Rituximab with high-dose methotrexate in primary central nervous system lymphoma

Role of Rituximab in Treatment of Patients With Primary Central Nervous System Lymphoma (PCNSL): A Systematic Review and Meta-Analysis

Primary central nervous system lymphoma (PCNSL) is a rare form of non-Hodgkin's lymphoma involving the brain, cerebrospinal fluid, spinal cord and eyes. Rituximab has played a prominent role in the treatment of non-Hodgkin's B-cell lymphomas, including aggressive diffuse large B lymphoma. However, as a macromolecular drug, the role of rituximab in the treatment of PCNSL has been controversial. In this systematic review and meta-analysis, we evaluated the role of rituximab in the treatment of PCNSL. We searched articles in the following electronic databases including PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov until October 20, 2022.We included 11 studies (3 RCTS and 8 retrospective studies) with a total of 1182 patients. We extracted the baseline characteristics and outcomes of the studies and assessed the risk of bias, then used Review Manager 5.4 for this meta-analysis. The primary outcomes included complete response rate (CR), overall survival (OS), and progression-free survival (PFS). Odds ratios (ORS) and corresponding 95% confidence intervals (CIS) for the primary outcome were analyzed and compared. The results of our statistical analysis show that the use of rituximab was closely correlated with a higher CR(OR 1.70,95%CI 1.17-2.46, P = .005), 3-year OS (OR 2.40, 95%CI 1.53-3.77, P = .0001), 5-year OS (OR 2.75, 95%CI 1.68-4.49, P < .0001), 3-year PFS(OR 4.42, 95%CI 1.15-16.97, P < .0001), 5-year PFS(OR 1.97, 95%CI 1.39-2.78, P = .0001).These results suggest that rituximab may have a positive impact on the prognosis of patients with PCNSL, and may be helpful in the determination of treatment plan for patients with PCNSL.

Primary Central Nervous System Lymphoma Presenting as Isolated Multiple Cranial Neuropathies: An Extremely Rare Case

Primary central nervous system lymphoma (PCNSL) is an uncommon malignancy of B-cell origin that typically involves the brain, eyes, and spinal cord without systemic spread. PCNSL typically involves the cerebral hemispheres, basal ganglia, or periventricular region. Isolated leptomeningeal PCNSL without any evidence of parenchymal involvement is very rare. We present a very unusual case of PCNSL presenting as persistent bilateral Bell's palsy and trigeminal neuralgia with magnetic resonance imaging (MRI) brain showing significantly hypertrophied enhancing bilateral facial and trigeminal nerves.

Rituximab with high-dose methotrexate is effective and cost-effective in newly diagnosed primary central nervous system lymphoma

Induction chemotherapy based on high-dose methotrexate is considered as the standard approach for newly diagnosed primary central nervous system lymphomas (PCNSLs). However, the best combination chemotherapeutic regimen remains unclear. This study aimed to determine the efficacy and toxicities of rituximab with methotrexate (R-M regimen). Consecutive 37 Chinese patients receiving R-M regimen as induction chemotherapy were retrospectively identified from January 2015 to June 2020 from our center in eastern China. Fourteen patients receiving rituximab plus methotrexate with cytarabine (R-MA regimen) at the same period were identified as the positive control group. The response rates, survival, toxicities, length of hospital stay (LOS), and cost were compared. Compared with the R-MA regimen, the R-M regimen showed comparable response rate and survival outcomes, but had fewer grade 3-4 hematological toxicities, shorter LOS, lower mean total hospitalization cost and lower mean total antibiotic cost. Complete remission at the end of induction chemotherapy and ECOG > 3 were independent prognostic factors for overall survival. In conclusion, R-M regimen is an effective and cost-effective combination treatment for PCNSLs, which warrants further evaluation in randomized trials.

First-line high-dose therapy and autologous blood stem cell transplantation in patients with primary central nervous system non-Hodgkin lymphomas—a single-centre experience in 61 patients

Primary central nervous system non-Hodgkin lymphomas (PCNS-NHLs) are extranodal B-cell lymphomas with poor prognosis. The role of high-dose therapy (HDT) followed by autologous blood stem cell transplantation (ASCT) as first-line therapy is still not clear. We retrospectively collected long-term follow up data of 61 consecutive patients with PCNS-NHL at the University Hospital Düsseldorf from January 2004 to December 2016. Thirty-six patients were treated with conventional chemoimmunotherapy (cCIT) only (CT-group). Seventeen patients received an induction cCIT followed by HDT and ASCT. In the CT-group, the overall response rate (ORR) was 61% (CR 47%, PR 14%), and there were 8% treatment-related deaths (TRD). Progression-free survival (PFS) was 31.8 months, and overall survival (OS) was 57.3 months. In the HDT-group, the ORR was 88% (59% CR, 29% PR), and there were 6% TRD. Median PFS and OS were not reached at 5 years. The 5-year PFS and OS were 64.7%. After a median follow up of 71 months, 10 patients (59%) were still alive in CR/PR following HDT and ASCT, one patient was treated for progressive disease (PD), and 7 had died (41%, 6 PD, 1 TRD). All patients achieving CR prior to HDT achieved durable CR. In the CT-group, 8 patients (22%) were alive in CR/PR after a median follow-up of 100 months. Twenty-eight patients died (78%, 24 PD, 2 TRD, 2 deaths in remission). In the univariate analysis, the HDT-group patients had significantly better PFS (not reached vs 31.8 months, p = 0.004) and OS (not reached vs 57.3 months, p = 0.021). The multivariate analysis showed HDT was not predictive for survival. Treatment with HDT + ASCT is feasible and offers the chance for long-term survival with low treatment-related mortality in younger patients. In this analysis, ORR, PFS and OS were better with HDT than with conventional cCIT alone. This result was not confirmed in the multivariate analysis, and further studies need to be done to examine the role of HDT in PCNSL.

