS Diagnosis of infectious pathogens in patients who are immunocompromised may be particularly challenging because a decreased immune response can lead to atypical imaging or laboratory findings. Next-generation sequencing and other novel diagnostic modalities may improve the rate of early identification of neurologic infections in patients who are immunocompromised and ultimately ameliorate outcomes in this vulnerable population. SUMMARY A broad range of bacterial, viral, fungal, and parasitic infections of the nervous system can complicate solid organ and hematopoietic cell transplantation as well as other forms of immunocompromise. In addition to neurologic infections, such patients are at risk of neurotoxic and neuroinflammatory complications related to immunomodulatory and immunosuppressive therapies. Early recognition of infectious and noninfectious complications of immunocompromise is essential to guide appropriate treatment, which can include antimicrobial therapy and, in some cases, withdrawal of the predisposing medication with a transition to an alternative regimen.
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7
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Krebs S, Barasch JG, Young RJ, Grommes C, Schöder H. Positron emission tomography and magnetic resonance imaging in primary central nervous system lymphoma-a narrative review. ANNALS OF LYMPHOMA 2021; 5. [PMID: 34223561 PMCID: PMC8248935 DOI: 10.21037/aol-20-52] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This review addresses the challenges of primary central nervous system (CNS) lymphoma diagnosis, assessment of treatment response, and detection of recurrence. Primary CNS lymphoma is a rare form of extra-nodal non-Hodgkin lymphoma that can involve brain, spinal cord, leptomeninges, and eyes. Primary CNS lymphoma lesions are most commonly confined to the white matter or deep cerebral structures such as basal ganglia and deep periventricular regions. Contrast-enhanced magnetic resonance imaging (MRI) is the standard diagnostic modality employed by neuro-oncologists. MRI often shows common morphological features such as a single or multiple uniformly well-enhancing lesions without necrosis but with moderate surrounding edema. Other brain tumors or inflammatory processes can show similar radiological patterns, making differential diagnosis difficult. [18F]-fluorodeoxyglucose (FDG) positron emission tomography (PET) has selected utility in cerebral lymphoma, especially in diagnosis. Primary CNS lymphoma can sometimes present with atypical findings on MRI and FDG PET, such as disseminated disease, non-enhancing or ring-like enhancing lesions. The complementary strengths of PET and MRI have led to the development of combined PET-MR systems, which in some cases may improve lesion characterization and detection. By highlighting active developments in this field, including advanced MRI sequences, novel radiotracers, and potential imaging biomarkers, we aim to spur interest in sophisticated imaging approaches.
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Affiliation(s)
- Simone Krebs
- Molecular Imaging and Therapy Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Julia G Barasch
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Robert J Young
- Neuroradiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Christian Grommes
- Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Heiko Schöder
- Molecular Imaging and Therapy Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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8
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Lim-Fat MJ, Dietrich J. Myelopathies from Neoplasms. Semin Neurol 2021; 41:291-302. [PMID: 34030192 DOI: 10.1055/s-0041-1725948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Benign and malignant tumors can be an important cause of myelopathy. Patients may present with a wide range of neurologic symptoms including back and neck pain, weakness, sensory abnormalities, and bowel and bladder dysfunction. Management can be challenging depending on the location and underlying biology of the tumor. Neuroimaging of the spine is an important component of diagnostic evaluation and patient management both during initial evaluation and when monitoring after treatment. This article provides a systematic and practical review of neoplasms that can cause myelopathy. Unique imaging and biological features of distinct tumors are discussed, and their management strategies are reviewed.
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Affiliation(s)
- Mary Jane Lim-Fat
- Division of Neurology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jorg Dietrich
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital Cancer Center, Boston, MA
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9
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Primary Leptomeningeal Lymphoma: A Rare Mimicker of Idiopathic Intracranial Hypertension. Can J Neurol Sci 2020; 48:440-442. [PMID: 32892769 DOI: 10.1017/cjn.2020.197] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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10
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Mulazzani M, Huber M, Borchard S, Langer S, Angele B, Schuh E, Meinl E, Dreyling M, Birnbaum T, Straube A, Koedel U, von Baumgarten L. APRIL and BAFF: novel biomarkers for central nervous system lymphoma. J Hematol Oncol 2019; 12:102. [PMID: 31615554 PMCID: PMC6792247 DOI: 10.1186/s13045-019-0796-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 09/25/2019] [Indexed: 12/22/2022] Open
Abstract
Background Early diagnosis of CNS lymphoma (CNSL) is essential for successful therapy of this rapidly progressing brain tumor. However, in patients presenting with focal brain lesions, fast and reliable diagnosis of PCNSL remains a challenge. A proliferation-inducing ligand (APRIL) and B cell activating factor (BAFF) are important factors in the pathophysiology, diagnosis, and prognosis of systemic B cell malignancies. However, their utility as biomarkers for the diagnosis of CNSL and their effects on CNSL cells remain unclear. Methods In this prospective study, we analyzed the levels of APRIL and BAFF in the cerebrospinal fluid (CSF) of 116 patients with suspected focal brain lesions, including 53 CNSL patients. Additionally, we serially measured their levels during chemotherapy and relapse. Furthermore, we analyzed the effect of APRIL and BAFF on two B cell lymphoma cell lines using proliferation, viability, and chemotaxis assays. Results CSF levels of APRIL and BAFF reliably differentiated CNSL from other focal brain lesions (including primary and metastatic brain tumors, autoimmune-inflammatory lesions, and neuroinfectious lesions) with a specificity of 93.7% (APRIL, BAFF) and a sensitivity of 62.3% (APRIL) and 47.1% (BAFF). Serial CSF analysis of CNSL patients during chemotherapy and relapse demonstrates a close correlation of APRIL CSF levels and the course of this disease. In vitro, APRIL and BAFF showed anti-apoptotic effects during MTX treatment and mediated chemotaxis of malignant B cells. Conclusion This study extends the spectrum of valuable diagnostic biomarkers in CNSL. In patients with focal brain lesions, measurement of APRIL in CSF could help accelerating the diagnosis of CNSL. Moreover, our results highlight an important role of APRIL and BAFF in the pathophysiology of CNSL.
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Affiliation(s)
| | - Marion Huber
- Department of Neurology, University Hospital, LMU, Munich, Germany
| | - Sabine Borchard
- Department of Neurology, University Hospital, LMU, Munich, Germany
| | - Sigrid Langer
- Department of Neurology, University Hospital, LMU, Munich, Germany
| | - Barbara Angele
- Department of Neurology, University Hospital, LMU, Munich, Germany
| | - Elisabeth Schuh
- Institute for Clinical Neuroimmunology, University Hospital, LMU, Munich, Germany
| | - Edgar Meinl
- Institute for Clinical Neuroimmunology, University Hospital, LMU, Munich, Germany
| | - Martin Dreyling
- Department of Oncology, University Hospital, LMU, Munich, Germany
| | - Tobias Birnbaum
- Department of Neurology, HELIOS Amper-Hospital Dachau, Dachau, Germany
| | - Andreas Straube
- Department of Neurology, University Hospital, LMU, Munich, Germany
| | - Uwe Koedel
- Department of Neurology, University Hospital, LMU, Munich, Germany
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11
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Bönig L, Möhn N, Ahlbrecht J, Wurster U, Raab P, Puppe W, Sühs KW, Stangel M, Skripuletz T, Schwenkenbecher P. Leptomeningeal Metastasis: The Role of Cerebrospinal Fluid Diagnostics. Front Neurol 2019; 10:839. [PMID: 31481919 PMCID: PMC6710356 DOI: 10.3389/fneur.2019.00839] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 07/19/2019] [Indexed: 01/30/2023] Open
Abstract
Background: Metastatic spread into the cerebrospinal fluid (CSF) represents a severe complication of malignant disease with poor prognosis. Although early diagnosis is crucial, broad spectrums of clinical manifestations, and pitfalls of magnetic resonance imaging (MRI) and CSF diagnostics can be challenging. Data are limited how CSF parameters and MRI findings relate to each other in patients with leptomeningeal metastasis. Methods: Patients with malignant cells in CSF cytology examination diagnosed between 1998 and 2016 at the Department of Neurology in the Hannover Medical School were included in this study. Clinical records, MRI findings and CSF parameters were retrospectively analyzed. Results: One hundred thirteen patients with leptomeningeal metastasis were identified. Seventy-six patients (67%) suffered from a solid malignancy while a hematological malignancy was found in 37 patients (33%). Cerebral signs and symptoms were most frequently found (78% in solid vs. 49% in hematological malignancies) followed by cranial nerve impairment (26% in solid vs. 46% in hematological malignancies) and spinal symptoms (26% in solid vs. 27% in hematological malignancies). In patients with malignant cells in CSF MRI detected signs of leptomeningeal metastasis in 62% of patients with solid and in only 33% of patients with hematological malignancies. Investigations of standard CSF parameters revealed a normal CSF cell count in 21% of patients with solid malignancies and in 8% of patients with hematological malignancies. Blood-CSF-barrier dysfunction was found in most patients (80% in solid vs. 92% in hematological malignancies). Elevated CSF lactate levels occurred in 68% of patients in solid and in 48% of patients with hematological malignancies. A high number of patients (30% in solid vs. 26% in hematological malignancies) exhibited oligoclonal bands in CSF. Significant correlations between the presence of leptomeningeal enhancement demonstrated by MRI and CSF parameters (cell count, lactate levels, and CSF/Serum albumin quotient) were not found in both malignancy groups. Conclusion: CSF examination is helpful to detect leptomeningeal metastasis since the diagnosis can be challenging especially when MRI is negative. CSF cytological investigation is mandatory whenever leptomeningeal metastasis is suspected, even when CSF cell count is normal.
