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Liu Z, Zhuang J, Wei L, Lu A, Hou J, Yang X. A Systematic Review of Cognitive Function, Anxiety, and Depression in Patients With Newly Diagnosed Primary Central Nervous System Lymphoma. Biol Res Nurs 2024; 26:56-67. [PMID: 37540088 DOI: 10.1177/10998004231190073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
OBJECTIVE To retrospectively analyze the effects of different treatments on cognitive functioning, anxiety, and depression in patients with primary central nervous system lymphoma (PCNSL). METHODS A comprehensive literature search was conducted in multiple databases including the Cochrane Library, CINAHL, PubMed, Web of Science, EMBASE, Sino Med, Wei Pu, Wan Fang, CNKI, and Google Scholar. The search included studies published through June 20, 2023, focusing on cognitive function, anxiety, and depression in adult patients newly diagnosed with PCNSL. Various measurement tools and scales were used to assess the primary outcomes. Descriptive systematic reviews were conducted to integrate the literature and summarize the effects of different treatment modalities on cognitive functioning, anxiety, and depression in PCNSL patients. This review was registered with PROSPERO (CRD42022370250). RESULTS A total of 43 studies were included. Induction chemotherapy was associated with improved cognitive function and reduced anxiety and depression in the majority of patients. Whole-brain radiotherapy (WBRT) was found to lead to cognitive impairment, particularly in executive, attention, memory, and motor function. Low-dose WBRT, autologous stem cell transplantation (ASCT), and blood-brain barrier disruption (BBBD) treatments did not result in significant cognitive impairment. Anxiety and depression were observed to decrease over the long term. CONCLUSIONS Overall, the cognitive functioning, anxiety, and depression of patients with PCNSL can be improved with appropriate treatments. However, patients treated with WBRT are at a higher risk of cognitive decline compared to those receiving other treatment modalities. Therefore, special attention should be given to patients undergoing WBRT, and a comprehensive analysis should be conducted to reduce neurotoxicity and address early cognitive problems in these patients.
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Affiliation(s)
- Ziyu Liu
- School of Nursing, Fudan University, Shanghai, China
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jingming Zhuang
- Department of Urology, School of Medicine, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Li Wei
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai, China
| | - Aiwen Lu
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jiangang Hou
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaoli Yang
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai, China
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Sun X, Lv L, Wu Y, Cui Q, Sun S, Ji N, Liu Y. Challenges in the management of primary central nervous system lymphoma. Crit Rev Oncol Hematol 2023:104042. [PMID: 37277008 DOI: 10.1016/j.critrevonc.2023.104042] [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: 09/08/2022] [Revised: 03/24/2023] [Accepted: 05/30/2023] [Indexed: 06/07/2023] Open
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare extranodal non-Hodgkin lymphoma. Stereotactic biopsy remains the gold standard for the pathological diagnosis of PCNSL. However, certain new auxiliary diagnostic methods are considered to have good application prospects; these include cytokine and tumor circulating DNA, among others. Although new drugs such as immunomodulators, immune checkpoint inhibitors, chimeric antigen receptor T-cells, and Bruton tyrosine kinase inhibitors have brought hope owing to their improved efficacy, the high recurrence rate and subsequent high mortality remain barriers to long-term survival. Increasing emphasis is therefore being placed on consolidation treatments. Consolidation treatment strategies include whole brain radiotherapy, autologous hematopoietic stem cell transplantation, and non-myeloablative chemotherapy. As studies directly comparing the effectiveness and safety of different consolidation treatment schemes are lacking, the optimal consolidation strategy remains uncertain. This article will review the diagnosis and treatment of PCNSL, focusing on the progress in research pertaining to consolidation therapy.
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Affiliation(s)
- Xuefei Sun
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liwei Lv
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuchen Wu
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qu Cui
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shengjun Sun
- Neuroimaging Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Nan Ji
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuanbo Liu
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Wu SY, Braunstein SE, Rubenstein JL, Sneed PK. Stereotactic Radiosurgery for Primary Central Nervous System Lymphoma. Cureus 2023; 15:e34817. [PMID: 36915845 PMCID: PMC10008121 DOI: 10.7759/cureus.34817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2023] [Indexed: 02/11/2023] Open
Abstract
Background Primary central nervous system lymphoma (PCNSL) is rare, with a treatment backbone that typically includes high-dose methotrexate-based chemotherapy, with radiation often reserved for persistent or progressive disease. In this study, we report the outcomes of stereotactic radiosurgery (SRS) in patients with PCNSL to potentially defer whole brain radiotherapy (WBRT) or as salvage after WBRT. Methodology We performed a single-institution, retrospective review of 20 patients with PCNSL who received single-fraction or fractionated SRS to 32 lesions between September 1992 and July 2019. Results The median age at SRS was 67 years (interquartile range (IQR) = 56-74 years). The median Karnofsky Performance Status (KPS) at SRS was 80 (IQR = 50-80). In total, 18 (90%) patients received methotrexate-based chemotherapy prior to SRS, with a median of eight cycles (IQR = 5-10). A total of 10 patients received SRS for recurrent disease after chemotherapy and/or WBRT, nine patients received SRS for the persistent disease after chemotherapy alone, and one patient received up-front SRS. Overall, five patients received SRS following WBRT. The median SRS dose was 16 Gy (IQR = 14-22.5 Gy) in one fraction (IQR = 1-5 fractions). Eight patients (40%) were treated with consolidative pomalidomide or lenalidomide following SRS. The local control rate was 100% (32/32 lesions at a median follow-up of 15 months). In total, 13 of 16 (81%) patients with available follow-up experienced distant brain recurrence. The median time to distant failure following SRS was 10 months (IQR = 1-16 months). Three patients received salvage SRS, and three patients received salvage WBRT. The median overall survival from diagnosis was 39 months (95% confidence interval = 24-54 months). KPS at the time of SRS was significantly correlated with time to progression (p = 0.002). The use of lenalidomide or pomalidomide after SRS was associated with improved overall survival after SRS (three vs. 14 months, p = 0.035). Consolidative etoposide and cytarabine after initial methotrexate-based chemotherapy was also associated with improved survival following SRS (eight vs. 47 months, p = 0.028). Conclusions SRS offers effective local tumor control for patients with PCNSL; however, the majority of patients experience distant progression. SRS may have a role in the salvage setting for patients with recurrence after WBRT, or allow deferral of WBRT in select patients, although systemic therapy appears to strongly influence outcomes in this cohort.