Central Nervous System Lymphoma: Approach to Diagnosis and Treatment

Central nervous system lymphoma (CNSL) is a rare form of extranodal non-Hodgkin lymphoma. Central nervous system lymphoma can be primary (isolated to the central nervous space) or secondary in the setting of systemic disease. Treatment of CNSL has improved since the introduction of high-dose methotrexate and aggressive consolidation regimens. However, results after treatment are durable in only half of patients, and long-term survivors may experience late neurotoxicity, impacting quality of life. Given the rarity of this disease, few randomized prospective trials exist. This leaves many questions unanswered regarding optimal first-line and salvage treatments. Recent advances in the knowledge of pathophysiology of CNSL will hopefully help the development of future treatments. This review gives an overview of the epidemiology, pathophysiology, clinical presentation, diagnosis, and treatment of immunocompetent patients with CNSL.

The Role of Rituximab in the Treatment of Primary Central Nervous System Lymphoma

Simple Summary

Primary central nervous system lymphoma (PCNSL) is a rare form of cancer and the treatment of newly diagnosed patients is challenging. Many chemotherapy regimens are being used, and methotrexate is an important component in most. The role of the immunotherapy rituximab is not as clear. This review focuses on the available evidence for the use of this monoclonal antibody in the treatment of patients with PCNSL.

Abstract

Primary central nervous system lymphoma (PCNSL) is a type of non-Hodgkin lymphoma limited to the central nervous system. It has a poor prognosis. Consensus has been reached on the treatment of newly diagnosed patients with high-dose methotrexate-based chemotherapy, but whether the addition of the monoclonal anti-CD20 antibody rituximab improves survival, as it does in systemic B-cell non-Hodgkin lymphoma, remains disputed. In this review, we reflect on the available evidence of the use of rituximab in PCNSL. Whether rituximab has any beneficial effect remains uncertain.

Consecutive single-institution case series of primary central nervous system lymphoma treated by R-MPV or high-dose methotrexate monotherapy

OBJECTIVE

The optimal regimen for use of high dose-methotrexate-based chemotherapy in primary central nervous system lymphoma is still under debate. We conducted a retrospective study to evaluate the treatment outcome of a combination immunochemotherapy consisting of rituximab, methotrexate, procarbazine and vincristine followed by with or without whole brain radiotherapy and consolidation cytarabine, in comparison with high dose-methotrexate monotherapy followed by full dose whole brain radiotherapy.

METHODS

Newly diagnosed primary central nervous system lymphoma patients treated with either rituximab, methotrexate, procarbazine and vincristine or high dose-methotrexate in Kyorin University Hospital were identified, and the response rates and survival were compared. Toxicities, post-treatment transition of Mini-Mental State Examination, Karnofsky performance status score, Fazekas scale and prognostic factors were analysed in the rituximab, methotrexate, procarbazine and vincristine group.

RESULTS

Ninety-five patients treated with rituximab, methotrexate, procarbazine and vincristine (n = 39) or high dose-methotrexate (n = 56) were analysed. The complete response/complete response unconfirmed rate was significantly higher in the rituximab, methotrexate, procarbazine and vincristine group (74.4 vs. 15.4%, P < 0.001). Accordingly, both median progression-free survival and overall survival were significantly longer in the rituximab, methotrexate, procarbazine and vincristine group (median progression-free survival: unreached vs. 14.75 months, P < 0.001) (median overall survival: unreached vs. 63.15 months, P = 0.005). Although the rate of grade 3/4 hematologic toxicities was high both during rituximab, methotrexate, procarbazine and vincristine and consolidation cytarabine, the rate of grade 3/4 infections was low, and no treatment related deaths were observed. Deterioration in Karnofsky performance status or Mini-Mental State Examination was rare, except on disease recurrence. Although whole brain radiotherapy was associated with Fazekas scale deterioration, its association with Karnofsky performance status or Mini-Mental State Examination deterioration was not significant.

CONCLUSIONS

Rituximab, methotrexate, procarbazine and vincristine was apparently promising in comparison with high dose-methotrexate monotherapy with manageable toxicity in this retrospective study, and further investigation is warranted.

High-dose methotrexate monotherapy for newly diagnosed primary central nervous system lymphoma: 15-year multicenter experience

AIM

Primary central nervous system lymphoma (PCNSL) is rare disease and shows poor prognosis although methotrexate-based chemotherapy is used. Here, we present our experiences with high-dose methotrexate (HD-MTX) monotherapy for immunocompetent patients with PCNSL at three institutions and investigate factors related to survival.

METHODS

PCNSL patients, who were histologically confirmed with diffuse large B cells and treated with HD-MTX monotherapy from 2001 to 2016, were retrospectively reviewed. Patients underwent induction chemotherapy with 8 g/m² of MTX every 10 days (maximum three cycles). Maintenance chemotherapy of 3.5 g/m² of MTX (maximum six cycles) was selectively performed depending on the response to induction chemotherapy.

