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Roschewski M, Hodson DJ. Diffuse large B-cell lymphoma involving the central nervous system: biologic rationale for targeted therapy. Haematologica 2024; 109:388-400. [PMID: 37706315 PMCID: PMC10828633 DOI: 10.3324/haematol.2021.278613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 09/04/2023] [Indexed: 09/15/2023] Open
Abstract
Diffuse large B-cell lymphoma (DLBCL) is an aggressive B-cell lymphoma curable even in advanced stages. DLBCL involving the central nervous system (CNS) is more difficult to cure and fewer treatment options exist. Primary CNS lymphoma (PCNSL) refers to aggressive lymphomas confined to the CNS, and are almost always DLBCL. Standard approaches for PCNSL use high-dose methotrexate-based combinations as induction therapy and younger patients often receive dose-intensive consolidation. However, dose-intensive therapies are not suitable for all patients, and older patients have fewer effective treatment options. Patients with relapsed or chemotherapy-refractory disease have a very poor prognosis. Secondary CNS lymphoma (SCNSL) describes aggressive lymphomas involving the CNS at initial presentation or relapses within the CNS after treatment for systemic DLBCL. Isolated CNS relapse is often managed as PCNSL, but patients with synchronous involvement of DLBCL in both the periphery and the CNS pose a unique clinical challenge. Insights into the molecular circuitry of DLBCL have identified distinct genetic subtypes including cases with a predilection for CNS invasion. PCNSL and subsets of SCNSL are characterized by chronically activated B-cell receptor and NFκB signaling along with genetic evidence of immune evasion which may be exploited therapeutically. Improved mechanistic understanding of targetable pathways underpinning CNS lymphomas has led to numerous clinical trials testing targeted agent combinations and immunotherapy approaches with promising early results. Biologically rational strategies may further improve the cure rate of CNS lymphomas, either by overcoming intrinsic or acquired treatment resistance and/or by being broadly applicable to patients of all ages.
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Affiliation(s)
- Mark Roschewski
- Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer nstitute, Bethesda, MD, 20892.
| | - Daniel J Hodson
- Wellcome MRC Cambridge Stem Cell Institute, University of Cambridge, Cambridge Biomedical Campus, Cambridge.
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Khwaja J, Kirkwood AA, Isbell LK, Steffanoni S, Goradia H, Pospiech L, Fail T, Nicholson E, Fletcher K, Linton KM, Parsons KE, Elmusharaf N, Eccersley L, Eyre TA, Chaganti S, Smith J, Thakrar N, Kutilina A, Calimeri T, Martinez-Calle N, El-Sharkawi D, Osborne W, Illerhaus G, Fox CP, Ferreri AJM, Schorb E, Cwynarski K. International multicenter retrospective analysis of thiotepa-based autologous stem cell transplantation for secondary central nervous system lymphoma. Haematologica 2023; 108:882-888. [PMID: 36300776 PMCID: PMC9973475 DOI: 10.3324/haematol.2022.281640] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
| | - Amy A Kirkwood
- Cancer Research UK and UCL Cancer Trials Centre, UCL Cancer Institute, University College London, UK
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- Oxford University Hospitals NHS Foundation Trust, Oxford
| | | | - Jeffrey Smith
- Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
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Bobillo S, Khwaja J, Ferreri AJM, Cwynarski K. Prevention and management of secondary central nervous system lymphoma. Haematologica 2023; 108:673-689. [PMID: 36384246 PMCID: PMC9973486 DOI: 10.3324/haematol.2022.281457] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Indexed: 11/18/2022] Open
Abstract
Secondary central nervous system (CNS) lymphoma (SCNSL) is defined by the involvement of the CNS, either at the time of initial diagnosis of systemic lymphoma or in the setting of relapse, and can be either isolated or with synchronous systemic disease. The risk of CNS involvement in patients with diffuse large B-cell lymphoma is approximately 5%; however, certain clinical and biological features have been associated with a risk of up to 15%. There has been growing interest in improving the definition of patients at increased risk of CNS relapse, as well as identifying effective prophylactic strategies to prevent it. SCNSL often occurs within months of the initial diagnosis of lymphoma, suggesting the presence of occult disease at diagnosis in many cases. The differing presentations of SCNSL create the therapeutic challenge of controlling both the systemic disease and the CNS disease, which uniquely requires agents that penetrate the blood-brain barrier. Outcomes are generally poor with a median overall survival of approximately 6 months in retrospective series, particularly in those patients presenting with SCNSL after prior therapy. Prospective studies of intensive chemotherapy regimens containing high-dose methotrexate, followed by hematopoietic stem cell transplantation have shown the most favorable outcomes, especially for patients receiving thiotepa-based conditioning regimens. However, a proportion of patients will not respond to induction therapies or will subsequently relapse, indicating the need for more effective treatment strategies. In this review we focus on the identification of high-risk patients, prophylactic strategies and recent treatment approaches for SCNSL. The incorporation of novel agents in immunochemotherapy deserves further study in prospective trials.
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Affiliation(s)
- Sabela Bobillo
- Department of Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron University Hospital, Barcelona
| | - Jahanzaib Khwaja
- Department of Haematology, University College London Hospitals, London
| | - Andrés J M Ferreri
- Lymphoma Unit, Department of Onco-Haematology, IRCCS San Raffaele Scientific Institute, Milan
| | - Kate Cwynarski
- Department of Haematology, University College London Hospitals, London
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