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Affiliation(s)
- Susan Y Wu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California San Francisco, San Francisco, USA
| | - James L Rubenstein
- Department of Medicine, University of California San Francisco, San Francisco, USA
| | - Penny K Sneed
- Department of Radiation Oncology, University of California San Francisco, San Francisco, USA
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Manickam Gurusamy V, Raveendran Divakar S, Halsnad Chandramouli S, Kunheri B, Hussain Al-Abdulla H, Shaikh G, Chaudary Apsani R, Riyaz Poolakundan M, Caparrotti P, Wafiq Hammoud R, Al-Hammadi N. The role of radiotherapy in newly diagnosed primary CNS lymphoma: A descriptive review and a pragmatic approach to clinical practice. Clin Transl Radiat Oncol 2022; 39:100559. [PMID: 36590826 PMCID: PMC9800264 DOI: 10.1016/j.ctro.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 12/06/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022] Open
Abstract
Earlier, prior to the development of effective systemic therapy, monotherapy with whole-brain radiotherapy (WBRT) was widely used to treat primary central nervous system lymphoma (PCNSL). Recently, chemotherapy, especially with high dose methotrexate (HDMTX), has largely replaced WBRT as upfront treatment, and the most accepted standard of care is induction with a combination drug therapy followed by consolidation therapy with either autologous stem-cell transplantation (ASCT) or radiation. Whilst WBRT is an effective component of treatment, it is occasionally associated with risk of permanent, irreversible neurotoxicity when doses of more than 30 Gy are used. Hence, there has been a strong focus on the optimization of radiotherapy (RT) which includes dose reduction in the consolidation phase. In this comprehensive review, we have summarized the progress on clinical results and evidence considering the role and use of radiation including combined treatment modalities, low-dose radiotherapy, and neurotoxicity. Finally, we present a practical approach to low-dose WBRT and boosting higher doses to the gross tumor that can be integrated into clinical practice.
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Reduced-dose WBRT as consolidation treatment for patients with primary CNS lymphoma: a LOC-network study. Blood Adv 2022; 6:4807-4815. [PMID: 35772168 PMCID: PMC9631661 DOI: 10.1182/bloodadvances.2022007011] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 06/07/2022] [Indexed: 11/21/2022] Open
Abstract
After consolidation rdWBRT in a subset of patients, most of the patients exhibited sustained or improved cognitive function. rdWBRT should be considered a strong consolidation treatment for PCNSL in patients aged <60 years showing CR after induction chemotherapy.
The optimal consolidation strategy for primary central nervous system lymphoma (PCNSL) remains controversial. Preventing radio-induced neurotoxicity of consolidation treatment through reduced-dose whole-brain radiotherapy (rdWBRT) at a dose of 23.4 Gy is an interesting alternative to conventional WBRT in patients aged <60 years. From the LOC Network (Network for Oculo-cerebral Lymphomas) database, we retrospectively selected patients with PCNSL aged <60 years who showed complete (CR) or unconfirmed CR after high-dose methotrexate–based chemotherapy and had received consolidation rdWBRT as the first-line treatment. If available, prospective neuropsychological follow-ups were reported. Twenty-nine patients diagnosed between 2013 and 2018 met the study selection criteria. Nine (31%) patients experienced relapse during the follow-up, with a median time from radiotherapy to recurrence of 8.7 months (interquartile range, 4-11.5). Five of those patients received salvage treatment and consolidation with intensive chemotherapy and autologous stem cell transplantation. Progression-free survival rates were 89% (95% confidence interval [CI] 79%-100%), 72% (95% CI, 56%-88%), and 69% (95% CI, 52%-85%) at 1, 2, and 5 years, respectively. Overall survival rates were 100%, 89% (95% CI, 79%-100%), and 86% (95% CI, 74%-99%) at 1, 2, and 5 years, respectively, and were consistent with those observed for standard-dose WBRT (sdWBRT). No prognostic factor was identified. The results of the 36-month neuropsychological follow-up for a subset of patients appeared reassuring, with most patients exhibiting maintenance of or improvements in their baseline conditions. Our results, combined with phase 2 study results, support the use of rdWBRT instead of sdWBRT as a consolidation treatment in <60-year-old patients showing CR after induction treatment.