RESULTS

A total of 67 patients were included. Although seven patients discontinued induction chemotherapy because of MTX toxicity, 40 (59.7%) patients showed a complete response (CR) to induction chemotherapy. Twenty-six (38.8%) and three (4.5%) patients showed a CR and partial response, respectively, after maintenance chemotherapy. Forty-one patients with recurrence or progression following HD-MTX underwent second-line treatment. Progression-free survival rates were 43% and 24% at 1 and 2 years, respectively. The median overall survival was 40.3 months. In a multivariate analysis, a radiological CR to induction chemotherapy was a significant factor related to prolonged progression-free survival and overall survival (P < 0.05).

CONCLUSION

MTX-monotherapy is tolerable in terms of adverse effects and still considered as a treatment option in patients with PCNSL. However, an additional therapeutic option should be prepared for non-CR responders to induction chemotherapy.

Molecular features of a large cohort of primary central nervous system lymphoma using tissue microarray

The objective of this study was to evaluate the distribution and prognostic impact of a broad range of molecular attributes in a large cohort of immunocompetent patients with primary central nervous system lymphoma (PCNSL) by using tissue microarray. Patients diagnosed with PCNSL were initially identified in the BC Cancer Lymphoid Cancer clinical and pathology databases. Tissue microarrays were constructed by using archival formalin-fixed paraffin-embedded diagnostic biopsy tissue. Immunohistochemistry and fluorescent in situ hybridization studies were performed. A total of 115 patients with PCNSL with diffuse large B-cell lymphoma (DLBCL) histology were identified. The majority of cases (≥75%) had a non-germinal center B-cell phenotype according to immunohistochemistry algorithms, but cell of origin did not affect progression-free or overall survival. MYC (40%), BCL2 (75%), and programmed death-ligand 1 (29%) protein expression were common, but their corresponding gene rearrangements were rare (≤1% each), suggesting that alternate mechanisms were driving expression. There were no dual rearrangements involving MYC and BCL2. Only 22% of cases had membranous expression of major histocompatibility complex class II, suggesting a mechanism for escape from immune surveillance. Epstein-Barr virus-encoded RNA was positive in 1 immunocompetent patient. BCL6 protein expression (77%) and BCL6 rearrangements (31%) were frequent; the latter was the only factor associated with a poor prognosis in the overall cohort and in the subgroup of 52 patients treated with high-dose methotrexate-based regimens. This large population-based study shows that prominent molecular features of PCNSL are unique and different from those of systemic DLBCL. These results may better inform drug development in PCNSL.

Primary central nervous system lymphoma after heart transplantation: A case report and literature review

RATIONALE

The heart transplantation is the most important treatment for patients with end-stage severe heart disease who failed to conventional therapy. Post-transplant lymphoproliferative disorder is the second most common malignancy in heart transplant recipients. However, primary central nervous system lymphoma (PCNSL) after heart transplantation is an extremely rare condition.

PATIENTS CONCERNS

This report described a 53-year-old male who was diagnosed as PCNSL 17 months after heart transplantation.

DIAGNOSES

The patient was admitted to the local hospital presenting with dizziness, headache, and reduced left-sided power and sensation for 1 week. He had a medical history of heart transplantation because of the dilated cardiomyopathy 17 months ago and had a 17-month history of immunosuppressive therapy with tacrolimus. A computed tomography scan of the brain revealed a bulky mass in the right temporal lobe. The emergency intracranial mass resection and cerebral decompression were performed in our hospital. The histopathology of the brain lesions showed diffuse large B-cell lymphoma. A further FDG positron emission tomography-computed tomography scan of the whole body showed no significantly increased metabolic activity in other regions. The final diagnosis of this patient was PCNSL after heart transplantation.

INTERVENTIONS

Given the poor health condition, with the patient's consent, the whole brain radiotherapy was performed with supportive care.

OUTCOMES

The disease deteriorated rapidly during the period of receiving radiotherapy, and he died within 2 months from the diagnosis.

LESSONS

PCNSL after heart transplantation is an extremely rare phenomenon with extremely poor prognosis. We should pay close attention to the heart recipients, especially when the patients present with neurological symptoms and signs. The available treatment options for PCNS-post-transplant lymphoproliferative disorder include the reduction of immunosuppressive drugs, immune-chemotherapy, operation, radiotherapy. However, individual treatments for heart transplant recipients with PCNSL should be based on the performance status and tolerance to treatment, combined with the doctor's experience and supportive care.

Systemic Approach to Recurrent Primary CNS Lymphoma: Perspective on Current and Emerging Treatment Strategies

There is no uniform standard of care for the treatment of refractory or recurrent primary central nervous lymphoma (r/r PCNSL). Many different systemic treatment regimens have been studied, but available data are based on small prospective or retrospective reports. There have been no randomized controlled trials in r/r PCNSL to date. Here, we provide an overview of published systemic regimens for the treatment of r/r PCNSL, as well as therapies that are under investigation. In addition, based on available data, we propose strategies of how to approach choice of therapy for different groups of patients in this disease setting. Patients can be mainly divided into three groups: 1) patients suitable for a re-challenge with high-dose methotrexate (HD-MTX)-based regimens and that may or may not be candidates for consolidation with high-dose chemotherapy with autologous stem cell transplant, 2) patients refractory to HD-MTX or that had early relapse, but suitable for an aggressive treatment strategy with re-induction with non-MTX-based therapy, possibly followed by high-dose chemotherapy with autologous transplant, and 3) patients not suitable for re-treatment with HD-MTX and that are not candidates for aggressive therapy. As PCNSL is a rare disease and as there is urgent need for better outcomes in r/r PCNSL, clinical trial participation is encouraged, especially in elderly or frail patients who are not candidates for high-dose chemotherapy and transplant.