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Affiliation(s)
- Lena Bönig
- Department of Neurology, Clinical Neuroimmunology and Neurochemistry, Hannover Medical School, Hanover, Germany
| | - Nora Möhn
- Department of Neurology, Clinical Neuroimmunology and Neurochemistry, Hannover Medical School, Hanover, Germany
| | - Jonas Ahlbrecht
- Department of Neurology, Clinical Neuroimmunology and Neurochemistry, Hannover Medical School, Hanover, Germany
| | - Ulrich Wurster
- Department of Neurology, Clinical Neuroimmunology and Neurochemistry, Hannover Medical School, Hanover, Germany
| | - Peter Raab
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hanover, Germany
| | - Wolfram Puppe
- Department of Virology, Hannover Medical School, Hanover, Germany
| | - Kurt-Wolfram Sühs
- Department of Neurology, Clinical Neuroimmunology and Neurochemistry, Hannover Medical School, Hanover, Germany
| | - Martin Stangel
- Department of Neurology, Clinical Neuroimmunology and Neurochemistry, Hannover Medical School, Hanover, Germany
| | - Thomas Skripuletz
- Department of Neurology, Clinical Neuroimmunology and Neurochemistry, Hannover Medical School, Hanover, Germany
| | - Philipp Schwenkenbecher
- Department of Neurology, Clinical Neuroimmunology and Neurochemistry, Hannover Medical School, Hanover, Germany
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Abstract
PURPOSE OF REVIEW This article discusses the diagnosis and management of neoplasms that affect the spinal cord as well as spinal cord disorders that can occur due to cancer treatments. RECENT FINDINGS Neoplastic myelopathies are uncommon neurologic disorders but cause significant morbidity when they occur. Primary spinal cord tumors can be classified into intramedullary, intradural extramedullary, or extradural tumors. Diffuse gliomas and ependymal tumors are the most common intramedullary tumors. Diffuse gliomas include the World Health Organization (WHO) grade II and grade III astrocytomas, the grade II and grade III oligodendrogliomas, the grade IV glioblastomas, and newly recognized pediatric diffuse midline gliomas with H3 K27M mutation. The majority of diffuse and anaplastic astrocytomas are IDH-mutant tumors, whereas only 10% of glioblastomas are IDH-mutant. Oligodendrogliomas are typically IDH-mutant and are characterized by the molecular signature of 1p/19q codeletion. Nine distinct molecular subgroups of ependymomas have been identified based on their genetic features and location. NF2 mutations are frequently found in spinal cord ependymomas. Metastatic tumors are the most common tumors of the spine and can be extradural, leptomeningeal, or, rarely, intramedullary. Extradural metastatic spinal cord compression is a neurologic emergency and should be promptly diagnosed as pretreatment neurologic status dictates the posttreatment outcome. SUMMARY Neoplastic myelopathies encompass many diagnoses ranging from benign and malignant spinal tumors to paraneoplastic syndromes heralding cancers. The knowledge of the clinical features and management of neoplastic myelopathies is essential to practicing neurologists as early diagnosis and treatment can prevent devastating neurologic sequelae.
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Buisson A, Hsibe M, Velentza A, Ketz F, Pautas E. [Not Available]. SOINS. GERONTOLOGIE 2019; 24:43-44. [PMID: 31084809 DOI: 10.1016/j.sger.2019.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Anne Buisson
- Service de gériatrie aiguë polyvalente, AP-HP, GHU Pitié-Salpêtrière Charles-Foix, hôpital Charles-Foix, 94205 Ivry-sur-Seine Cedex, France; UFR Médecine Sorbonne Université, 91 boulevard de l'Hôpital, 75013 Paris, France.
| | - Mélanie Hsibe
- Service de gériatrie aiguë polyvalente, AP-HP, GHU Pitié-Salpêtrière Charles-Foix, hôpital Charles-Foix, 94205 Ivry-sur-Seine Cedex, France
| | - Athanasia Velentza
- Service de gériatrie aiguë polyvalente, AP-HP, GHU Pitié-Salpêtrière Charles-Foix, hôpital Charles-Foix, 94205 Ivry-sur-Seine Cedex, France
| | - Flora Ketz
- Service de gériatrie aiguë polyvalente, AP-HP, GHU Pitié-Salpêtrière Charles-Foix, hôpital Charles-Foix, 94205 Ivry-sur-Seine Cedex, France; UFR Médecine Sorbonne Université, 91 boulevard de l'Hôpital, 75013 Paris, France
| | - Eric Pautas
- Service de gériatrie aiguë polyvalente, AP-HP, GHU Pitié-Salpêtrière Charles-Foix, hôpital Charles-Foix, 94205 Ivry-sur-Seine Cedex, France; UFR Médecine Sorbonne Université, 91 boulevard de l'Hôpital, 75013 Paris, France
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Yu W, Si M, Li L, He P, Fan Z, Zhang Q, Jiao X. Biomarkers Reflecting The Destruction Of The Blood-Brain Barrier Are Valuable In Predicting The Risk Of Lymphomas With Central Nervous System Involvement. Onco Targets Ther 2019; 12:9505-9512. [PMID: 31807026 PMCID: PMC6857655 DOI: 10.2147/ott.s222432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/25/2019] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE We aimed to identify the biomarkers in cerebrospinal fluid (CSF) that facilitate the diagnosis of lymphomas with central nervous system (CNS) involvement. METHODS Four cases of non-Hodgkin's lymphoma (NHL) patients with/without CNS involvement were enrolled respectively, and non-CNS tumor patients (n=3) were selected to be the controls. Lab biomarkers, cytokines, and tight junction proteins (TJs) in CSF and serum were measured. RESULTS When comparing the CNS to non-CNS group, cytokine including MMP-9 (15.24 vs 0.36 ng/mL), CCL-2 (1922.04 vs 490.68 pg/mL), and sVCAM-1 (61.36 vs 9.00 pg/mL), TJs including OCLN (6.68 vs 2.59 pg/mL), and ZO-1 (710.04 vs 182.98 pg/mL) in CSF were significantly higher in lymphomas patients with CNS involvement than those without CNS involvement. However, serum biomarkers were not significantly elevated. Contrary to the major findings, all conventional biomarkers and MRI results showed no significant change. CONCLUSION CSF biomarkers affecting BBB disruption are valuable in mirroring the risk of lymphoma CNS metastasis. Further study with a larger sample size is needed to verify these biomarkers in predicting lymphoma CNS involvement.