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Suzuki Y, Imoto N, Ishihara S, Fujiwara S, Ito R, Sakai T, Yamamoto S, Sugiura I, Kurahashi S. A Retrospective Analysis of R-MPV Plus Response-adapted Whole-brain Radiotherapy for Elderly Patients with Primary Central Nervous System Lymphoma. Intern Med 2022; 61:1345-1352. [PMID: 34670884 PMCID: PMC9152862 DOI: 10.2169/internalmedicine.7805-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective Few reports have described the real-world outcomes of rituximab, methotrexate (MTX), procarbazine, and vincristine (R-MPV) plus response-adapted whole-brain radiotherapy (WBRT) for elderly patients with primary central nervous system lymphoma (PCNSL). We evaluated the outcome of this regimen. Methods We evaluated >60-year-old patients with newly diagnosed PCNSL who received R-MPV plus WBRT from January 2010 to December 2019 at Toyohashi Municipal Hospital. The patients' characteristics, regimen enforcement, response rate, survival, and toxicity were analyzed. Patients Ten patients were consecutively enrolled. Their median age was 69 years old, and 60% had a performance status of 3 or 4 before induction therapy. Results Seven patients achieved a complete response after induction, and all 10 patients achieved a complete response after consolidation. Seven received reduced-dose WBRT at 23.4 Gy, and 2 received WBRT at 45 Gy. The median follow-up was 44.4 months; the 3-year progression-free survival and overall survival rates were 60% and 80%, respectively; and the cumulative incidence of relapse was 40%. The incidence of symptomatic delayed neurotoxicity was 70%. Of the 7 patients who received reduced-dose WBRT, 4 (57%) developed delayed neurotoxicity, including 1 severely affected patient. Only one patient survived without relapse and delayed neurotoxicity. The ratio of patients who developed relapse or delayed neurotoxicity that impaired daily life was 33% and 100% in the MTX high- and low-intensity groups, respectively. Conclusion This regimen in elderly patients is unsatisfactory because of delayed neurotoxicity. We should consider maintaining an adequate MTX intensity, postponing or minimizing WBRT, and choosing high-dose consolidation therapy for select patients.
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Affiliation(s)
- Yutaro Suzuki
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Japan
| | - Naoto Imoto
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Japan
| | | | - Shinji Fujiwara
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Japan
| | - Rie Ito
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Japan
| | - Toshiyasu Sakai
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Japan
| | - Satomi Yamamoto
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Japan
| | - Isamu Sugiura
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Japan
| | - Shingo Kurahashi
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Japan
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Tang D, Chen Y, Shi Y, Tao H, Tao S, Zhang Q, Ding B, He Z, Yu L, Wang C. Epidemiologic Characteristics, Prognostic Factors, and Treatment Outcomes in Primary Central Nervous System Lymphoma: A SEER-Based Study. Front Oncol 2022; 12:817043. [PMID: 35223498 PMCID: PMC8867087 DOI: 10.3389/fonc.2022.817043] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/18/2022] [Indexed: 11/20/2022] Open
Abstract
Objective This study was conducted in order to study the clinical characteristics, prognostic factors, and treatment outcomes in patients with primary central nervous system lymphoma (PCNSL). Materials and Methods The data of a total of 5,166 PCNSL patients diagnosed between 2000 and 2018 from the Surveillance, Epidemiology, and End Results (SEER) database were obtained. Results The mean age was 63.1 ± 14.9 years, with a male to female ratio of 1.1:1.0. The most common histologic subtype was diffuse large B-cell lymphoma (DLBCL) (84.6%). The 1-, 3-, and 5-year overall survival (OS) rates were 50.1%, 36.0%, and 27.2%, respectively, and the corresponding disease-specific survival (DSS) rates were 54.4%, 41.3%, and 33.5%, respectively. Multivariate analysis with Cox regression showed that race, sex, age, marital status, surgical resection, and chemotherapy were independent prognostic factors for OS and DSS, but radiotherapy was only for OS. Nomograms specially for DLBCL were established to predict the possibility of OS and DSS. The concordance index (C-index) values of OS and DSS were 0.704 (95% CI 0.687–0.721) and 0.698 (95% CI 0.679–0.717), suggesting the high discrimination ability of the nomograms. Conclusion Surgical resection and/or chemotherapy was favorably associated with better OS and DSS. However, radiotherapy was not beneficial for OS and DSS in the long term. A new predictive nomogram and a web-based survival rate calculator we developed showed favorable applicability and accuracy to predict the long-term OS for DLBCL patients specifically.
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Affiliation(s)
- Dongsheng Tang
- Department of Hematology, The Huaian Clinical College of Xuzhou Medical University, Huai'an, China
| | - Yue Chen
- Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, China
| | - Yuye Shi
- Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, China
| | - Hong Tao
- Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, China
| | - Shandong Tao
- Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, China
| | - Quan'e Zhang
- Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, China
| | - Banghe Ding
- Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, China
| | - Zhengmei He
- Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, China
| | - Liang Yu
- Department of Hematology, The Huaian Clinical College of Xuzhou Medical University, Huai'an, China.,Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, China
| | - Chunling Wang
- Department of Hematology, The Huaian Clinical College of Xuzhou Medical University, Huai'an, China.,Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, China
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Steffanoni S, Calimeri T, Anzalone N, Mastaglio S, Bernardi M, Ferreri AJ. A narrative review of consolidation strategies for young and fit patients with newly-diagnosed primary central nervous system lymphoma. Expert Rev Hematol 2021; 15:33-43. [PMID: 34904506 DOI: 10.1080/17474086.2022.2018297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION The modern treatment of patients with primary central nervous system lymphoma (PCNSL) consists of two phases: induction, currently represented by a high-dose-methotrexate-based polychemotherapy, and consolidation. The optimal consolidation therapy has not been defined yet, but several strategies, such as whole-brain radiotherapy (WBRT), high-dose chemotherapy supported by autologous stem cell transplantation (HDC/ASCT) or non-myeloablative chemotherapy, have been addressed in important randomized trials. AREAS COVERED This review provides an overview of the current role of consolidation strategies in young and fit patients with newly-diagnosed PCNSL. Publications in English language, peer-reviewed, from high-quality international journals, edited from 2003 to 2021 were identified on PubMed. EXPERT OPINION Consolidation treatment significantly improved outcomes of PCNSL. Radiotherapy had represented for years the only choice in the consolidation therapy, but large randomized trials have demonstrated that HDC/ASCT is equally effective and associated with lower neurotoxicity risk in patients younger than 65-70 years. Encouraging results have been obtained using reduced-dose WBRT, while a recent randomized trial failed to demonstrate that consolidation with non-myeloablative chemotherapy is more effective than HDC/ASCT in PCNSL patients. A personalized consolidation treatment, driven also by a response prediction model based on radiological and molecular details, may improve the management of PCNSL patients.