The Role of Rituximab in Primary Central Nervous System Lymphoma

Purpose of Review

The treatment of primary central nervous system lymphoma (PCNSL) is still under debate. One of the issues is the role of rituximab in improving the outcome. Here, we summarize the existing evidence, and comment on the literature on this topic.

Recent Findings

Two randomized controlled studies have been published recently, with conflicting results. Although the evidence of the benefit of rituximab is limited, it is already incorporated into many treatment regimens, both in studies and in standard clinical practice.

Summary

The use of rituximab in PCNSL is still a matter of debate. A positive effect on the outcome is uncertain. However, there are no clinical signs of significantly increased toxicity. The uncertain positive effect should therefore be weighed against the increased costs of the treatment.

Performance of diffusion and perfusion MRI in evaluating primary central nervous system lymphomas of different locations

Background

Diffusion and perfusion MRI can invasively define physical properties and angiogenic features of tumors, and guide the individual treatment. The purpose of this study was to investigate whether the diffusion and perfusion MRI parameters of primary central nervous system lymphomas (PCNSLs) are related to the tumor locations.

Methods

We retrospectively reviewed the diffusion, perfusion, and conventional MRI of 68 patients with PCNSLs at different locations (group 1: cortical gray matter, group 2: white matter, group 3: deep gray matter). Relative maximum cerebral blood volume (rCBV_max) from perfusion MRI, minimum apparent diffusion coefficients (ADC_min) from DWI of each group were calculated and compared by one-way ANOVA test. In addition, we compared the mean apparent diffusion coefficients (ADC_mean) in three different regions of control group.

Results

The rCBV_max of PCNSLs yielded the lowest value in the white matter group, and the highest value in the cortical gray matter group (P < 0.001). However, the ADC_min of each subgroup was not statistically different. The ADC_mean of each subgroup in control group was not statistically different.

Conclusion

Our study confirms that rCBV_max of PCNSLs are related to the tumor location, and provide simple but effective information for guiding the clinical practice of PCNSLs.

Advances and challenges in the treatment of primary central nervous system lymphoma

Primary central nervous system lymphoma (PCNSL), a rare variant of non-Hodgkin's lymphoma, is characterized by distinct biological characteristics and clinical behaviors, and patient prognosis is not satisfactory. The advent of high-dose (HD) methotrexate (HD-MTX) therapy has significantly improved PCNSL prognosis. Currently, HD-MTX-based chemotherapy regimens are recognized as first-line treatment. PCNSL is sensitive to radiotherapy, and whole-brain radiotherapy (WBRT) can consolidate response to chemotherapy; however, WBRT-associated delayed neurotoxicity leads to neurocognitive impairment, especially in elderly patients. Other effective approaches include rituximab, temozolomide, and autologous stem-cell transplantation (ASCT). In addition, new drugs against PCNSL such as those targeting the B-cell receptor signaling pathway, are undergoing clinical trials. However, optimal therapeutic approaches in PCNSL remain undefined. This review provides an overview of advances in surgical approaches, induction chemotherapy, radiotherapy, ASCT, salvage treatments, and novel therapeutic approaches in immunocompetent patients with PCNSL in the past 5 years. Additionally, therapeutic progress in elderly patients and in those with relapsed/refractory PCNSL is also summarized based on the outcomes of recent clinical studies.

Autologous Stem-Cell Transplantation for Primary Central Nervous System Lymphoma: Systematic Review and Meta-analysis

BACKGROUND

Primary central nervous system lymphoma (PCNSL) is an aggressive form of non-Hodgkin lymphoma. Methotrexate is first-line chemotherapy. Autologous stem-cell transplantation (ASCT) is increasingly used as an alternative consolidative treatment to whole-brain radiotherapy.

METHODS

A systematic search of several databases was conducted up through January 10, 2018. Two investigators independently assessed study eligibility and extracted the data. Studies that reported survival outcomes after ASCT were included.

RESULTS

We screened 1517 references and included 43 studies. ASCT was used as consolidative treatment or as salvage treatment/at relapse. Thiotepa, busulfan, and cyclophosphamide and carmustine/thiotepa were commonly used conditioning regimens. In the consolidation setting, 94% of patients experienced or maintained complete or partial response after ASCT. The rates of overall survival (OS) and progression-free survival (PFS) were 94%, 86%, 82%, and 70% and 79%, 70%, 64%, and 54% after 1, 2, 3, and 5 years, respectively. The overall risk of relapse at 5 years was 24%. In the salvage/relapse settings, 85% of patients experienced or maintained complete response or partial response after ASCT. The rates of OS and PFS were 75%, 63%, 56%, and 54% and 85%, 62%, 59%, and 54% after 1, 2, 3, and 5 years, respectively. The risk of relapse at 5 years was 29%. Subgroup analysis showed that the use of carmustine and thiotepa as a conditioning regimen carried the lowest risk of transplant-related mortality. The thiotepa, busulfan, and cyclophosphamide regimen, on the other hand, showed numerically superior OS and PFS rates.

CONCLUSION

This review provides estimates for response and survival to aid in decision making when considering ASCT for patients with PCNSL.