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Affiliation(s)
- Wenjun Yu
- Department of Hematology, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong515041, People’s Republic of China
| | - Mengya Si
- Clinical Laboratory, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong515041, People’s Republic of China
| | - Li Li
- Obstetrics Department, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong515041, People’s Republic of China
| | - Ping He
- Department of Cell Biology and Genetics, Shantou University Medical College, Shantou, Guangdong, People’s Republic of China
| | - Zhiqiang Fan
- Department of Cell Biology and Genetics, Shantou University Medical College, Shantou, Guangdong, People’s Republic of China
| | - Qiaoxin Zhang
- Clinical Laboratory, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong515041, People’s Republic of China
| | - Xiaoyang Jiao
- Department of Cell Biology and Genetics, Shantou University Medical College, Shantou, Guangdong, People’s Republic of China
- Correspondence: Xiaoyang Jiao Department of Cell Biology and Genetics, Shantou University Medical College, 22 Xinling Road, Guangdong515041, People’s Republic of China Email
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Abstract
PURPOSE OF REVIEW Primary central nervous system (CNS) lymphoma is a rare and aggressive extranodal non-Hodgkin lymphoma confined to the brain, eyes, spinal cord, or leptomeninges without systemic involvement. This article provides an overview of the clinical features, diagnosis, and management of primary CNS lymphoma in patients who are immunocompetent, focusing on recent advances in treatment. RECENT FINDINGS Primary CNS lymphoma is sensitive to radiation therapy; however, whole-brain radiation therapy inadequately controls the disease when used alone and causes delayed neurotoxicity with significant neurocognitive impairment, especially in patients who are elderly. A number of clinical trials have demonstrated durable disease control and less neurotoxicity with methotrexate-based induction chemotherapy with or without autologous stem cell transplantation or reduced-dose whole-brain radiation therapy. SUMMARY Prompt diagnosis and initiation of treatment are vital to improving clinical outcomes in patients with primary CNS lymphoma. The optimal treatment has yet to be defined, but high-dose methotrexate-based induction chemotherapy is considered standard for newly diagnosed primary CNS lymphoma. Ongoing randomized trials will attempt to address the roles of rituximab and consolidative treatment using autologous stem cell transplantation or reduced-dose whole-brain radiation therapy. Despite high tumor response rates to initial treatment, many patients will relapse. The choice of salvage treatment will depend on age, previous treatment and response, performance status, and comorbidities at the time of relapse.
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Primary CNS Lymphomas: Challenges in Diagnosis and Monitoring. BIOMED RESEARCH INTERNATIONAL 2018; 2018:3606970. [PMID: 30035121 PMCID: PMC6033255 DOI: 10.1155/2018/3606970] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 04/12/2018] [Accepted: 05/17/2018] [Indexed: 12/22/2022]
Abstract
Primary Central Nervous System Lymphoma (PCNSL) is a rare neoplasm that can involve brain, eye, leptomeninges, and rarely spinal cord. PCNSL lesions most typically enhance homogeneously on T1-weighted magnetic resonance imaging (MRI) and appear T2-hypointense, but high variability in MRI features is commonly encountered. Neurological symptoms and MRI findings may mimic high grade gliomas (HGGs), tumefactive demyelinating lesions (TDLs), or infectious and granulomatous diseases. Advanced MRI techniques (MR diffusion, spectroscopy, and perfusion) and metabolic imaging, such as Fluorodeoxyglucose Positron Emission Tomography (FDG-PET) or amino acid PET (usually employing methionine), may be useful in distinguishing these different entities and monitoring the disease course. Moreover, emerging data suggest a role for cerebrospinal fluid (CSF) markers in predicting prognosis and response to treatments. In this review, we will address the challenges in PCNSL diagnosis, assessment of response to treatments, and evaluation of potential neurotoxicity related to chemotherapy and radiotherapy.
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Murthy H, Anasetti C, Ayala E. Diagnosis and Management of Leukemic and Lymphomatous Meningitis. Cancer Control 2018; 24:33-41. [DOI: 10.1177/107327481702400105] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Hemant Murthy
- From the University of South Florida Morsani College of Medicine, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Claudio Anasetti
- From the University of South Florida Morsani College of Medicine, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Ernesto Ayala
- From the University of South Florida Morsani College of Medicine, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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18
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Hottenrott T, Schorb E, Fritsch K, Dersch R, Berger B, Huzly D, Rauer S, Tebartz van Elst L, Endres D, Stich O. The MRZ reaction and a quantitative intrathecal IgG synthesis may be helpful to differentiate between primary central nervous system lymphoma and multiple sclerosis. J Neurol 2018; 265:1106-1114. [DOI: 10.1007/s00415-018-8779-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 01/29/2018] [Accepted: 01/30/2018] [Indexed: 01/04/2023]
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19
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Han CH, Batchelor TT. Diagnosis and management of primary central nervous system lymphoma. Cancer 2017; 123:4314-4324. [DOI: 10.1002/cncr.30965] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 07/06/2017] [Accepted: 07/11/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Catherine H. Han
- Department of Neurology, Division of Hematology/Oncology; Massachusetts General Hospital Cancer Center and Harvard Medical School; Boston Massachusetts
- Auckland Cancer Society Research Centre, School of Medical Sciences, Faculty of Medical and Health Sciences; University of Auckland; Auckland New Zealand
| | - Tracy T. Batchelor
- Department of Neurology, Division of Hematology/Oncology; Massachusetts General Hospital Cancer Center and Harvard Medical School; Boston Massachusetts
- Department of Radiation Oncology, Division of Hematology/Oncology; Massachusetts General Hospital Cancer Center and Harvard Medical School; Boston Massachusetts
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20
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Ambady P, Fu R, Netto JP, Kersch C, Firkins J, Doolittle ND, Neuwelt EA. Patterns of relapse in primary central nervous system lymphoma: inferences regarding the role of the neuro-vascular unit and monoclonal antibodies in treating occult CNS disease. Fluids Barriers CNS 2017; 14:16. [PMID: 28577579 PMCID: PMC5457655 DOI: 10.1186/s12987-017-0064-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 05/22/2017] [Indexed: 12/22/2022] Open
Abstract
Background and purpose The radiologic features and patterns of primary central nervous system lymphoma (PCNSL) at initial presentation are well described. High response rates can be achieved with first-line high-dose methotrexate (HD-MTX) based regimens, yet many relapse within 2 years of diagnosis. We describe the pattern of relapse and review the potential mechanisms involved in relapse. Methods We identified 78 consecutive patients who attained complete radiographic response (CR) during or after first-line treatment for newly diagnosed PCNSL (CD20+, diffuse large B cell type). Patients were treated with HD-MTX based regimen in conjunction with blood–brain barrier disruption (HD-MTX/BBBD); 44 subsequently relapsed. Images and medical records of these 44 consecutive patients were retrospectively reviewed. The anatomical location of enhancing lesions at initial diagnosis and at the time of relapse were identified and compared. Results 37/44 patients fulfilled inclusion criteria and had new measureable enhancing lesions at relapse; the pattern and location of relapse of these 37 patients were identified. At relapse, the new enhancement was at a spatially distinct site in 30 of 37 patients. Local relapse was found only in seven patients. Discussion Unlike gliomas, the majority of PCNSL had radiographic relapse at spatially distinct anatomical locations within the brain behind a previously intact neurovascular unit (NVU), and in few cases outside, the central nervous system (CNS). This may suggest either (1) reactivation of occult reservoirs behind an intact NVU in the CNS (or ocular) or (2) seeding from bone marrow or other extra CNS sites. Conclusion Recognizing patterns of relapse is key for early detection and may provide insight into potential mechanisms of relapse as well as help develop strategies to extend duration of complete response.
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Affiliation(s)
- Prakash Ambady
- Department of Neurology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, L603, Portland, OR, 97239, USA.,Portland Veterans Affairs Medical Center, Portland, OR, USA
| | - Rongwei Fu
- School of Public Health, Oregon Health & Science University, Portland, OR, USA.,Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Joao Prola Netto
- Department of Neurology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, L603, Portland, OR, 97239, USA.,Department of Radiology, Oregon Health & Science University, Portland, OR, USA
| | - Cymon Kersch
- Department of Neurology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, L603, Portland, OR, 97239, USA
| | - Jenny Firkins
- Department of Neurology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, L603, Portland, OR, 97239, USA
| | - Nancy D Doolittle
- Department of Neurology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, L603, Portland, OR, 97239, USA
| | - Edward A Neuwelt
- Department of Neurology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, L603, Portland, OR, 97239, USA. .,Portland Veterans Affairs Medical Center, Portland, OR, USA. .,Department of Neurosurgery, Oregon Health & Science University, Portland, OR, USA.