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Affiliation(s)
- Sara Steffanoni
- Department of Medicine, Division of Hematology, Valduce Hospital, Como, Italy
| | - Teresa Calimeri
- Lymphoma Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicoletta Anzalone
- Neuroradiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Sara Mastaglio
- Hematology and BMT Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Bernardi
- Hematology and BMT Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrés Jm Ferreri
- Lymphoma Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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9
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Martinez-Calle N, Isbell LK, Cwynarski K, Schorb E. Advances in treatment of elderly primary central nervous system lymphoma. Br J Haematol 2021; 196:473-487. [PMID: 34448202 DOI: 10.1111/bjh.17799] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The management of older individuals (≥60 years) with primary central nervous system lymphoma remains a clinical challenge. Identification of optimal therapy and delivering adequate dose intensity are two of the major issues in treating elderly patients. Premorbid performance status and comorbidities influence individualised treatment approaches and geriatric assessment tools are increasingly utilised. Optimal induction treatment remains high-dose methotrexate-based immunochemotherapy, delivery is feasible in the majority of patients and the goal of treatment remains achieving complete remission. Consolidation strategies are also relevant in the elderly, aiming to maximise duration of response and quality of life (QoL). Potential options include high-dose therapy with haematopoietic stem cell consolidation, non-myeloablative chemotherapy and whole-brain radiotherapy. Efficacy of novel agents, such as Bruton tyrosine kinase inhibitors and lenalidomide, have been reported; these represent an alternative for elderly patients unfit for chemotherapy. Prognosis remains poor, improvement of outcomes in this age group is urgently needed.
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Affiliation(s)
- Nicolas Martinez-Calle
- Clinical Haematology Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Lisa K Isbell
- Department of Haematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kate Cwynarski
- Department of Haematology, University College Hospital, London, UK
| | - Elisabeth Schorb
- Department of Haematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Kim N, Lim DH, Yoon SE, Kim SJ, Kim WS. Role of 23.4 Gy upfront whole-brain radiation therapy following high-dose methotrexate for primary central nervous system lymphoma: a comparative analysis of whole-brain radiation therapy versus no radiation therapy. J Neurooncol 2021; 154:207-217. [PMID: 34331673 DOI: 10.1007/s11060-021-03815-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 07/27/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION We aimed to investigate the role of upfront whole-brain radiation therapy (RT), with a reduced dose of 23.4 Gy, following high-dose methotrexate (HD-MTX) in patients with primary central nervous system lymphoma (PCNSL). METHODS We retrospectively reviewed 185 patients with PCNSL treated with HD-MTX between January 2013 and January 2020; 145 patients underwent no RT and 40 patients underwent upfront RT. Using propensity score matching (PSM) to adjust for clinical factors, 40 patients were selected from each treatment group. Event-free survival (EFS) and overall survival (OS) were compared between treatment groups. RESULTS At baseline, patients in the upfront RT group were younger, had higher LDH levels, received less frequent rituximab and stem cell transplantation than those in the no-RT group. Patients in the upfront RT group also showed a lower response rate after initial HD-MTX than those in the no-RT group (73% vs. 88%, p = 0.038). The median follow-up was 25.1 (interquartile range 13.7-43.0) months. Comparable 2-year EFS and OS rates were observed between the upfront RT and no-RT groups (56.6% vs. 53.8%, p = 0.170; and 81.7% vs. 75.3%, p = 0.097, respectively). Upfront RT was related to improved EFS and OS in patients with stable disease or progressive disease after HD-MTX, but not in patients with complete or partial response after HD-MTX. Upfront RT was also an independent predictor of EFS and OS in the PSM cohort. The cumulative incidences of treatment-related neurotoxicity at 3 years were 20.2% and 21.2% in the upfront RT and no-RT groups, respectively (p = 0.630). CONCLUSIONS Upfront RT with a reduced dose of 23.4 Gy, showed favorable outcomes in patients with stable disease or progressive disease after initial HD-MTX. In addition, upfront RT appears to be an effective treatment for PCNSL when rituximab or stem cell transplantation is not feasible.
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Affiliation(s)
- Nalee Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Do Hoon Lim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
| | - Sang Eun Yoon
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Seok Jin Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Won Seog Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
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11
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Schaff LR, Ambady P, Doolittle ND, Grommes C. Primary central nervous system lymphoma: a narrative review of ongoing clinical trials and goals for future studies. ACTA ACUST UNITED AC 2021; 5. [PMID: 33912868 PMCID: PMC8078860 DOI: 10.21037/aol-20-47] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare disease of the brain, spine, cerebrospinal fluid (CSF) and/or vitreoretinal space. PCNSL is chemo and radiosensitive but relapse is common even years after initial treatment. Outside of consensus regarding the use of high-dose methotrexate (HD-MTX) for first line treatment, there is little uniformity in the management of newly diagnosed or relapsed PCNSL. The lack of consensus is driven by a paucity of randomized trials in this disease. Prospective studies are troubled by low enrollment, the lack of a standard induction regimen, and a varied approach to consolidation strategies. Moreover, the PCNSL patient population is heterogeneous and includes a high proportion of elderly or frail patients and consists of patients manifesting disease in varied compartments of the central nervous system (CNS). As a result, current treatment strategies vary widely and are often dictated by physician and institutional preference or regional practice. This review provides an overview of recently completed and ongoing therapeutic studies for patients with newly diagnosed and recurrent or refractory PCNSL. It discusses the existing evidence behind common approaches to induction and consolidation or maintenance regimens as well as the recent data regarding management of recurrent disease. Finally, it highlights the complexity of trial design in this disease and provides a framework for the design of future studies, which are needed to identify patient populations likely to benefit from specific induction, consolidation, or maintenance therapies.
