Methotrexate based chemotherapy and deferred radiotherapy for primary central nervous system lymphoma (PCNSL): single institution experience

The risk of venous thromboembolism in primary central nervous system lymphoma: a systematic review and meta-analysis

Primary central nervous system lymphoma (PCNSL) is a rare extranodal lymphoma localized to the central nervous system. Small single-center studies have suggested that patients with PCNSL may be at high risk of venous thromboembolism (VTE). This systematic review aimed to estimate the risk of VTE in patients with PCNSL. A systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. MEDLINE, Embase, and CINAHL were searched from 1990 to 2022. Prospective and retrospective observational studies as well as clinical trials were included. The primary efficacy outcome was VTE, and the primary safety outcome was major bleeding as defined by the individual studies. After screening 883 studies, 46 studies (3688 patients) with PCNSL were included. Mean age was 62.4 years. Five studies explored the use of thromboprophylaxis (acetyl salicylic acid or anticoagulation [n = 1]) and low-molecular-weight heparin (n = 4). Overall, 420 patients developed VTE (11.4%), including 17 fatal events (4% of all VTE). Two studies that reported on VTE prophylaxis representing 77 patients identified 8 breakthrough VTE events (10.4%). Most studies (n = 34; 74.5%) did not report major bleeding complications. Among studies reporting on bleeding, 174 major bleeding (7.4%) events were reported out of 2361 patients, 3 of which were attributed to thromboprophylaxis. Patients with PCNSL seem to be at high risk of both VTE and bleeding complications. Future clinical trials in this population should routinely collect data on incidence of VTE and bleeding to help clinicians assess the risk-to-benefit ratio of thromboprophylaxis in this high-risk patient population.

Response-adapted treatment with upfront high-dose chemotherapy followed by autologous stem-cell transplantation rescue or consolidation phase high-dose methotrexate for primary central nervous system lymphoma: a long-term mono-center study

Treatment regimens for primary central nervous system lymphoma (PCNSL) include high-dose methotrexate (HD-MTX)-based chemotherapy, with or without radiotherapy and are based on studies of selected patient groups. This retrospective study assessed a consistent strategy of response-adapted protocol applied for patients including age >65 years in a cancer center for 10 years longitudinally. Case notes were studied of 61 consecutively treated patients with PCNSL histologically diagnosed between 2003 and 2013. Clinical follow-up during and after treatment included neurologic examination and magnetic resonance imaging. Of the patients studied, 14.8 % (9/61) were clinically unfit for chemotherapy; the remaining 85.2 % (52/61) of patients were treated with HD-MTX. Of these patients, 58 % (30/52) achieved an initial complete response, with a median survival of 100.1 months. Of these response-adapted patients, 33 % (10/30) were <65 years and were treated with upfront high-dose chemotherapy and autologous stem-cell transplantation (HDC-ASCT). The remaining response-adapted patients included 53 % (16/30) who were ≥65 years underwent consolidation with HD-MTX, and 14 % (4/30) who chose radiotherapy. The median survival of patients with HDC-ASCT had not yet been reached compared with 67.6 months for patients with HD-MTX consolidation treatment (p = 0.26). At the end of the study, 75 % (39/52) of patients had died mainly owing to progression or relapse of PCNSL. Multivariate analysis showed that age younger than 65 years (p = 0.02) and complete response for up-front HD-MTX (p = 0.001) were independent prognostic indicators of overall survival. In conclusion, this single-center retrospective clinical study has shown that treatment of PCNSL with upfront HDC-ASCT and consolidation phase HD-MTX monotherapy may be feasible, even for elderly patients in a routine clinical setting, using the three-step selection by eligibility and response to initial HD-MTX, and age threshold of 65 years for ASCT.

The influence of rituximab, high-dose therapy followed by autologous stem cell transplantation, and age in patients with primary CNS lymphoma