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Citterio G, Reni M, Gatta G, Ferreri AJM. Primary central nervous system lymphoma. Crit Rev Oncol Hematol 2017; 113:97-110. [DOI: 10.1016/j.critrevonc.2017.03.019] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 02/24/2017] [Accepted: 03/15/2017] [Indexed: 12/26/2022] Open
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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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Korfel A, Nowosielski M, Pardo-Moreno J, Penalver FJ, Buda G, Bennani H, Costopoulos M, Le Garff-Tavernier M, Soussain C, Schmid M, Orfao JA, Glantz M. How to facilitate early diagnosis of CNS involvement in malignant lymphoma. Expert Rev Hematol 2016; 9:1081-1091. [PMID: 27677656 DOI: 10.1080/17474086.2016.1242405] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Making the diagnosis of secondary CNS involvement in lymphoma can be difficult due to unspecific signs and symptoms, limited accessibility of brain/myelon parenchyma and low sensitivity and/or specifity of imaging and cerebrospinal fluid (CSF) examination currently available. Areas covered: MRI of the total neuroaxis followed by CSF cytomorphology and flow cytometry are methods of choice when CNS lymphoma (CNSL) is suspected. To reduce the numerous pitfalls of these examinations several aspects should be considered. New CSF biomarkers might be of potential diagnostic value. Attempts to standardize response criteria are presented. Expert commentary: Diagnosing CNSL remains challenging. Until diagnostic methods combining high sensitivity with high specifity are routinely introduced, high level of awareness and optimal utilization of examinations currently available are needed to early diagnose this potentially devastating disease.
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Affiliation(s)
- Agnieszka Korfel
- a Department of Hematology, Oncology and Tumor Immunology , Charite University Medicine Berlin , Berlin , Germany
| | - Martha Nowosielski
- b Department of Neurology , Medical University Innsbruck , Innsbruck , Austria
| | - Javier Pardo-Moreno
- c Department of Neurology , University Hospital King Juan Carlos , Madrid , Spain
| | | | - Gabriele Buda
- e Department of Hematology and Oncology , University of Pisa , Pisa , Italy
| | - Hind Bennani
- f Department of Biology , Hôpital Foch , Suresnes , France
| | - Myrto Costopoulos
- g Department of Biological Hematology , Pitie Salpetriere Hospital , Paris , France
| | | | - Carole Soussain
- h Department of Hematology , Institut Curie - Hôpital René Huguenin , Paris , France
| | - Mathias Schmid
- i Department of Hematology and Oncology , Stadtspital Triemli Zürich , Zürich , Switzerland
| | - Jose Alberto Orfao
- j Department of Medicine and Cytometry Service , University of Salamanca , Salamanca , Spain
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Pang H, Ren Y, Dang X, Feng X, Yao Z, Wu J, Yao C, Di N, Ghinda DC, Zhang Y. Diffusional kurtosis imaging for differentiating between high-grade glioma and primary central nervous system lymphoma. J Magn Reson Imaging 2016; 44:30-40. [PMID: 26588793 DOI: 10.1002/jmri.25090] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/27/2015] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The aim of this study was to assess the diagnostic accuracy of diffusion kurtosis magnetic resonance imaging parameters for differentiating high-grade gliomas (HGGs) from primary central nervous system lymphomas (PCNSLs). METHODS Diffusion parameters, including fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (λ// ), radial diffusivity (λ⊥ ); and kurtosis parameters, including mean kurtosis (MK), axial kurtosis (K// ), and radial kurtosis (K⊥ ), were normalized to contralateral normal-appearing white matter (NAWMc) to decrease inter-individual and inter-regional changes across the entire brain, and then compared with the solid parts of 20 HGGs and 11 PCNSLs [median 95% confidence interval (CI), P < 0.004; 0.05/14], significance level, Kolmogorov-Smirnov test, Bonferroni correction]. RESULTS FA, MD, λ// , and λ⊥ values were higher in HGGs than in PCNSLs, but not significantly [HGGs: 0.209 (95% CI, 0.134-0.338), 1.385 (95% CI, 1.05-1.710), 1.655 (95% CI, 1.30-2.060), 1.228 (95% CI, 0.932-1.480), respectively; PCNSLs: 0.143 (95% CI, 0.110-0.317), 1.070 (95% CI, 0.842-1.470), 1.260 (95% CI, 0.960-1.930), 1.010 (95% CI, 0.782-1.240)], respectively; P = 0.120, 0.010, 0.004, and 0.004, respectively). However, MK and K// were significantly higher in PCNSLs compared with HGGs [PCNSLs: 0.765 (95% CI, 0.697-0.890), 0.787 (95% CI, 0.615-1.030), respectively; HGGs: 0.531 (95% CI, 0.402-0.766), 0.532 (95% CI, 0.432-0.680], respectively; P = 0.001, 0.000, respectively); but not K⊥ [0.774 (95% CI, 0.681-0.899) for PCNSLs; 0.554 (95% CI, 0.389-0.954) for HGGs; P = 0.024]. CONCLUSION There were significant differences in kurtosis parameters (MK and K// ) between HGGs and PCNSLs, while differences in diffusion parameters between them did not reach significance; hence, better separation was achieved with these parameters than with conventional diffusion imaging parameters. J. Magn. Reson. Imaging 2016;44:30-40.
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Affiliation(s)
- Haopeng Pang
- Department of Radiology, Affiliated Huashan Hospital of Fudan University, Shanghai, PR China
| | - Yan Ren
- Department of Radiology, Affiliated Huashan Hospital of Fudan University, Shanghai, PR China
| | - Xuefei Dang
- Department of Breast Cancer, The 307th Hospital of Chinese People's liberation Army, Beijing, PR China
| | - Xiaoyuan Feng
- Department of Radiology, Affiliated Huashan Hospital of Fudan University, Shanghai, PR China
| | - Zhenwei Yao
- Department of Radiology, Affiliated Huashan Hospital of Fudan University, Shanghai, PR China
| | - Jingsong Wu
- Department of Neurosurgery, Affiliated Huashan Hospital of Fudan University, Shanghai, PR China
| | - Chengjun Yao
- Department of Glioma Surgery Division, Affiliated Huashan Hospital of Fudan University, Shanghai, PR China
| | - Ning Di
- Department of Radiology, Affiliated Huashan Hospital of Fudan University, Shanghai, PR China
| | - Diana Cristina Ghinda
- Department of Neurosurgery, Affiliated Ottawa Hospital of Ottawa University, Ottawa, Canada
| | - Yong Zhang
- Department of MR Research, GE Healthcare, Shanghai, PR China
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Scharf EL, Hanson CA, Howard MT, Keegan BM. Serial cerebrospinal fluid examinations to diagnose hematological malignancy causing neurological disease. J Neurooncol 2016; 129:77-83. [DOI: 10.1007/s11060-016-2140-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 05/03/2016] [Indexed: 10/21/2022]
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Tang YT, Jiao XY, Chang XL, Huang DY. Risk factors for the evaluation of potential central nervous system metastasis in Burkitt's lymphoma: a case study and literature review. Hematol Oncol 2016; 34:36-41. [PMID: 25312095 DOI: 10.1002/hon.2159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Revised: 05/10/2014] [Accepted: 07/10/2014] [Indexed: 02/05/2023]
Abstract
Burkitt's lymphoma (BL) is a malignancy of B lymphocytes. The rapid growth rate and frequent systemic spread result in most patients presenting with advanced disease at diagnosis. Cerebrospinal fluid cytology is the gold standard (with very high accuracy) for diagnosing BL central nervous system (CNS) metastasis; however, the low sensitivity of this method limits its clinical applications. Here, we report a case of BL with CNS metastasis. The levels of vascular endothelial growth factor (VEGF)-A and VEGF-C in the serum and cerebrospinal fluid were used to evaluate the status of BL remission and recurrence. Comparisons were made between VEGF and the other risk factors used in evaluating CNS metastasis. Although not in strict accordance, VEGF levels mirrored the disease course. Therefore, VEGF may reflect the status of BL CNS metastasis. Understanding the role of VEGF in CNS metastasis may help to improve the staging and risk classification of BL as well as the investigation of targeted therapy.