Characteristics and Outcomes of Primary Central Nervous System Lymphoma: A Retrospective Study of 91 Cases in a Chinese Population

BACKGROUND

Primary central nervous system lymphoma (PCNSL) is a rare disease affecting the brain, leptomeninges, spinal cord, cerebrospinal fluid, or vitreoretinal compartment, without evidence of systemic disease. Prognosis is still poor after intensive methotrexate-based chemotherapy.

METHODS

Clinical data of 91 patients treated in a tertiary referral center during a 13-year period were retrospectively reviewed.

RESULTS

The estimated median progression-free survival and overall survival (OS) for the entire cohort were 39.1 months (95% confidence interval [CI], 14.1-64.0 months) and 54.5 months (95% CI, 28.9-80.1 months), respectively. Estimated 5-year progression-free survival and OS were 37.0% ± 6.5% and 47.5% ± 7.5%. Survival was associated with cycles of methotrexate only in multivariate analysis. Seventy-four patients received methotrexate-based chemotherapy after diagnosis. Thirty-nine patients experienced disease progression. Patients with relapsed/refractory disease had a poor survival, with median second OS (calculated from the date of first disease progression to the time of death from any cause) being 7.2 months (95% CI, 2.5-12.00 months). Three patients responded to ibrutinib after disease progression and incurred no fungal infection.

CONCLUSIONS

The outcomes of patients with PCNSL treated in our cohort are still poor. Relapse or refractory PCNSL and those not tolerating aggressive chemotherapy urgently require new approaches to improve their still dismal prognosis. Novel agents such as ibrutinib have shown promising clinical activity. Future studies should focus on the predictive biomarkers for the treatment of PCNSL with novel agents to provide precision medicine for PCNSL.

Impact of front line relative dose intensity for methotrexate and comorbidities in immunocompetent elderly patients with primary central nervous system lymphoma

Primary central nervous system lymphomas (PCNSL) are non-Hodgkin lymphomas strictly localized to the CNS, occurring mainly in elderly patients with comorbidities. Current treatment in fit patients relies on high-dose methotrexate and high-dose cytarabine. The aim of this study was to evaluate the efficacy and feasibility of this treatment in elderly patients and to assess potential prognostic factors associated with survival. We conducted a retrospective study in two centers between January 2008 and September 2015 including 35 elderly immunocompetent patients who received first-line treatment with high-dose methotrexate. With a median follow-up of 19.8 months (range: 1.7-73.4 months), median overall survival (OS) was 39.5 months (95% confidence interval (95% CI): 18.3-60.7) and median progression-free survival (PFS) was 25.8 months (95% CI: 5.2-46.4). In univariate analysis, administration of high-dose cytarabine and achieving a relative dose intensity for methotrexate > 75% were associated with increased OS (p = 0.006 and p = 0.003, respectively) and PFS (p = 0.003 and p = 0.04, respectively) whereas comorbidities, defined by a CIRS-G score ≥ 8, were associated with decreased OS and PFS (p = 0.02 and p = 0.04, respectively). A high MSKCC score was associated with decreased OS (p = 0.02). In multivariate analysis, administration of high-dose cytarabine was associated with increased OS and PFS (p = 0.02 and p = 0.007, respectively). Comorbidities and relative dose intensity for methotrexate are important for the prognosis of elderly patients with PCNSL. These results must be confirmed in prospective trials.

Primary central nervous system lymphoma: time for diagnostic biomarkers and biotherapies?

PURPOSE OF REVIEW

Primary central nervous system lymphoma (PCNSL) is a rare cancer with a somber prognosis in older patients, which it affects predominantly. Only in recent years have molecular alterations characterizing PCNSL been thoroughly described. This opens possibilities for the use of targeted therapies. Developments in imaging and biomarkers have also great potential to help clinicians faced with diagnostic and prognostic uncertainties.

RECENT FINDINGS

Several biomarkers for PCNSL, such as different microRNAs, which could be tested in cerebrospinal fluid and vitreous fluid, and IL-10, which has been shown to have excellent sensitivity and specificity in the cerebrospinal fluid, have emerged in the last years. Methotrexate-based regimens remain the gold standard first-line treatment, with recent studies looking at the best adjunctive molecules to methotrexate, including rituximab, and at the role of autologous stem cell transplantation. As mutations leading to the activation of nuclear factor-kappa-B signaling are found in most PCNSLs, with mutations of MYD88 and CD79B particularly, ibrutinib is studied as molecule of great interest and encouraging results have been found in pilot studies. There is also great interest in the immunomodulatory drugs (lenalidomide) and immunotherapy (anti-programmed cell death 1/programmed cell death 1 ligand 1).

SUMMARY

Identification of molecular genetic and cytokine changes in tumor and liquid biopsies will have an increasing role in the diagnostic and follow-up of PCNSL but also in the treatment and management of the disease.

Methotrexate-cytarabine-dexamethasone combination chemotherapy with or without rituximab in patients with primary central nervous system lymphoma

Purpose

High-dose methotrexate based chemotherapy is the standard treatment for patients with newly diagnosed primary central nervous system lymphoma (PCNSL). The role of rituximab is controversial because of its large size, which limits its penetration of the blood-brain barrier. In this study, we investigated the efficacy and tolerability of adding rituximab to methotrexate-cytarabine-dexamethasone combination therapy (RMAD regimen).