For patients with diffuse large B cell lymphoma without the involvement of the CNS, the addition of rituximab to standard chemotherapy has significantly improved survival. In this single-center, retrospective analysis, a total of 81 primary CNS lymphoma (PCNSL) patients treated in our institution between 2000 and 2011 were included. Beside first-line chemotherapy with or without rituximab, we evaluated the impact of age (≤/>60 years), autologous stem cell transplantation (ASCT +/-), and other factors upon overall survival (OS) and progression-free survival (PFS). In patients treated with rituximab (n = 27), 3-year OS was 77.8 % (95 % confidence interval (CI) 62-93 %). In contrast, in patients treated without rituximab (n = 52), 3-year OS was only 39.9 % (CI 27-53 %, Fig. 1). The difference in OS was significant in the univariate (p = 0.002) as well as in the multivariate analysis (p = 0.049, hazard ratio (HR) = 0.248). Patients ≤60 years of age (n = 28) had a 3-year OS of 78.2 % (CI 63-94 %); in patients >60 years (n = 51), 3-year OS was 38.7 % (CI 25-52 %). Patients who received high-dose therapy and ASCT had a 3-year OS of 85.2 % (CI 72-99 %), and 65.1 % were alive up to the time of analysis (range 9-131 months). Without ASCT, median OS was only 16 months (CI 11-21) and 3-year OS was 35.2 % (CI 22-48 %). Age and ASCT were significantly associated with better OS in univariate (p = 0.002 and p < 0.001) as well in multivariate analysis (p = 0.004, HR = 0.023 and p = 0.001, HR = 0.014). Rituximab treatment, ASCT, and age are independent prognostic factors for OS in the first-line treatment of PCNSL.

Combined modality therapy versus chemotherapy alone as an induction regimen for primary central nervous system lymphoma: a cost-effectiveness analysis

BACKGROUND

In immunocompetent patients with primary central nervous system lymphoma (PCNSL), combined modality therapy (CMT) using high-dose methotrexate and radiotherapy (WBRT) has improved response rates compared with chemotherapy alone. The trade-off is delayed and potentially devastating treatment-related neurotoxicity (NT).

METHODS

A cost-effectiveness analysis using a Markov model compared CMT with chemotherapy alone in age-stratified patients with PCNSL. Baseline probabilities were derived from a systematic literature review. Direct and lost productivity costs were collected from a Canadian perspective and presented in Can$ in 2011. Outcomes were life expectancy, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio.

RESULTS

The quality-adjusted life expectancy was 1.55 QALYs for CMT and 1.53 QALYs for chemotherapy alone. In younger patients (aged <60 years), CMT yielded 2.44 QALYs, compared with 1.89 QALYs for chemotherapy alone, yielding an expected benefit with CMT of 0.55 QALYs or 6.6 quality-adjusted months. The CMT strategy dominated in younger patients, as it was Can$11 951 less expensive than chemotherapy alone. The chemotherapy-alone strategy dominated in older patients, as it was Can$11 244 less expensive than CMT, and there was no difference in QALYs between the strategies. The model was robust in sensitivity analyses of key variables tested through the plausible ranges obtained from costing sources and published literature.

CONCLUSION

The preferred induction strategy for younger patients with PCNSL appears to be CMT, which minimized cost while maximizing life expectancy and QALYs. This analysis confirms that the preferred strategy for older patients is chemotherapy alone.

Advantages of dose-dense methotrexate protocol for primary central nervous system lymphoma: comparison of two different protocols at a single institution

The efficacy and toxicity of high-dose methotrexate (HD-MTX)-based chemotherapy were retrospectively reviewed in patients with primary central nervous system lymphoma (PCNSL). All immunocompetent patients with histologically or radiographically diagnosed PCNSL treated between 2006 and 2012 at Niigata University Hospital were enrolled. Thirty-eight patients with a diagnosis of PCNSL were treated with one of two regimens during different time periods. During the first period, from 2006 to 2009, three 3-week cycles of MPV (MTX + procarbazine + vincristine) were administered (MPV3 group). In the second period, from 2010 to 2012, five 2-week cycles of MTX were administered (MTX5 group). High-dose cytarabine was used in both groups following HD-MTX-based chemotherapy. Whole-brain radiotherapy was used for patients who did not attain a complete response (CR) based on magnetic resonance images. In the MPV3 group, 20 out of 23 patients (87%) completed the planned treatment. The CR rate after chemotherapy was 30%, and 57% after radiation therapy. Thirteen out of 15 patients (87%) in the MTX5 group completed the planned treatment. The CR rates after chemotherapy and radiation therapy were 53% and 93%, respectively. Renal dysfunction was assessed by measuring creatinine clearance rates, which were very similar in both groups. In terms of hematologic toxicity and other adverse reactions, there was no significant difference between the two groups. In conclusion, dose-dense MTX chemotherapy improved outcome with acceptable toxicity compared with the treatment schedule for three cycles of MPV treatment.