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Affiliation(s)
- Yue-Ting Tang
- Department of Hematology Laboratory, First Affiliated Hospital Of Shantou University Medical College, Guangdong, China
| | - Xiao-Yang Jiao
- Department of cell biology and genetics, Shantou University Medical College, Guangdong, China
- Department of Hematology Laboratory, First Affiliated Hospital Of Shantou University Medical College, Guangdong, China
| | - Xiao-Lan Chang
- Department of cell biology and genetics, Shantou University Medical College, Guangdong, China
| | - Dong-Yang Huang
- Department of cell biology and genetics, Shantou University Medical College, Guangdong, China
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Fraser E, Gruenberg K, Rubenstein JL. New approaches in primary central nervous system lymphoma. Chin Clin Oncol 2016; 4:11. [PMID: 25841718 DOI: 10.3978/j.issn.2304-3865.2015.02.01] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 11/30/2014] [Indexed: 12/19/2022]
Abstract
Primary central nervous system lymphoma (PCNSL) has long been associated with an inferior prognosis compared to other aggressive non-Hodgkin's lymphomas (NHLs). However, during the past 10 years an accumulation of clinical experience has demonstrated that long-term progression-free survival (PFS) can be attained in a major proportion of PCNSL patients who receive dose-intensive consolidation chemotherapy and avoid whole brain radiotherapy. One recent approach that has reproducibly demonstrated efficacy for newly diagnosed PCNSL patients is an immunochemotherapy combination regimen used during induction that consists of methotrexate, temozolomide, and rituximab followed by consolidative infusional etoposide plus high-dose cytarabine (EA), administered in first complete remission (CR). Other high-dose chemotherapy-based consolidative regimens have shown efficacy as well. Our goal in this review is to update principles of diagnosis and management as well as data regarding the molecular pathogenesis of PCNSL, information that may constitute a basis for development of more effective therapies required to make additional advances in this phenotype of aggressive NHL.
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Affiliation(s)
- Eleanor Fraser
- Division of Hematology/Oncology, University of California, San Francisco, CA 94143, USA
| | - Katherine Gruenberg
- UCSF School of Pharmacy, University of California, San Francisco, CA 94143, USA
| | - James L Rubenstein
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA 94143, USA.
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Strati P, Uhm JH, Kaufmann TJ, Nabhan C, Parikh SA, Hanson CA, Chaffee KG, Call TG, Shanafelt TD. Prevalence and characteristics of central nervous system involvement by chronic lymphocytic leukemia. Haematologica 2016; 101:458-65. [PMID: 26819053 DOI: 10.3324/haematol.2015.136556] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 01/22/2016] [Indexed: 11/09/2022] Open
Abstract
Abroad array of conditions can lead to neurological symptoms in chronic lymphocytic leukemia patients and distinguishing between clinically significant involvement of the central nervous system by chronic lymphocytic leukemia and symptoms due to other etiologies can be challenging. Between January 1999 and November 2014, 172 (4%) of the 4174 patients with chronic lymphocytic leukemia followed at our center had a magnetic resonance imaging of the central nervous system and/or a lumbar puncture to evaluate neurological symptoms. After comprehensive evaluation, the etiology of neurological symptoms was: central nervous system chronic lymphocytic leukemia in 18 patients (10% evaluated by imaging and/or lumbar puncture, 0.4% overall cohort); central nervous system Richter Syndrome in 15 (9% evaluated, 0.3% overall); infection in 40 (23% evaluated, 1% overall); autoimmune/inflammatory conditions in 28 (16% evaluated, 0.7% overall); other cancer in 8 (5% evaluated, 0.2% overall); and another etiology in 63 (37% evaluated, 1.5% overall). Although the sensitivity of cerebrospinal fluid analysis to detect central nervous system disease was 89%, the specificity was only 42% due to the frequent presence of leukemic cells in the cerebrospinal fluid in other conditions. No parameter on cerebrospinal fluid analysis (e.g. total nucleated cells, total lymphocyte count, chronic lymphocytic leukemia cell percentage) were able to offer a reliable discrimination between patients whose neurological symptoms were due to clinically significant central nervous system involvement by chronic lymphocytic leukemia and another etiology. Median overall survival among patients with clinically significant central nervous system chronic lymphocytic leukemia and Richter syndrome was 12 and 11 months, respectively. In conclusion, clinically significant central nervous system involvement by chronic lymphocytic leukemia is a rare condition, and neurological symptoms in patients with chronic lymphocytic leukemia are due to other etiologies in approximately 80% of cases. Analysis of the cerebrospinal fluid has high sensitivity but limited specificity to distinguish clinically significant chronic lymphocytic leukemia involvement from other etiologies.
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Affiliation(s)
- Paolo Strati
- Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Joon H Uhm
- Mayo Clinic College of Medicine, Rochester, MN, USA
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Reynolds A, Byrd E, Mossa-Basha M, Khot SP, Davis A. A 61-Year-Old Woman With Headaches and Aphasia. Neurohospitalist 2015; 5:245-50. [PMID: 26425252 PMCID: PMC4572380 DOI: 10.1177/1941874415569071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Adam Reynolds
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Erica Byrd
- Department of Neurology, University of Washington, Seattle, WA, USA
| | | | - Sandeep P. Khot
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Arielle Davis
- Department of Neurology, University of Washington, Seattle, WA, USA
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Baraniskin A, Schroers R. Modern cerebrospinal fluid analyses for the diagnosis of diffuse large B-cell lymphoma of the CNS. CNS Oncol 2015; 3:77-85. [PMID: 25054902 DOI: 10.2217/cns.13.63] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
CNS lymphomas represent rare and aggressive variants of extranodal non-Hodgkin's lymphomas, which may present with diverse neurological symptoms and are often diagnostically challenging. Primary CNS lymphomas develop within the CNS and characteristically involve the brain, leptomeninges, eyes and, in rare cases, spinal cord. Secondary CNS lymphomas are characterized by expansion of systemic lymphomas to the CNS. Multimodal investigation of cerebrospinal fluid (CSF) comprises an important component of the diagnostic work-up for patients with suspected CNS lymphomas. Cytopathological examination of the CSF is still regarded as the 'gold standard' for the diagnosis of leptomeningeal malignant disease. However, cytopathology has only a low sensitivity in detecting leptomeningeal lymphoma involvement. Modern technologies including proteochemical and immunophenotypic studies by flow cytometry, and molecular genetic analyses of CSF may increase sensitivity and specificity, therefore, facilitating the diagnosis of CNS lymphomas. This review gives an overview and discussion of the current aspects of CSF analyses in CNS lymphomas.
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Affiliation(s)
- Alexander Baraniskin
- Department of Medicine, Hematology & Oncology, Ruhr-University of Bochum, Germany
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MicroRNAs as Potential Biomarkers for Diagnosing Cancers of Central Nervous System: a Meta-analysis. Mol Neurobiol 2014; 51:1452-61. [PMID: 25081587 DOI: 10.1007/s12035-014-8822-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 07/16/2014] [Indexed: 12/24/2022]
Abstract
Recent studies have shown abnormal microRNA (miRNA) expression levels in the central nervous system (CNS) of cancer patients, suggesting that miRNAs may serve as promising biomarkers for cancers of CNS. However, other studies have arrived at conflicting results. Therefore, this meta-analysis aims to systematically measure the potential diagnostic value of miRNAs for CNS cancers. Electronic databases as well as other sources were searched until to April 12, 2014 for relevant articles. Data from different studies were pooled using the random-effects model. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative LR (NLR), diagnostic odds ratio (DOR), together with the summary receiver operator characteristic (SROC) curve, and area under the SROC curve (AUC) value were used to estimate overall diagnostic performance. Twenty-three studies from 6 articles were included in the current meta-analysis with a total of 299 CNS cancer patients and 418 controls. The pooled sensitivity, specificity, PLR, NLR, DOR, and AUC were 0.85 (95% CI, 0.80-0.89), 0.83 (95% CI, 0.76-0.88), 5.1 (95% CI, 3.4-7.5), 0.18 (95% CI, 0.12-0.26), 28 (95% CI, 14-58), and 0.91 (95% CI, 0.88-0.93), respectively. Subgroup analyses showed that cerebrospinal fluid (CSF)-based miRNAs assays yielded more accurate results and seemed to be more sensitive in diagnosing of primary central nervous system lymphoma (PCNSL). In conclusion, miRNAs may be suitable for serving as noninvasive biomarkers for CNS cancers detection. However, further validation based on a larger sample of patients and controls is still required.