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Affiliation(s)
- Lauren R Schaff
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Prakash Ambady
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | - Nancy D Doolittle
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | - Christian Grommes
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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12
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Yu J, Du H, Ye X, Zhang L, Xiao H. High-dose methotrexate-based regimens and post-remission consolidation for treatment of newly diagnosed primary CNS lymphoma: meta-analysis of clinical trials. Sci Rep 2021; 11:2125. [PMID: 33483528 PMCID: PMC7822904 DOI: 10.1038/s41598-020-80724-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 12/22/2020] [Indexed: 11/09/2022] Open
Abstract
With the exception of high-dose methotrexate (HD-MTX), there is currently no defined standard treatment for newly diagnosed primary central nervous system lymphoma (PCNSL). This review focused on first-line induction and consolidation treatment of PCNSL and aimed to determine the optimal combination of HD-MTX and the long-term beneficial consolidation methods. A comprehensive literature search of MEDLINE identified 1407 studies, among which 31 studies met the inclusion criteria. The meta-analysis was performed by using Stata SE version 15. Forest plots were generated to report combined outcomes like the complete response rate (CRR), overall survival, and progression-free survival. We also conducted univariate regression analyses of the baseline characteristics to identify the source of heterogeneity. Pooled analysis showed a CRR of 41% across all HD-MTX-based regimens, and three- and four-drug regimens had better CRRs than HD-MTX monotherapy. In all combinations based on HD-MTX, the HD-MTX + procarbazine + vincristine (MPV) regimen showed pooled CRRs of 63% and 58% with and without rituximab, respectively, followed by the rituximab + HD-MTX + temozolomide regimen, which showed a pooled CRR of 60%. Pooled PFS and OS showed that post-remission consolidation with autologous stem cell transplantation (ASCT) was associated with the best survival outcome, with a pooled 2-year OS of 80%, a 2-year PFS of 74%, a 5-year OS of 77%, and a 5-year PFS of 63%. Next, whole-brain radiation therapy (WBRT) + chemotherapy showed a pooled 2-year OS of 72%, 2-year PFS of 56%, 5-year OS of 55%, and 5-year PFS of 41%, with no detectable CR heterogeneity throughout the entire treatment process. In HD-MTX-based therapy of newly diagnosed PCNSL, MPV with or without rituximab can be chosen as the inductive regimen, and the rituximab + HD-MTX + temozolomide regimen is also a practical choice. Based on our study, high-dose chemotherapy supported by ASCT is an efficacious approach for consolidation. Consolidation with WBRT + chemotherapy can be another feasible approach.
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Affiliation(s)
- Junyao Yu
- Department of Hematology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 3 Qingchun East Rd., Hangzhou, 310016, Zhejiang Province, People's Republic of China
| | - Huaping Du
- Department of Hematology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 3 Qingchun East Rd., Hangzhou, 310016, Zhejiang Province, People's Republic of China
| | - Xueshi Ye
- Department of Hematology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 3 Qingchun East Rd., Hangzhou, 310016, Zhejiang Province, People's Republic of China
| | - Lifei Zhang
- Department of Hematology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 3 Qingchun East Rd., Hangzhou, 310016, Zhejiang Province, People's Republic of China
| | - Haowen Xiao
- Department of Hematology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 3 Qingchun East Rd., Hangzhou, 310016, Zhejiang Province, People's Republic of China.
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Iorio-Morin C, Gahide G, Morin C, Vanderweyen D, Roy MA, St-Pierre I, Massicotte-Tisluck K, Fortin D. Management of Primary Central Nervous System Lymphoma Using Intra-Arterial Chemotherapy With Osmotic Blood-Brain Barrier Disruption: Retrospective Analysis of the Sherbrooke Cohort. Front Oncol 2021; 10:543648. [PMID: 33552946 PMCID: PMC7855856 DOI: 10.3389/fonc.2020.543648] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 11/25/2020] [Indexed: 12/16/2022] Open
Abstract
Background Primary central nervous system lymphomas (PCNSL) are rare and aggressive CNS tumors. Current management involves high-dose methotrexate (HD-MTX) typically administered intravenously (IV), despite the existence of the blood-brain barrier (BBB), which significantly decreases its bioavailability. Cerebral intra-arterial chemotherapy (CIAC) coupled with osmotic BBB disruption (OBBBD) can theoretically circumvent this issue. Methods We performed a retrospective analysis of patients with newly diagnosed PCNSL treated with HD-MTX-based CIAC+OBBBD at our center between November 1999 and May 2018. OBBBD was achieved using a 25% mannitol intra-arterial infusion. Patients were followed clinically and radiologically every month until death or remission. Demographics, clinical and outcome data were collected from the medical record. All imaging studies were reviewed for evidence of complication and outcome assessment. Kaplan-Meier analyses were used to compute remission, progression-free survival (PFS) as well as overall survival times. Subgroup analyses were performed using the log rank test. Results Forty-four patients were included in the cohort. Median follow-up was 38 months. Complete response was achieved in 34 patients (79%) at a median of 7.3 months. Actuarial median survival and PFS were 45 months and 24 months, respectively. Age, ECOG and lesion location did not impact outcome. Complications included thrombocytopenia (39%), neutropenia (20%), anemia (5%), seizures (11%), stroke (2%), and others (20%). Conclusion CIAC using HD-MTX-based protocols with OBBBD is a safe and well-tolerated procedure for the management of PCNSL. Our data suggests better PFS and survival outcomes compared to IV protocols with less hematologic toxicity and good tolerability, especially in the elderly.