Results

The patients treated with RMAD had a complete remission rate of 66.7% after induction chemotherapy; this rate was only 33.3% in patients treated with MAD alone (p = .011). The most common grade 1–3 adverse events were similar and included hematologic toxicity, increased aminotransferase levels, and gastrointestinal reactions. Multivariate analysis revealed that rituximab treatment was associated with longer progression-free survival (PFS, p = .005) but not overall survival (OS). Additionally, we observed that elevated serum lactate dehydrogenase was associated with shorter OS and PFS.

Materials and Methods

We retrospectively analyzed 60 immunocompetent patients with newly diagnosed PCNSL at Beijing Tiantan Hospital, Capital Medical University from January 2010 to June 2016. Twenty-four patients received 3–6 courses of 3.5 g/m² methotrexate on day 1; 0.5–1 g/m² cytarabine on day 2; and 5–10 mg dexamethasone on days 1, 2 and 3. Thirty-six patients received the same combination plus rituximab 375 mg/m² on day 0. All patients repeated the treatment every 3 weeks.

Conclusions

High-dose methotrexate based chemotherapy with rituximab yields a higher complete remission rate and does not increase serious toxicities. PFS benefits from the addition of rituximab. OS has an increasing trend in patients treated with rituximab without statistical significance.

Updates on Primary Central Nervous System Lymphoma

PURPOSE OF REVIEW

Primary central nervous system lymphoma (PCNSL) is an aggressive malignancy confined to the brain, spinal cord, leptomeninges, and eyes. Due to its rarity, there is a paucity of randomized trials and a varied approach to its management in the oncologic community. This review summarizes recent literature guiding current clinical practice.

RECENT FINDINGS

The presentation, work up, and management of PCNSL are discussed. Induction therapy incorporates a methotrexate-based chemotherapy regimen and is generally followed by a consolidation regimen including high dose chemotherapy (with or without autologous stem cell rescue). Whole brain radiation therapy (WBRT) is a potential additional consolidation strategy. Management of relapsed and refractory disease poses a special challenge due to poor outcomes. Immunotherapy and targeted treatments are promising novel strategies for recurrent/refractory patients. Currently, there is little consensus in the management of PCNSL. Treatment recommendations should be tailored to the individual patient, with consideration for risk of neurotoxicity. New, exciting strategies are in development and when feasible, enrollment in a clinical trial should be considered.

Immunochemotherapy using rituximab (RTX) and high-dose methotrexate (HD-MTX): an evaluation of the addition of RTX to HD-MTX in recurrent primary central nervous system lymphoma (PCNSL)

Background

There is increasing evidence that MTX-based chemotherapy is superior to HD-MTX alone. Rituximab (RTX) is effective in a variety of B-cell lymphomas and may enter the brain. The purpose of this study is to evaluate the addition of RTX to HD-MTX in recurrent primary central nervous system lymphoma (PCNSL).

Methods

Patients diagnosed with recurrent PCNSL at our institution between 2004 and 2009 were treated with HD-MTX (3.5-5.5 g/m2) every 2 weeks. From 2010, RTX (375 mg/m2) was administered every 2 weeks along with HD-MTX.

Results

Fifteen recurrences in 10 patients were treated with HD-MTX alone (MTX group). Another 15 recurrences in 10 patients were treated with RTX and HD-MTX (RTX group). In 13 (86.6%) of the 15 recurrences in both groups the pre-planned chemotherapy cycles were completed. In the MTX group, 10/15 (66.6%) recurrences achieved a complete response (CR/CRu), 2/15 (13.3%) recurrences achieved a partial response (PR) and 3/15 (20%) recurrences had progressive disease (PD). In the RTX group, the CR/CRu, PR and PD rates were the same as that in the MTX group. The median time to tumor progression (mTTP) was 9.1 months (range, 1.4-120.9 months) in the MTX group and 7.8 months (range, 0.9-52.3 months) in the RTX group. We found no significant difference in mTTP (9.1 vs. 7.8 months, HR 1.02, 95% CI 0.48-2.18, P = 0.94) between the two groups. All treatment-related toxicities were manageable without any severe events.

Conclusions

The addition of RTX to HD-MTX may not be a promising strategy for recurrent PCNSL. A future study with a larger sample size, longer follow-up, or different RTX dosing/schedule is warranted.

Primary central nervous system lymphoma: Retrospective analysis of 34 cases in a single centre

Objective

To retrospectively analyse outcomes in patients with primary central nervous system lymphoma (PCNSL), which is a malignant CNS non-Hodgkin’s lymphoma with a poor prognosis.

Methods

This study retrospectively analysed the treatment and outcomes of patients with PCNSL, which were divided into two groups: surgery (S) group and surgery/biopsy+chemotherapy (SC) group. The latter group was further subdivided into four cohorts based on the treatment regimen: cyclophosphamide, epidoxorubicin, vincristine and prednisone (CHOP), high-dose methotrexate (HDM)+dexamethasone+rituximab (HDM+D+R), HDM+D+temozolomide (HDM+D+T), and HDM+D+R+T.

Results

The study enrolled 34 patients; 10 of which received surgery only. Between the S and SC groups, the median progression-free survival (PFS) and overall survival (OS) of intracranial PCNSLs (n = 32) were 8.5 months versus 29 months, respectively; and 8.5 months versus 54 months, respectively (5-year OS: 10.0% versus 48.7%, respectively; 2-year PFS: 0.0% versus 52.6%, respectively). Comparing the CHOP and HDM-based chemotherapy cohorts, the median PFS and OS were 15 months versus not achieved, respectively, and 25 months versus not achieved, respectively (5-year OS: 20.0% versus 60.8%, respectively; 2-year PFS: 20.0% versus 62.7%, respectively).