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Wang CC, Carnevale J, Rubenstein JL. Progress in central nervous system lymphomas. Br J Haematol 2014; 166:311-25. [PMID: 24837460 DOI: 10.1111/bjh.12938] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 03/28/2014] [Indexed: 12/13/2022]
Abstract
Until recently, primary central nervous system lymphoma (PCNSL) was associated with a uniformly dismal prognosis. It is now reasonable to anticipate long-term survival and possibly cure for a significant proportion of patients diagnosed with PCNSL. Accumulated data generated over the past 10 years has provided evidence that long-term progression-free survival (PFS) can reproducibly be attained in a significant fraction of PCNSL patients that receive dose-intensive chemotherapy consolidation, without whole brain radiotherapy. One consolidative regimen that has reproducibly demonstrated promise is the combination of infusional etoposide plus high-dose cytarabine (EA), administered in first complete remission after methotrexate, temozolomide and rituximab-based induction. Given evolving principles of management and the mounting evidence for reproducible improvements in survival rates in prospective clinical series, our goal in this review is to highlight and update principles in diagnosis, staging and management as well as to review data regarding the pathogenesis of central nervous system lymphomas, information that is likely to constitute a basis for the implementation of novel therapies that are requisite for further progress in this unique phenotype of non-Hodgkin lymphoma.
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Affiliation(s)
- Chia-Ching Wang
- Division of Hematology/Oncology, Helen Diller Comprehensive Cancer Center University of California, San Francisco, CA, USA
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Liu L, Cao F, Wang S, Zhou J, Yang G, Wang C. Detection of malignant B lymphocytes by PCR clonality assay using direct lysis of cerebrospinal fluid and low volume specimens. Int J Lab Hematol 2014; 37:165-73. [PMID: 24815498 DOI: 10.1111/ijlh.12255] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Accepted: 04/07/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The diagnosis of lymphoid malignancies is often challenging in paucicellular specimens. PCR may also be limited by insufficient cells for DNA isolation and incomplete coverage of gene rearrangements. This study aims to evaluate a PCR method for IgH clonality using direct cell lysates. METHODS PCR amplification used cell lysate from detergent-based lysis and BIOMED-2 primers. CSF specimens were tested for 20 patients with primary CNS lymphoma or systemic lymphoma suspected for CNS involvement. Cytology and flow cytometry analysis was performed in parallel with PCR. RESULTS Direct lysis produced a better yield than the column-based method for DNA isolation. PCR using lysate showed an efficiency of clonality detection from a minimum of 20 tumor cells. PCR clonality was found in nine of the 20 CSFs, and positive PCR was concordant with both cytology and flow cytometry in seven cases. There were two cases positive for PCR, but indeterminate for flow cytometry because of insufficient cell events. Of the eleven PCR-negative cases, two were considered as false negative, as flow cytometry showed positive for malignant cells. The PCR was also performed successfully with a specimen from the anterior chamber of the eye. CONCLUSION PCR clonality with direct cell lysis of CSF is feasible, and it may overcome the limitation of DNA isolation. This PCR method may be particularly useful for small volume and low cell CSF when flow cytometry is inconclusive.
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Affiliation(s)
- L Liu
- Department of Hematology, The First Hospital of Harbin Medical University, Harbin, China
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Abstract
The lymphomas and leukemias are a heterogenous group of hematologic malignancies with protean manifestations. Neurologic sequelae of the diseases have been recognized since the time the conditions were first described in the mid-1800s. Although our understanding of the various presentations of these blood disorders evolved along with our knowledge of malignancies, accurate diagnosis can still be difficult. It is critical for neurologists to have a high index of clinical suspicion to appropriately recognize their heralding features. This review's focus is the relevant clinical neurologic features and diagnostic studies that identify leukemias and lymphomas affecting the nervous system.
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Affiliation(s)
- Matthew McCoyd
- Department of Neurology, Loyola University Medical Center, Maywood, IL, USA.
| | - Gregory Gruener
- Department of Neurology, Loyola University Medical Center, Maywood, IL, USA; Leischner Institute for Medical Education, Loyola University Medical Center, Maywood, IL, USA
| | - Patrick Foy
- Department of Hematology, Medical College of Wisconsin, Milwaukee, WI, USA
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Dalal M, Casady M, Moriarty E, Faia L, Nussenblatt R, Chan CC, Sen HN. Diagnostic Procedures in Vitreoretinal Lymphoma. Ocul Immunol Inflamm 2013; 22:270-6. [DOI: 10.3109/09273948.2013.848905] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Neoplastic meningitis: How MRI and CSF cytology are influenced by CSF cell count and tumor type. ScientificWorldJournal 2013; 2013:248072. [PMID: 24453817 PMCID: PMC3881671 DOI: 10.1155/2013/248072] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 09/30/2013] [Indexed: 11/17/2022] Open
Abstract
Background. Although CSF cytology and MRI are standard methods to diagnose neoplastic meningitis (NM), this complication of neoplastic disease remains difficult to detect. We therefore reevaluated the sensitivity of gadolinium (GD)-enhanced MRI and cerebrospinal-fluid (CSF)-cytology and the relevance of tumor type and CSF cell count. Methods. We retrospectively identified 111 cases of NM diagnosed in our CSF laboratory since 1990 with complete documentation of both MRI and CSF cytology. 37 had haematological and 74 solid neoplasms. CSF cell counts were increased in 74 and normal in 37 patients. Results. In hematological neoplasms, MRI was positive in 49% and CSF cytology in 97%. In solid tumors, the sensitivity of MRI was 80% and of cytology 78%. With normal CSF cell counts, MRI was positive in 59% (50% hematological, 72% solid malignancies) and CSF cytology in 76% (92% in hematological, 68% in solid neoplasms). In cases of elevated cell counts, the sensitivity of MRI was 72% (50% for hematological, 83% for solid malignancies) and of CSF cytology 91% (100% for haematological and 85% for solid neoplasms). 91% of cytologically positive cases were diagnosed at first and another 7% at second lumbar puncture. Routine protein analyses had a low sensitivity in detecting NM. Conclusions. The high overall sensitivity of MRI was only confirmed for NM from solid tumors and for elevated CSF cell counts. With normal cell counts and haematological neoplasms, CSF-cytology was superior to MRI. None of the analysed routine CSF proteins had an acceptable sensitivity and specificity in detecting leptomeningeal disease.
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Taylor JW, Flanagan EP, O'Neill BP, Siegal T, Omuro A, Deangelis L, Baehring J, Nishikawa R, Pinto F, Chamberlain M, Hoang-Xuan K, Gonzalez-Aguilar A, Batchelor T, Blay JY, Korfel A, Betensky RA, Lopes MBS, Schiff D. Primary leptomeningeal lymphoma: International Primary CNS Lymphoma Collaborative Group report. Neurology 2013; 81:1690-6. [PMID: 24107866 DOI: 10.1212/01.wnl.0000435302.02895.f3] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate clinical presentation, optimal diagnostic evaluation and treatment, and outcome in primary leptomeningeal lymphoma, a rare form of primary CNS lymphoma without parenchymal or systemic involvement. METHODS The International Primary CNS Lymphoma Collaborative Group, a multidisciplinary group of physicians with a particular interest in primary CNS lymphoma, retrospectively identified cases of lymphoma isolated to the leptomeninges as diagnosed by CSF cytology, flow cytometry, or biopsy, without systemic or parenchymal brain/spinal cord lymphoma or immunodeficiency. RESULTS Forty-eight patients were identified, with median age at diagnosis of 51 years and median Eastern Cooperative Oncology Group performance status of 2. Presenting symptoms were multifocal in 68%. Leptomeningeal enhancement was seen in 74% and CSF profile was abnormal in all cases. CSF cytology detected malignant lymphocytes in 67%. Flow cytometry identified monoclonal population in 80%, as did receptor gene rearrangement studies in 71%. Sixty-two percent had B-cell lymphoma, 19% T-cell, and 19% unclassified. Treatment varied and included fractionated radiotherapy (36%), systemic chemotherapy (78%), and intra-CSF chemotherapy (66%), with 66% receiving ≥ 2 modalities. Seventy-one percent had a favorable clinical response; ultimately, 44% received salvage treatment. Median overall survival was 24 months, with 11 patients still alive at 50 months follow-up. CONCLUSION Primary leptomeningeal lymphoma is a rare form of primary CNS lymphoma. Patients usually present with multifocal symptoms, with evidence of leptomeningeal enhancement and diagnostic CSF analysis. Although treatment is highly variable, patients have a better prognosis than previously reported and a subset may be cured.