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Affiliation(s)
- Christian Iorio-Morin
- Division of Neurosurgery, Department of Surgery, Université de Sherbrooke, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Gérald Gahide
- Department of Diagnostic Radiology, Université de Sherbrooke, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Christophe Morin
- Division of Neurosurgery, Department of Surgery, Université de Sherbrooke, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Davy Vanderweyen
- Division of Neurosurgery, Department of Surgery, Université de Sherbrooke, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Marie-André Roy
- Division of Neurosurgery, Department of Surgery, Université de Sherbrooke, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Isabelle St-Pierre
- Division of Neurosurgery, Department of Surgery, Université de Sherbrooke, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Karine Massicotte-Tisluck
- Department of Diagnostic Radiology, Université de Sherbrooke, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - David Fortin
- Division of Neurosurgery, Department of Surgery, Université de Sherbrooke, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
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Franca RA, Travaglino A, Varricchio S, Russo D, Picardi M, Pane F, Pace M, Del Basso De Caro M, Mascolo M. HIV prevalence in primary central nervous system lymphoma: A systematic review and meta-analysis. Pathol Res Pract 2020; 216:153192. [PMID: 32956921 DOI: 10.1016/j.prp.2020.153192] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 08/22/2020] [Accepted: 08/25/2020] [Indexed: 12/30/2022]
Abstract
HIV infection is considered a major risk factor for primary central nervous system lymphoma (PCNSL). However, the percentage of PCNSL that occurs in HIV + patients is not well defined. We aimed to assess the prevalence of HIV infection in patients with PCNSL through a systematic review and meta-analysis. Electronic databases were searched for studies assessing the presence of HIV infection in series of patients with PCNSL. Pooled prevalence of HIV infection in PCNSL was calculated, with a subgroup analysis based on the geographic area. Twenty-seven studies with 6422 patients were included. Overall, pooled prevalence of HIV infection among PCNSL patients was 6.1 % with high heterogeneity. In the subgroup analysis, pooled prevalence was 3.6 % in India with low heterogeneity, 30.2 % (overall) and 16.5 % (after 2000) in the USA with high heterogeneity, 5.7 % in Europe with high heterogeneity, 2.2 % in East Asia with null heterogeneity, 7.3 % in South America with moderate heterogeneity. In conclusion, only a minor part of PCNSL occurs in patients with HIV. The results stratified by geographic area reflect the different prevalence of HIV infection in the general population, except for India, probably due to the shorter life expectancy of HIV + patients.
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Affiliation(s)
- Raduan Ahmed Franca
- Department of Advanced Biomedical Sciences, Pathology Section, Federico II University of Naples, Naples, Italy
| | - Antonio Travaglino
- Department of Advanced Biomedical Sciences, Pathology Section, Federico II University of Naples, Naples, Italy
| | - Silvia Varricchio
- Department of Advanced Biomedical Sciences, Pathology Section, Federico II University of Naples, Naples, Italy
| | - Daniela Russo
- Department of Advanced Biomedical Sciences, Pathology Section, Federico II University of Naples, Naples, Italy
| | - Marco Picardi
- Department of Clinical Medicine and Surgery, Hematology Section, Federico II University of Naples, Naples, Italy
| | - Fabrizio Pane
- Department of Clinical Medicine and Surgery, Hematology Section, Federico II University of Naples, Naples, Italy
| | - Mirella Pace
- Department of Advanced Biomedical Sciences, Pathology Section, Federico II University of Naples, Naples, Italy
| | | | - Massimo Mascolo
- Department of Advanced Biomedical Sciences, Pathology Section, Federico II University of Naples, Naples, Italy.
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Zheng X, Yang S, Chen F, Wu S, Li W. The Efficacy and Safety of Cytarabine on Newly Diagnosed Primary Central Nervous System Lymphoma: A Systematic Review and Meta-Analysis. Front Oncol 2020; 10:1213. [PMID: 32903796 PMCID: PMC7438862 DOI: 10.3389/fonc.2020.01213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/15/2020] [Indexed: 02/03/2023] Open
Abstract
Background: The role of cytarabine on newly diagnosed primary central nervous system lymphoma (PCNSL) remains controversial. The present study mainly aimed to assess the efficacy and safety of cytarabine in the induction treatment of PCNSL. Methods: We systematically searched PubMed, Embase, and the Cochrane library for randomized controlled trials comparing treatment of PCNSL patients with or without cytarabine. A meta-analysis was conducted to compare the odds ratios (ORs) with corresponding 95% confidence intervals (95% CI) for complete remission (CR) rate, overall response rate (ORR), grade 3–4 toxic effects, hazard ratios (HRs) with 95% CIs for progression-free survival (PFS), and overall survival (OS) using Stata 12.0. Results: In total, three randomized clinical trials were analyzed in this study. The result of our statistical analysis demonstrated that the application of cytarabine was closely correlated with a higher CR (OR: 2.27, 95% CI: 1.29–3.99, P < 0.01) and ORR (OR: 2.11, 95% CI: 1.14–3.93, P = 0.02). No significant difference was found in OS (HR: 0.75, 95% CI: 0.50–1.13, P = 0.17), but PFS had been improved (HR: 0.66, 95% CI: 0.45–0.97, P = 0.04) when cytarabine was added to the treatment regimen. The grade 3–4 side effect rate of the cytarabine group was higher (overall OR: 2.95, 95% CI: 1.37–6.34, P < 0.01) than that of the cytarabine-free group. Conclusions: This meta-analysis verifies that adding cytarabine to the therapeutic regimen is helpful for newly diagnosed PCNSL patients in terms of CR, ORR, and PFS. Moreover, it should be noted that the grade 3–4 toxic effects, especially hematological toxicity, are higher in the cytarabine group than in the cytarabine-free group. The results indicate that cytarabine plays an important role in the induction therapy of PCNSL. Large-sample and high-quality RCTs should be conducted to verify our results and confirm the effects of cytarabine on newly diagnosed PCNSL.