Combined modality therapy versus chemotherapy alone as an induction regimen for primary central nervous system lymphoma: a decision analysis

In immunocompetent patients with primary central nervous system (CNS) lymphoma, combined modality therapy (CMT) using high-dose methotrexate and whole brain radiotherapy has improved response rates compared to chemotherapy alone. The trade-off is delayed and potentially devastating treatment-related neurotoxicity. A Markov decision-analytic model compared CMT to chemotherapy alone in patients with primary CNS lymphoma. Baseline probabilities were derived from a systematic literature review. Outcomes were life expectancy and quality-adjusted life expectancy. Sensitivity analyses were performed. The life expectancy was 2·69 years for CMT and 2·77 years for chemotherapy alone. The quality-adjusted life expectancies for the two strategies were 1·70 and 1·67 quality-adjusted life years (QALYs) respectively. In younger patients <60 years of age, CMT yielded a quality-adjusted life expectancy of 2·71 QALYs, compared to 2·09 QALYs for chemotherapy alone, yielding an expected benefit with CMT of 0·62 QALYs or 7·4 quality-adjusted months. There was no difference between the strategies in the older group. The model was robust to key variables for the younger group. The preferred induction strategy for younger patients appears to be CMT, maximizing life expectancy, and QALYs. This analysis confirms that the preferred strategy for older patients is chemotherapy alone.

Reduced time for urinary alkalinization before high-dose methotrexate with preadmission oral bicarbonate

Purpose: Hydration and urinary alkalinization are essential for reducing renal dysfunction with high dose methotrexate (HDMTX). This report presents an analysis of institutional methods used to achieve adequate urinary alkalinization and output for patients receiving single agent HDMTX. Renal and metabolic parameters of tolerance were examined.

Methods: Medical records of adult patients receiving HDMTX during the calendar years of 2008–2009 were retrospectively reviewed to determine the time to achieve urine pH > 7. Number of hospital days, bicarbonate dose, ordered hydration rate, urine output, and urine pH were assessed. A survival analysis model was run for time to urine pH > 7 using preadmission oral bicarbonate as a predictor variable and including a frailty term. Observational statistics were performed for other parameters.

Results: The analysis included 79 encounters for ten patients. Urine pH > 7 was achieved more rapidly in patients receiving preadmission oral bicarbonate (P = 0.012). The number of patients receiving HDMTX on the same day as admission was greater for those receiving preadmission oral bicarbonate (47%) in comparison to those who did not (2%), and they spent less time in the hospital. A standard regimen for hydration and urinary alkalinization based on this project is reported. The nature and frequency of adverse events were as expected for this treatment.

Conclusion: At our institution, the time to achieve urinary alkalinization was reduced for patients receiving preadmission oral bicarbonate which facilitated chemotherapy infusion on the same day as admission and decreased the number of calendar days that patients stayed in the hospital.

Factors influencing the response to high dose methotrexate-based vincristine and procarbazine combination chemotherapy for primary central nervous system lymphoma

The authors investigated objective response rate to high dose methotrexate (HDMTX)-based combination chemotherapy in primary central nervous system lymphoma (PCNSL), and sought to identify factors that influence response to HDMTX-based combination therapy. Prospective observational analysis was performed on 52 PCNSL patients. All patients received HDMTX (3.5 g/m(2)) and vincristine (1.4 mg/m(2)/day) for one day during weeks 1, 3, 5, 7, and 9, and procarbazine (100 mg/m(2)/day) for one week during weeks 1, 5, and 9. Forty-one patients (78.8%) achieved complete or partial remission. Higher objective response rates were observed for patients with: 1) age < 60 yr; 2) Eastern Cooperative Oncology Group (ECOG) performance score of < 2; 3) low risk status as defined by the International Extranodal Lymphoma Study Group; 4) p53 positivity; 5) XBP-1 negativity; 6) MUM-1 negativity; and 7) homogenous gadolinium enhancement in MR images. Multivariate analysis showed that ECOG performance score of < 2, low risk, negativity for XBP-1, homogenous gadolinium enhancement by MRI, and response to chemotherapy were associated with longer overall survival. In particular, it is interesting to note that patients with a PCNSL that is homogeneously enhanced by gadolinium have a higher objective response rate, and a longer progression-free survival and overall survival.

Salvage radiotherapy in patients with recurrent or refractory primary or secondary central nervous system lymphoma after methotrexate-based chemotherapy

BACKGROUND

To assess the efficacy of salvage radiation therapy (RT) in patients with recurrent/refractory primary or secondary central nervous system lymphoma (CNSL) after initial methotrexate (MTX)-based chemotherapy and to identify factors associated with treatment outcome.