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Affiliation(s)
- Jennie W Taylor
- From the Massachusetts General Hospital (J.W.T., T.B., R.A.B.), Boston; Mayo Clinic (E.P.F., B.P.O.), Rochester, MN; Hadassah Hebrew University Medical Center (T.S.), Jerusalem, Israel; Memorial Sloan-Kettering (A.O., L.D.), New York, NY; Yale University (J.B.), New Haven, CT; Saitama Medical University (R.N.), Japan; Kings College Hospital (F.P.), London, UK; University of Washington (M.C.), Seattle; LOC National Expert Center (K.H.-X., A.G.-A.), APHP, UPMC, Pitie-Salpetriere, Paris; Centre Leon Berard (J.-Y.B.), Lyon, France; Campus Benjamin Franklin (A.K.), Charite Universitätsmedizin Berlin, Germany; Department of Biostatistics (R.A.B.), Harvard School of Public Health, Boston, MA; and University of Virginia (M.-B.S.L., D.S.), Charlottesville
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Perini GF, Campregher PV, Santos FPDS, Hamerschlak N. Primary central nervous system lymphoma: what a neurologist/neurosurgeon should know? ARQUIVOS DE NEURO-PSIQUIATRIA 2013; 71:254-7. [PMID: 23588288 DOI: 10.1590/0004-282x20130011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Accepted: 09/24/2012] [Indexed: 11/21/2022]
Abstract
Primary central nervous system lymphoma is a rare disease, with bad prognosis. Neurologists and neurosurgeons should be familiar with the diagnostic,and biologic features, as well as the initial management of patients. A correct approach to these patients is mandatory for a better outcome.
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Abstract
The pathogenesis of primary and secondary central nervous system (CNS) lymphoma poses a unique set of diagnostic, prognostic, and therapeutic challenges. During the past 10 years, there has been significant progress in the elucidation of the molecular properties of CNS lymphomas and their microenvironment, as well as evolution in the development of novel treatment strategies. Although a CNS lymphoma diagnosis was once assumed to be uniformly associated with a dismal prognosis, it is now reasonable to anticipate long-term survival, and possibly a cure, for a significant fraction of CNS lymphoma patients. The pathogenesis of CNS lymphomas affects multiple compartments within the neuroaxis, and proper treatment of the CNS lymphoma patient requires a multidisciplinary team with expertise not only in hematology/oncology but also in neurology, neuroradiology, neurosurgery, clinical neuropsychology, ophthalmology, pathology, and radiation oncology. Given the evolving principles of management and the evidence for improvements in survival, our goal is to provide an overview of current knowledge regarding the pathogenesis of CNS lymphomas and to highlight promising strategies that we believe to be most effective in establishing diagnosis, staging, and therapeutic management.
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Deckert M, Brunn A, Montesinos-Rongen M, Terreni MR, Ponzoni M. Primary lymphoma of the central nervous system--a diagnostic challenge. Hematol Oncol 2013; 32:57-67. [PMID: 23949943 DOI: 10.1002/hon.2087] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 06/24/2013] [Indexed: 01/20/2023]
Abstract
Primary lymphoma of the central nervous system is a distinct diffuse large B-cell lymphoma confined to the nervous system. Whereas classical cases can be classified easily, differential diagnosis can be a challenge in particular in patients who had received treatment prior to biopsy. In the differential diagnosis, other tumours and inflammatory diseases of autoimmune and infectious aetiology need to be considered.
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Affiliation(s)
- Martina Deckert
- Department of Neuropathology, University Hospital of Cologne, Cologne, Germany
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Ambroise MM, Ghosh M, Mallikarjuna V, Annapurneswari S, Kurian A, Chakravarthy R. Primary central nervous system lymphoma: a clinicopathological and cytomorpholgical study from a tertiary care centre in Chennai, India. Asian Pac J Cancer Prev 2013; 14:727-31. [PMID: 23621227 DOI: 10.7314/apjcp.2013.14.2.727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study was to analyze the clinicopathological and immunohistochemical features of primary central nervous system lymphoma (PCNSL) cases occurring in Indian patients and also study the utility of the crush smear preparation in intraoperative diagnosis. MATERIALS AND METHODS The immune status, clinical, radiological details, immunohistochemical profile, histopathological findings and cytological features in smear preparation of 32 cases of PCNSL were analyzed. Patients with systemic NHL and skull-base lymphomas were excluded. RESULTS The mean age of our patients was 52 years with a male: female ratio 1:1. A periventricular location was found in 62.5% of patients. None of our PCNSL cases were associated with AIDS. All cases except one were diffuse large B-cell lymphomas. Intraoperative diagnosis using crush smears allowed correct prediction in 93% of cases. CONCLUSIONS Our study shows that PCNSL is seen predominantly in immunocompetent patients in India .The age of presentation is relatively young as compared to the West. Our study also stresses the utility of crush smear preparation in establishing an intraoperative diagnosis.
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Scott BJ, Douglas VC, Tihan T, Rubenstein JL, Josephson SA. A systematic approach to the diagnosis of suspected central nervous system lymphoma. JAMA Neurol 2013; 70:311-9. [PMID: 23319132 DOI: 10.1001/jamaneurol.2013.606] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Central nervous system (CNS) lymphoma can present a diagnostic challenge. Currently, there is no consensus regarding what presurgical evaluation is warranted or how to proceed when lesions are not surgically accessible. We conducted a review of the literature on CNS lymphoma diagnosis (1966 to October 2011) to determine whether a common diagnostic algorithm can be generated. We extracted data regarding the usefulness of brain and body imaging, serum and cerebrospinal fluid (CSF) studies, ophthalmologic examination, and tissue biopsy in the diagnosis of CNS lymphoma. Contrast enhancement on imaging is highly sensitive at the time of diagnosis: 98.9% in immunocompetent lymphoma and 96.1% in human immunodeficiency virus-related CNS lymphoma. The sensitivity of CSF cytology is low (2%-32%) but increases when combined with flow cytometry. Cerebrospinal fluid lactate dehydrogenase isozyme 5, β2-microglobulin, and immunoglobulin heavy chain rearrangement studies have improved sensitivity over CSF cytology (58%-85%) but have only moderate specificity (85%). New techniques of proteomics and microRNA analysis have more than 95% specificity in the diagnosis of CNS lymphoma. Positive CSF cytology, vitreous biopsy, or brain/leptomeningeal biopsy remain the current standard for diagnosis. A combined stepwise systematic approach outlined here may facilitate an expeditious, comprehensive presurgical evaluation for cases of suspected CNS lymphoma.
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Affiliation(s)
- Brian J Scott
- Department of Neurology, University of California-San Francisco, 505 Parnassus Ave, San Francisco, CA 94143, USA.
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Schäfer N, Glas M, Herrlinger U. Primary CNS lymphoma: a clinician's guide. Expert Rev Neurother 2013; 12:1197-206. [PMID: 23082736 DOI: 10.1586/ern.12.120] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Primary CNS lymphoma is a high malignant disease of the brain which can lead rapidly to death if diagnosis and/or the start of treatment is delayed. The age at time of diagnosis is a strong factor influencing prognosis so that in younger patients <65 years of age long-term survival may be achieved in a substantial percentage of patients, while in elderly patients long-term survival is seen much more rarely. First-line therapy consists of high-dose methotrexate-based (poly)chemotherapy. This review provides an overview of clinical presentation, steps to diagnosis, detailed information about current treatment concepts and specific information for particular clinical situations.