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Affiliation(s)
- Xiaohong Zheng
- Department of Neuro-Oncology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shoubo Yang
- Department of Neuro-Oncology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Chen
- Department of Neuro-Oncology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Si Wu
- School of Management and Economics, Beijing Institute of Technology, Beijing, China
| | - Wenbin Li
- Department of Neuro-Oncology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Abstract
OPINION STATEMENT Primary central nervous system lymphoma is a complex disease with no agreed-upon standard-of-care therapy. Induction therapy involves multiagent chemotherapy based on high-dose methotrexate, with several regimens available. We have a preference for a regimen using rituximab, methotrexate (3.5 g/m2), procarbazine, and vincristine (R-MPV) for initial induction therapy, given the favorable balance between toxicities and very high response rates (80-90%), which allow for decreasing disease burden and increasing the effectiveness of consolidation treatments. However, in the absence of consolidation therapies, R-MPV is not an effective regimen to achieve long-term remission.Based on high rates of long-term remission, our first choice for consolidation therapy is high-dose chemotherapy with autologous stem-cell transplant using thiotepa, busulfan, and cyclophosphamide as a myeloablative regimen, with a curative intent. This typically applies to patients with a favorable performance status at the end of induction, typically with ECOG performance status of 2 or better, adequate organ function, and age younger than 70. Patients with a high transplant-related mortality risk may still be considered for milder myeloablative regimens such as carmustine/thiotepa.For patients who are not transplant candidates, we typically offer consolidation with reduced dose whole-brain radiation therapy (WBRT) (23.4 Gy), which seems to be associated with lower risks of neurotoxicity as compared with higher doses of radiation. For patients who are not transplant candidates and that do not accept the risk of cognitive decline from the radiotherapy, we typically offer consolidation high-dose cytarabine, provided the patient understands the high risk of relapse. For these patients, a clinical trial is strongly recommended.
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17
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Yang H, Xun Y, Yang A, Liu F, You H. Advances and challenges in the treatment of primary central nervous system lymphoma. J Cell Physiol 2020; 235:9143-9165. [PMID: 32420657 DOI: 10.1002/jcp.29790] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 05/02/2020] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Hua Yang
- Department of Basic Medicine and Biomedical Engineering, School of Stomatology and Medicine, Foshan University, Foshan, Guangdong, China
| | - Yang Xun
- Department of Basic Medicine and Biomedical Engineering, School of Stomatology and Medicine, Foshan University, Foshan, Guangdong, China
| | - Anping Yang
- Department of Basic Medicine and Biomedical Engineering, School of Stomatology and Medicine, Foshan University, Foshan, Guangdong, China
| | - Fang Liu
- Department of Basic Medicine and Biomedical Engineering, School of Stomatology and Medicine, Foshan University, Foshan, Guangdong, China
| | - Hua You
- Department of Oncology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, Guangdong, China
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18
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Patekar M, Adhikari N, Biswas A, Raina V, Kumar L, Mohanti BK, Gogia A, Sharma A, Batra A, Bakhshi S, Garg A, Thulkar S, Sharma MC, Vishnubhatla S, Baghmar S, Sahoo RK. Primary CNS Lymphoma in India: A 17-Year Experience From the All India Institute of Medical Sciences. J Glob Oncol 2019; 5:1-9. [PMID: 30811305 PMCID: PMC6426510 DOI: 10.1200/jgo.18.00124] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The information about the outcome of primary CNS lymphoma (PCNSL) in India is scarce, because there is no population-based or large hospital-based data. MATERIALS AND METHODS This is a retrospective study that spanned 17 years (2001 to 2017) to study the outcome of PCNSL at the All India Institute of Medical Sciences (AIIMS), which is a tertiary care center in Northern India. RESULTS Only one of 99 patients was positive for HIV serology. Diffuse large B-cell lymphoma was the most common histology (97.7%). The median patient age was 50 years (range, 13 to 70 years), and the ratio of men to women was 1.9. The median duration of symptoms before diagnosis was 3.5 months (range, 0.5 to 48 months), and 58.5% had a performance status (PS) of 3 or more. Multiple intracranial lesions were present in 81.8% of patients. Surgical resection was performed in 45%, and approximately 22% of patients were ineligible for treatment. Most patients (n = 73) were treated with high-dose methotrexate (HDMTX)–based regimens (ie, methotrexate, vincristine, and procarbazine with or without rituximab). Pharmacokinetic monitoring of methotrexate was not available at our center. HDMTX-related mortality was 3.9%. The median follow-up duration, event-free survival (EFS), and overall survival (OS) were 34 months, 20.4 months, and 31.7 months, respectively. Addition of rituximab (n = 27) to MVP resulted in a higher objective response rate (88.9% v 73.9% without rituximab; P = .12), complete remission (81.5% v 56.5%; P = .03), 2-year EFS (57.3% v 40.4%; P = .02), and 2-year OS (61.6% v 53.4%; P = .056). CONCLUSION This is the largest study of PCNSL from India. The patients were immunocompetent and young but presented with a high-burden disease that precluded treatment in approximately 22%. The treatment with HDMTX appears safe without pharmacokinetic monitoring. The outcome is comparable to those observed in the West, and rituximab use showed additional benefit. There are notable barriers with respect to management of PCNSL in the real world, and efforts are required to improve the outcome more.