Conclusion

Chemotherapy appears to provide a better OS and PFS for patients with PCNSLs compared with surgery alone. HDM+D+T and HDM+D+R+T may be effective choices for PCNSL treatment.

Effect of rituximab on primary central nervous system lymphoma: a meta-analysis

The effect of rituximab on primary central nervous system lymphoma (PCNSL) is controversial. We performed this meta-analysis to assess the efficacy of treatment with or without rituximab for PCNSL. We first conducted a search for qualified studies using PubMed, the Cochrane Library, and the Web of Science. The meta-analysis was conducted to compare odds ratios (ORs) with the corresponding 95% confidence interval (95% CI) for complete remission (CR) rate, progression-free survival (PFS), and overall survival (OS) using Review Manager 5.0. We included two randomized clinical trials and six retrospective studies in this meta-analysis. The results of our statistical analysis show that the use of rituximab was closely correlated with a higher CR (OR 1.70, 95% CI 1.17-2.46, P = 0.005), 2-year PFS (OR 2.11, 95% CI 1.08-4.11, P = 0.03), 5-year PFS (OR 2.54, 95% CI 1.64-3.93, P < 0.0001), 2-year OS (OR 2.40, 95% CI 1.73-3.34, P < 0.00001), and 5-year OS (OR 2.87, 95% CI 2.02-4.08, P < 0.00001). These results may help to inform therapeutic strategies including the use of rituximab and to improve therapeutic planning for PCNSL patients.

Prognostic role of the neutrophil-to-lymphocyte ratio in patients with primary central nervous system lymphoma

Neutrophil-to-lymphocyte ratio (NLR) is one of the parameters of a complete blood cell count (CBC) test and has been reported to be an easily accessible prognostic marker in aggressive cancer, including non-Hodgkin lymphoma (NHL). Primary central nervous system lymphoma (PCNSL) is an extranodal NHL with highly aggressive features. However, the importance of the NLR has never been assessed in PCNSL. This retrospective study enrolled 62 biopsy-proven patients whose baseline NLR was available, and reviewed their medical records to compare both high (≥2.0) and low NLR (<2.0) groups, in terms of clinical characteristics and outcomes. The low NLR group showed significantly better response rates to induction chemotherapy compared to the high NLR group (p=0.041). At a median follow-up of 41.5 months, the high NLR group revealed a significantly worse 3-year overall survival (OS) (42.5 vs. 71.2%; p=0.031) and a worse 3-year progression-free survival (PFS) (37.3 vs. 60.1%; p=0.028). Univariable Cox analysis results showed that a high NLR at diagnosis was a poor prognostic factor for both 3-year OS (HR 2.64, 95% CI 1.06-6.60; p=0.038) and 3-year PFS (HR 2.41, 95% CI 1.07-5.42; p=0.034). However, multivariable analyses adjusting for International Extranodal Lymphoma Study Group (IELSG) score and induction chemotherapy regimen with rituximab, which were strongly prognostic in this study, showed no statistical significance even with the high NLR group's tendency towards a worse 3-year OS (HR 2.36, 95% CI 0.84-6.62, p=0.102) and a worse 3-year PFS (HR 2.28, 95% CI 0.93-5.63, p=0.073). In conclusion, given that NLR is simple and easily obtainable, it might play a potentially prognostic role in PCNSL from early disease onset.

Methotrexate plus idarubicin improves outcome of patients with primary central nervous system lymphoma

Primary central nervous system lymphoma (PCNSL) is a rare form of non-Hodgkin lymphoma with poor long-term survival. This study assessed methotrexate (MTX) plus idarubicin (IDA) in treating patients of PCNSL comparing to MTX alone therapy. A total of 100 patients were retrospectively enrolled and subjected to MTX alone (n = 52) and MTX plus IDA (n = 48). The completed response (CR) rate in patients treated with MTX plus IDA was 62.50%, and overall response (OR) rate was 79.17%, which in MTX alone cohort were 42.31% and 63.46% respectively. Median progression-free survival (PFS) of patients treated with MTX plus IDA was significantly better than those treated with MTX alone (18.35 months vs.8.45months, P = 0.000). The MTX plus IDA regimen exhibited a significantly better control of PCNSL. Further studies would be needed to confirm these results.

Treatment of Primary Central Nervous System Posttransplant Lymphoproliferative Disorder in an Adult Kidney Transplant Recipient: A Case Report

Posttransplant lymphoproliferative disorder is a serious complication of solid-organ transplant. Extranodal involvement is common; however, isolated involvement of the central nervous system is extremely rare and represents a particularly difficult therapeutic challenge with no current consensus on optimal treatment. Here, we describe a 70-year-old woman who developed Epstein-Barr virus-related primary central nervous system lymphoma 19 months after kidney transplant. Immunosuppression was reduced, and the patient was started on high-dose methotrexate, which was complicated by acute kidney injury and discontinued. She then received a rituximab and temozolomide chemotherapeutic regimen and achieved complete clinical response. Seventeen months after diagnosis, she is alive and has not developed any other posttransplant lymphoproliferative disorder. We review the current literature and discuss treatment options for patients with primary central nervous system posttransplant lymphoproliferative disorder following kidney transplant.

Primary central nervous system lymphoma: essential points in diagnosis and management

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.