PATIENTS AND METHODS

We reviewed 36 patients with primary or secondary CNSL who relapsed after MTX therapy and received salvage RT. Primary end points were radiographic response and overall survival (OS).

RESULTS

After salvage RT, 18 patients (50%) achieved a complete radiographic response and 6 (17%) achieved a partial response, for an overall response rate of 67% [95% confidence interval (CI) 49% to 81%]. The median OS from start of salvage RT was 11.7 months (range: 0.6-94.7). Patients treated with less than five cycles of MTX before failure had a significantly shorter OS than patients who received five or more cycles (9.2 months versus not reached, P = 0.04). Patients with CNSL limited to brain only had a significantly longer OS than patients with disease in the brain and other central nervous system locations (16.5 versus 4.5 months, P=0.01).

CONCLUSION

Salvage RT is effective for patients with recurrent/refractory primary or secondary CNSL after initial MTX therapy. Having received five or more cycles of MTX before failure and CNSL limited to the brain at relapse are associated with longer OS.

[Therapeutic management of central nervous system lymphomas in a single hematological institute]

Primary central nervous system lymphoma is defined as an extranodal lymphoma arising in the central nervous system in the absence of systemic disease. Because of their rare occurrence among lymphomas, optimal treatment could hardly be established.

AIMS

In this retrospective survey we analyzed the result of combined treatment (systemic and intrathecal chemotherapy followed by consolidation radiotherapy) in patients with primary or relapsed central nervous system lymphomas diagnosed and treated in our hematological department between 1998-2009.

PATIENTS AND METHODS

During this period (mean follow-up of 13.2 months) from 427 patients with newly diagnosed non-Hodgkin's lymphomas, 22 primary central nervous system lymphoma was diagnosed (5.15%, 16 cerebral and 6 spinal cord lymphoma cases). Significant male predominance (14:8) was registered with an age distribution of 34-77 years (mean = 60.7, median = 64 years). No patients were immunocompromised. All central nervous system lymphoma specimens taken with neurosurgical resection or stereotaxic biopsies were confirmed histopathologically. All cerebral lymphoma cases proved to be diffuse large B-cell of origin, while in epidural lymphomas low grade subtypes also occurred. Epidural lymphomas were treated with local radiotherapy (30-40 Gy), except for patients with follicular lymphomas getting rituximab-containing polychemotherapy (R + CHOP regimen) before irradiation. In cerebral lymphoma (every patients had supratentorial localization) the following combined therapy protocol was used: up to three courses of high dose methotrexate (HD MTX 3g/m 2 in a single dose for 4 hours lasting drop-infusion) were given at 4-week intervals, followed by leucovorin-rescue 24 hours after MTX infusion. Intrathecal combination of methotrexate, cytosin-arabinosid and dexamethasone was given three times after HD MTX infusion. In complete response after chemotherapy (evaluated by cranial MRI or CT, PET/CT), whole-brain irradiation was used in a total dose of 30 Gy. In case of partial response, boost irradiation for the tumor bed was also given. In relapse or resistant cases, salvage regimen was applied: HD MTX course combined with high dose cytosin-arabinosid (HD Ara-C) 3g/m 2 /dose b.i.d. over 4 h c.i., repeated in three cycles every four weeks.

RESULTS

Complete remission has been achieved in 9 patients with cerebral and in 4 patients with spinal cord lymphoma (13/22; 59.0%), however, one relapsed patient became resistant and later expired, despite salvage therapy. Primarily 9 patients were not evaluable for response: 5 received only one or two HD MTX because of side effects, 4 patients died due to progression of the disease. Mean of the overall survival (OS) in cerebral lymphoma was 19.5 (3-46, median of 10) months, in epidural group 14.1 (2-76, median of 5) months, whilst mean time to progression (TTP) was 4.5 (2-6.5, median of 4 months). The 2-year survival for all patients was 50%. Acute toxicity of chemotherapy was usually hematological, moreover, in 8 patients impaired renal function and sepsis developed. No serious adverse effect of radiotherapy could be detected.

CONCLUSION

In primary central nervous system lymphoma, basic treatment HD methotrexate together with intrathecal combination of methotrexate + cytosin-arabinosid + dexamethasone followed by whole-brain irradiation of at least 30 Gy could produce a medium response rate in our study. In case of relapse or progression, other salvage regimens containing HD Ara-C alternating with HD MTX could reduce the treatment failure, as well. After therapy PET/CT was negative in five patients with prolonged disease-free survival.