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Affiliation(s)
- Mukesh Patekar
- 1 Dr B.R.A. Institute Rotary Cancer Hospital, New Delhi, India.,2 All India Institute of Medical Sciences, New Delhi, India
| | - Narayan Adhikari
- 1 Dr B.R.A. Institute Rotary Cancer Hospital, New Delhi, India.,2 All India Institute of Medical Sciences, New Delhi, India
| | - Ahitagni Biswas
- 1 Dr B.R.A. Institute Rotary Cancer Hospital, New Delhi, India.,2 All India Institute of Medical Sciences, New Delhi, India
| | - Vinod Raina
- 1 Dr B.R.A. Institute Rotary Cancer Hospital, New Delhi, India.,2 All India Institute of Medical Sciences, New Delhi, India
| | - Lalit Kumar
- 1 Dr B.R.A. Institute Rotary Cancer Hospital, New Delhi, India.,2 All India Institute of Medical Sciences, New Delhi, India
| | - Bidhu Kalyan Mohanti
- 1 Dr B.R.A. Institute Rotary Cancer Hospital, New Delhi, India.,2 All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Gogia
- 1 Dr B.R.A. Institute Rotary Cancer Hospital, New Delhi, India.,2 All India Institute of Medical Sciences, New Delhi, India
| | - Atul Sharma
- 1 Dr B.R.A. Institute Rotary Cancer Hospital, New Delhi, India.,2 All India Institute of Medical Sciences, New Delhi, India
| | - Atul Batra
- 1 Dr B.R.A. Institute Rotary Cancer Hospital, New Delhi, India.,2 All India Institute of Medical Sciences, New Delhi, India
| | - Sameer Bakhshi
- 1 Dr B.R.A. Institute Rotary Cancer Hospital, New Delhi, India.,2 All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Garg
- 1 Dr B.R.A. Institute Rotary Cancer Hospital, New Delhi, India.,2 All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Thulkar
- 1 Dr B.R.A. Institute Rotary Cancer Hospital, New Delhi, India.,2 All India Institute of Medical Sciences, New Delhi, India
| | - Meher Chand Sharma
- 1 Dr B.R.A. Institute Rotary Cancer Hospital, New Delhi, India.,2 All India Institute of Medical Sciences, New Delhi, India
| | - Sreenivas Vishnubhatla
- 1 Dr B.R.A. Institute Rotary Cancer Hospital, New Delhi, India.,2 All India Institute of Medical Sciences, New Delhi, India
| | - Saphalta Baghmar
- 1 Dr B.R.A. Institute Rotary Cancer Hospital, New Delhi, India.,2 All India Institute of Medical Sciences, New Delhi, India
| | - Ranjit Kumar Sahoo
- 1 Dr B.R.A. Institute Rotary Cancer Hospital, New Delhi, India.,2 All India Institute of Medical Sciences, New Delhi, India
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19
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Biswas A, Adhikari N, Bakhshi S, Gopinathan VR, Sharma MC. A Rare Case of Primary Central Nervous System Lymphoma in an Adolescent Female Treated with High-Dose Methotrexate and Rituximab-Based Chemoimmunotherapy and Consolidation Whole Brain Radiotherapy. Pediatr Neurosurg 2019; 54:57-65. [PMID: 30669145 DOI: 10.1159/000495789] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 11/23/2018] [Indexed: 01/23/2023]
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare pediatric brain tumor. A 16-year-old female patient presented to the clinic with complaints of multiple episodes of generalized tonic clonic seizures, nystagmus, and weakness on the left side of the body for 3 weeks. She had similar symptoms, waxing and waning for the last 2 years, responding to corticosteroids. Repeat magnetic resonance imaging (MRI) of the brain showed multiple areas of signal abnormalities involving the left temporal lobe, the basal ganglion, the thalamus, and the right frontal and occipital lobes with contrast enhancement in bitemporal lesions. With a clinico- radiological diagnosis of demyelinating disorder, she underwent an image-guided right frontal lobe biopsy, which revealed sheets of atypical lymphoid cells diffusely immunopositive for CD20 but negative for CD3, CD10, BCL-6, and MUM-1, suggesting diffuse large B-cell lymphoma, germinal center B-cell subtype. The systemic lymphoma workup was essentially normal. She received 5 cycles of chemoimmunotherapy with rituximab, high-dose methotrexate (HDMTX), vincristine, and procarbazine and had a complete radiological response (CR). This was followed by whole brain radiotherapy (WBRT) to a dose of 36 Gy in 20 fractions over 4 weeks. Subsequently she received 2 cycles of consolidation chemoimmunotherapy with rituximab and high-dose cytarabine. Serial brain MRI done 1, 4, and 8 months after completion of treatment showed persistence of the CR. At the last follow-up visit, 15 months from the date of diagnosis, she was disease free and asymptomatic. This report underlines the fact that PCNSL in adolescents may be effectively treated with a combination of HDMTX- and rituximab-based chemoimmunotherapy followed by consolidation with WBRT.
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Affiliation(s)
- Ahitagni Biswas
- Department of Radiotherapy and Oncology, All India Institute of Medical Sciences, New Delhi, India,
| | - Narayan Adhikari
- Department of Radiotherapy and Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Sameer Bakhshi
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Mehar Chand Sharma
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
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20
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The importance of adequate methotrexate and adequate folinic acid rescue doses in the treatment of primary brain lymphoma. J Neurooncol 2018; 140:757. [PMID: 30242556 DOI: 10.1007/s11060-018-2999-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 09/10/2018] [Indexed: 10/28/2022]
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