Case-based review: primary central nervous system lymphoma

Primary CNS lymphoma (PCNSL) is a rare diffuse large B-cell lymphoma originating within the central nervous system. The overall incidence of PCNSL is rising, particularly in the elderly population. Immunosuppression is a strong risk factor, but most patients with this tumor are apparently immunocompetent. Diagnosis of PCNSL can be challenging. Non-invasive or minimally invasive tests such as ophthalmological evaluation and spinal fluid analysis may be useful, but the majority of patients require tumor biopsy for definitive diagnosis. Our knowledge concerning optimum treatment of PCNSL is fragmentary due to paucity of adequately sized trials. Most patients are now initially treated with high-dose-methotrexate-based chemotherapy alone, as the addition of whole-brain radiotherapy at standard doses has not been shown to increase survival and does increase the risk of neurological toxicity. Ongoing trials are addressing issues such as the roles of reduced-dose radiotherapy, the addition of the CD20 antibody rituximab to chemotherapy, high-dose chemotherapy followed by autologous stem cell transplantation, and maintenance therapy in the primary management of PCNSL.

Therapy and outcomes of primary central nervous system lymphoma in the United States: analysis of the National Cancer Database

Although the role of radiation therapy and chemotherapy in primary central nervous system lymphoma (PCNSL) has evolved considerably over the past decade, the application of treatment modalities in the community has not been evaluated. We analyzed the use of chemotherapy, radiation therapy, and associated overall survival, among 9165 HIV-negative PCSNL cases reported to the US National Cancer Database in 2004-2013. During this time, the proportion of patients receiving chemotherapy significantly increased from 65.6% to 78.8% (P for trend <.0001), whereas the proportion receiving radiation therapy decreased from 37.6% to 18.8% (P < .0001). Adjusting for the varying distribution of clinical and sociodemographic characteristics by type of treating facility, the risk of not receiving chemotherapy was significantly lower in academic/research cancer programs compared with community programs (adjusted relative risk, 0.69; 95% confidence interval [CI], 0.62-0.76; P < .0001). Furthermore, omission of chemotherapy was associated with increasing age, comorbidities, black race, and indicators of poor socioeconomic status. Overall survival at 3 years was 37.7% (95% CI, 36.6-38.8) and ranged from 14.1% for patients treated with radiation therapy alone to 51.8% for those who received multiagent chemotherapy. There was evidence of improved survival over time (P for trend =.0002). The disparities in application of chemotherapy for PCNSL underscore the need to provide access to expert management for this rare disease and improve safe delivery of systemic treatment in the community setting, where most older patients receive their care.

Diffusion-Weighted Imaging for Predicting and Monitoring Primary Central Nervous System Lymphoma Treatment Response

BACKGROUND AND PURPOSE

Whether ADC value predicts the therapy response and outcomes of primary central system lymphoma remains controversial. This study assessed the minimum ADC correlated with treatment response in patients with primary central nervous system lymphoma undergoing methotrexate-based chemotherapy.

MATERIALS AND METHODS

Thirty-five patients with primary central nervous system lymphoma underwent conventional MR imaging and DWI before chemotherapy and after 1 and 5 cycles of chemotherapy. Treatment response was determined according to the International PCNSL Collaborative Group criteria and was classified as a complete response, partial response, or progressive disease. Pretreatment minimum ADC, minimum ADC after 1 cycle, minimum ADC after 5 cycles, and change in minimum ADC were compared among the different response groups. The Pearson correlation test was calculated between these ADC parameters and tumor response.

RESULTS

The pretreatment minimum ADC of the progressive disease group was lower than that of the complete response and partial response groups, but there was no significant difference among them. The minimum ADC after 1 cycle and minimum ADC after 5 cycles were statistically significantly higher than the pretreatment minimum ADC. A comparison among groups showed that minimum ADC after 1 cycle, minimum ADC after 5 cycles, minimum ADC change, and the percentage of minimum ADC change were all significantly different among the 3 groups. A significant positive correlation was observed between the percentage of minimum ADC after 1 cycle of chemotherapy and the size reduction percentage after 5 cycles of chemotherapy. The minimum ADC change and the percentage of minimum ADC change performed better in the differentiation of the final treatment response, specifically in complete response and partial response from progressive disease.

CONCLUSIONS

The minimum ADC after 1 cycle and minimum ADC changes were better correlated with the treatment response than the pretreatment minimum ADC. Minimum ADC after early therapy may potentially to be used to predict and monitor the response of primary central nervous system lymphoma to chemotherapy.

Role of rituximab in treatment of patients with primary central nervous system lymphoma: a retrospective analysis of the Czech lymphoma study group registry

We have investigated whether the addition of rituximab to methotrexate, procarbazine, vincristine, radiotherapy and cytarabine was associated with improved outcome of primary central nervous system lymphomas (PCNSL). Of 164 patients, 49 received rituximab. Median age was 63 years, median Karnofsky performance score (KPS) was 60 and median follow-up of living patients was 59.5 months. 1- and 2-year PFS were 49.7 and 37.9%, 1- and 2-year OS were 57.0 and 45.3%. Median progression-free survival (PFS), but not overall survival (OS) was significantly better for patients treated with rituximab (22.9 vs. 10.9 months, p = 0.037). In multivariate analysis, age ≤70 years and KPS ≥90 were predictive for PFS and OS, rituximab was an independent prognostic factor for PFS only. In landmark analyses, rituximab was not found beneficial for long-term survivors and no group particularly benefited from rituximab. In conclusion, addition of rituximab was associated with improved PFS, but not OS in this unselected cohort of PCNSL patients.