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Affiliation(s)
- Niklas Schäfer
- Division of Clinical Neurooncology, Department of Neurology, University Hospital of Bonn, Bonn, Germany
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Roth P, Korfel A, Martus P, Weller M. Pathogenesis and management of primary CNS lymphoma. Expert Rev Anticancer Ther 2012; 12:623-33. [PMID: 22594897 DOI: 10.1586/era.12.36] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Primary CNS lymphoma (PCNSL), a rare variant of extranodal non-Hodgkin's lymphoma, may cause various neurological symptoms and signs. The best therapeutic strategy is still a matter of debate. High-dose methotrexate (HD-MTX) is the most active compound and should be used as the backbone for any chemotherapy applied. Several other chemotherapeutic drugs have been assessed in combination with HD-MTX, but no standard has yet been defined. Whole-brain radiotherapy is active against PCNSL, but typically does not confer long-lasting remission and is associated with significant neurotoxicity in many patients. The recently published G-PCNSL-SG1 trial has shown that consolidating whole-brain radiotherapy after HD-MTX-based chemotherapy does not prolong overall survival and may therefore be deferred. Combined systemic and intraventricular polychemotherapy, or high-dose chemotherapy followed by stem cell transplantation may offer cures to younger patients. Improving treatment regimens without adding significant (neuro-)toxicity should be the focus of ongoing and future studies.
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Affiliation(s)
- Patrick Roth
- Department of Neurology, University Hospital Zurich, Frauenklinikstrasse 26, Zurich, Switzerland.
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Schulte-Altedorneburg G, Heuser L, Pels H. MRI patterns in recurrence of primary CNS lymphoma in immunocompetent patients. Eur J Radiol 2012; 81:2380-5. [DOI: 10.1016/j.ejrad.2011.05.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Accepted: 05/21/2011] [Indexed: 10/18/2022]
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Korfel A, Weller M, Martus P, Roth P, Klasen HA, Roeth A, Rauch M, Hertenstein B, Fischer T, Hundsberger T, Leithäuser M, Birnbaum T, Kirchen H, Mergenthaler HG, Schubert J, Berdel W, Birkmann J, Hummel M, Thiel E, Fischer L. Prognostic impact of meningeal dissemination in primary CNS lymphoma (PCNSL): experience from the G-PCNSL-SG1 trial. Ann Oncol 2012; 23:2374-2380. [PMID: 22396446 DOI: 10.1093/annonc/mdr627] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We evaluated the frequency and prognostic impact of meningeal dissemination (MD) in immunocompetent adult patients with primary central nervous system lymphoma treated in a randomized phase III trial. PATIENTS AND METHODS MD was evaluated at study entry and defined by lymphoma proof in the meningeal compartment detected by at least one of the following methods: cerebrospinal fluid (CSF) cytomorphology, detection of clonal B cells by IgH PCR in CSF or contrast enhancement of the leptomeninges on magnetic resonance imaging (MRI). RESULTS Data on MD were available in 415 patients, of those, MD was detected in 65 (15.7%): in 44/361 (12.2%) by CSF cytomorphology, in 16/152 (10.5%) by PCR and in 17/415 (4.1%) by MRI. Major patients' characteristics and therapy did not significantly differ between patients with MD (MD+) versus those without MD (MD-). There was a significant correlation of MD with CSF pleocytosis (>5/μl; P < 0.0001), but no correlation with CSF protein elevation (>45 mg/dl). Median progression-free survival was 6.7 months [95% confidence interval (CI) 0-14.5] in MD+ and 8.3 months (5.7-10.8) in MD- patients (P = 0.95); median overall survival was 21.5 months (95% CI 16.8-26.1) and 24.9 months (17.5-32.3), respectively (P = 0.98). CONCLUSION MD was detected infrequently and had no impact on outcome in this trial.
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Affiliation(s)
- A Korfel
- Department of Hematology & Oncology, Campus Benjamin Franklin, Charite Berlin, Berlin, Germany.
| | - M Weller
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland; Department of Neurology, University Hospital Tuebingen, Tuebingen
| | - P Martus
- Institute of Biostatistics, University Tuebingen, Tuebingen; Institute of Biostatistics, University Hospital Tuebingen, Tuebingen
| | - P Roth
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland; Department of Neurology, University Hospital Tuebingen, Tuebingen
| | - H A Klasen
- Department of Hematology & Oncology, Pius Hospital, Oldenburg
| | - A Roeth
- Department of Hematology, West German Cancer Center, University Hospital Essen, Essen
| | - M Rauch
- Department of Hematology & Oncology, Evangelisches Krankenhaus Bielefeld, Bielefeld
| | - B Hertenstein
- Department of Hematology & Oncology, Klinikum Bremen Mitte, Bremen
| | - T Fischer
- Department of Hematology & Oncology, University of Magdeburg, Magdeburg
| | - T Hundsberger
- Department of Hematology & Oncology, University Hospital Mainz, Mainz, Germany; Department of Neurology, Cantonal Hospital, St Gallen, Switzerland
| | - M Leithäuser
- Department of Hematology & Oncology, University Hospital Rostock, Rostock
| | - T Birnbaum
- Department of Neurology, University Hospital Grosshadern, Munich
| | - H Kirchen
- Department of Hematology & Oncology, Hospital Trier, Trier
| | - H-G Mergenthaler
- Department of Oncology & Hematology, Klinikum Stuttgart, Stuttgart
| | - J Schubert
- Department of Neurology, Hospital Minden, Minden
| | - W Berdel
- Department of Medicine A, University Hospital Muenster, Muenster
| | - J Birkmann
- Department of Hematology & Oncology, Hospital Nürnberg, Nürnberg
| | - M Hummel
- Department of Pathology, Campus Benjamin Franklin, Charite Berlin, Germany
| | - E Thiel
- Department of Hematology & Oncology, Campus Benjamin Franklin, Charite Berlin, Berlin, Germany
| | - L Fischer
- Department of Hematology & Oncology, Campus Benjamin Franklin, Charite Berlin, Berlin, Germany
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Baraniskin A, Deckert M, Schulte-Altedorneburg G, Schlegel U, Schroers R. Current strategies in the diagnosis of diffuse large B-cell lymphoma of the central nervous system. Br J Haematol 2011; 156:421-32. [PMID: 22077417 DOI: 10.1111/j.1365-2141.2011.08928.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Lymphomas can arise within the central nervous system (CNS) as primary CNS lymphoma (PCNSL) typically involving the brain and less often the leptomeninges, eyes, and spinal cord. In contrast to PCNSL, secondary CNS lymphoma (SCNSL) is considered to originate as quasi metastasis from systemic lymphoma spreading to the CNS. Both types of CNS lymphomas are predominantly tumours of the diffuse large B-cell type and represent aggressive diseases necessitating a rapid diagnosis. Following neuroimaging based on magnetic resonance imaging, stereotaxy and histopathological diagnosis of CNS lymphoma currently remain obligatory to plan treatment. However, progress in cytopathological, immunophenotypic, and molecular genetic analyses of the cerebrospinal fluid (CSF) has been achieved recently and potentially will facilitate lymphoma diagnosis in the future. This review describes the diagnostic procedures in patients with suspected CNS lymphomas, primarily PCNSL. In addition to a summary of the standard diagnostic work-up, an overview and discussion of current data on different techniques for evaluation of the CSF in CNS lymphoma are given.
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Affiliation(s)
- Alexander Baraniskin
- Department of Medicine, Haematology and Oncology, Ruhr-University of Bochum, Germany
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Deckert M, Engert A, Brück W, Ferreri AJM, Finke J, Illerhaus G, Klapper W, Korfel A, Küppers R, Maarouf M, Montesinos-Rongen M, Paulus W, Schlegel U, Lassmann H, Wiestler OD, Siebert R, DeAngelis LM. Modern concepts in the biology, diagnosis, differential diagnosis and treatment of primary central nervous system lymphoma. Leukemia 2011; 25:1797-807. [PMID: 21818113 DOI: 10.1038/leu.2011.169] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Recent studies addressing the molecular characteristics of PCNSL, which is defined as malignant B-cell lymphoma with morphological features of DLBCL, have significantly improved our understanding of the pathogenesis of this lymphoma entity, which is associated with an inferior prognosis as compared with DLBCL outside the CNS. This unfavorable prognosis stimulated intense efforts to improve therapy and induced recent series of clinical studies, which addressed the role of radiotherapy and various chemotherapeutic regimens. This review combines the discussion of diagnosis, differential diagnosis and recent progress in studies addressing the molecular pathogenesis as well as therapeutic options in PCNSL.
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Affiliation(s)
- M Deckert
- Department of Neuropathology, University Hospital of Cologne, Cologne, Germany.
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