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Chua BJG, Low CE, Yau CE, Tan YH, Chiang J, Chang EWY, Chan JY, Poon EYL, Somasundaram N, Rashid MFBH, Tao M, Lim ST, Yang VS. Recent updates on central nervous system prophylaxis in patients with high-risk diffuse large B-cell lymphoma. Exp Hematol Oncol 2024; 13:1. [PMID: 38173015 PMCID: PMC10765685 DOI: 10.1186/s40164-023-00467-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
The use of central nervous system (CNS) prophylaxis for patients with diffuse large B-cell lymphoma (DLBCL) remains controversial. Although uncommon, CNS relapses are invariably fatal in this otherwise curable disease. Accurate identification of patients at risk and the optimal approach to CNS prophylaxis therefore remains an area of unmet need. The existing literature, largely retrospective in nature, provides mixed conclusions regarding the efficacy of CNS prophylaxis. The utility of CNS prophylaxis has itself been challenged. In this review, we dissect the issues which render the value of CNS prophylaxis uncertain. We first compare international clinical guidelines for CNS prophylaxis. We then interrogate the factors that should be used to identify high-risk patients accurately. We also explore how clinical patterns of CNS relapse have changed in the pre-rituximab and rituximab era. We then discuss the efficacy of CNS-directed approaches, intensification of systemic treatment and other novel approaches in CNS prophylaxis. Improved diagnostics for early detection of CNS relapses and newer therapeutics for CNS prophylaxis are areas of active investigation. In an area where prospective, randomized studies are impracticable and lacking, guidance for the use of CNS prophylaxis will depend on rigorous statistical review of retrospective data.
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Affiliation(s)
- Bernard Ji Guang Chua
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
| | - Chen Ee Low
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Chun En Yau
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Ya Hwee Tan
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
| | - Jianbang Chiang
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
| | - Esther Wei Yin Chang
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
| | - Jason Yongsheng Chan
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
- Duke-NUS Medical School, Oncology Academic Clinical Program, 8 College Road, Singapore, 169857, Singapore
| | - Eileen Yi Ling Poon
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
| | - Nagavalli Somasundaram
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
- Duke-NUS Medical School, Oncology Academic Clinical Program, 8 College Road, Singapore, 169857, Singapore
| | - Mohamed Farid Bin Harunal Rashid
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
- Duke-NUS Medical School, Oncology Academic Clinical Program, 8 College Road, Singapore, 169857, Singapore
| | - Miriam Tao
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
- Duke-NUS Medical School, Oncology Academic Clinical Program, 8 College Road, Singapore, 169857, Singapore
| | - Soon Thye Lim
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
- Duke-NUS Medical School, Oncology Academic Clinical Program, 8 College Road, Singapore, 169857, Singapore
| | - Valerie Shiwen Yang
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore.
- Duke-NUS Medical School, Oncology Academic Clinical Program, 8 College Road, Singapore, 169857, Singapore.
- Translational Precision Oncology Lab, Institute of Molecular and Cell Biology (IMCB), 61 Biopolis Dr Proteos, Singapore, 138673, A*STAR, Singapore.
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Fowler MJ, Cotter JD, Knight BE, Sevick-Muraca EM, Sandberg DI, Sirianni RW. Intrathecal drug delivery in the era of nanomedicine. Adv Drug Deliv Rev 2020; 165-166:77-95. [PMID: 32142739 DOI: 10.1016/j.addr.2020.02.006] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 12/17/2019] [Accepted: 02/28/2020] [Indexed: 12/23/2022]
Abstract
Administration of substances directly into the cerebrospinal fluid (CSF) that surrounds the brain and spinal cord is one approach that can circumvent the blood-brain barrier to enable drug delivery to the central nervous system (CNS). However, molecules that have been administered by intrathecal injection, which includes intraventricular, intracisternal, or lumbar locations, encounter new barriers within the subarachnoid space. These barriers include relatively high rates of turnover as CSF clears and potentially inadequate delivery to tissue or cellular targets. Nanomedicine could offer a solution. In contrast to the fate of freely administered drugs, nanomedicine systems can navigate the subarachnoid space to sustain delivery of therapeutic molecules, genes, and imaging agents within the CNS. Some evidence suggests that certain nanomedicine agents can reach the parenchyma following intrathecal administration. Here, we will address the preclinical and clinical use of intrathecal nanomedicine, including nanoparticles, microparticles, dendrimers, micelles, liposomes, polyplexes, and other colloidalal materials that function to alter the distribution of molecules in tissue. Our review forms a foundational understanding of drug delivery to the CSF that can be built upon to better engineer nanomedicine for intrathecal treatment of disease.
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Affiliation(s)
- M J Fowler
- Vivian L. Smith Department of Neurosurgery, McGovern Medical School/University of Texas Health Science Center at Houston, Houston, TX 77030, United States of America
| | - J D Cotter
- Vivian L. Smith Department of Neurosurgery, McGovern Medical School/University of Texas Health Science Center at Houston, Houston, TX 77030, United States of America
| | - B E Knight
- Vivian L. Smith Department of Neurosurgery, McGovern Medical School/University of Texas Health Science Center at Houston, Houston, TX 77030, United States of America
| | - E M Sevick-Muraca
- Brown Foundation Institute of Molecular Medicine, Center for Molecular Imaging, Houston, TX 77030, United States of America
| | - D I Sandberg
- Vivian L. Smith Department of Neurosurgery, McGovern Medical School/University of Texas Health Science Center at Houston, Houston, TX 77030, United States of America; Department of Pediatric Surgery, McGovern Medical School/University of Texas Health Science Center at Houston, Houston, TX 77030, United States of America; Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, United States of America
| | - R W Sirianni
- Vivian L. Smith Department of Neurosurgery, McGovern Medical School/University of Texas Health Science Center at Houston, Houston, TX 77030, United States of America.
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Nanocarriers as Magic Bullets in the Treatment of Leukemia. NANOMATERIALS 2020; 10:nano10020276. [PMID: 32041219 PMCID: PMC7075174 DOI: 10.3390/nano10020276] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 01/30/2020] [Accepted: 02/01/2020] [Indexed: 12/21/2022]
Abstract
Leukemia is a type of hematopoietic stem/progenitor cell malignancy characterized by the accumulation of immature cells in the blood and bone marrow. Treatment strategies mainly rely on the administration of chemotherapeutic agents, which, unfortunately, are known for their high toxicity and side effects. The concept of targeted therapy as magic bullet was introduced by Paul Erlich about 100 years ago, to inspire new therapies able to tackle the disadvantages of chemotherapeutic agents. Currently, nanoparticles are considered viable options in the treatment of different types of cancer, including leukemia. The main advantages associated with the use of these nanocarriers summarized as follows: i) they may be designed to target leukemic cells selectively; ii) they invariably enhance bioavailability and blood circulation half-life; iii) their mode of action is expected to reduce side effects. FDA approval of many nanocarriers for treatment of relapsed or refractory leukemia and the desired results extend their application in clinics. In the present review, different types of nanocarriers, their capability in targeting leukemic cells, and the latest preclinical and clinical data are discussed.
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Abstract
OPINION STATEMENT Central nervous system (CNS) relapse is an undesirable event in the course of patients with diffuse large B cell lymphoma (DLBCL) with a median survival of approximately 6 months following CNS relapse. CNS prophylaxis for the prevention of CNS recurrence, in addition to the standard R-CHOP chemotherapy, is thus preferable. For an overall relapse risk of 2-5%, administration of CNS-directed therapies for all patients with DLBCL is unnecessary and prophylaxis should be targeted for the high-risk patients. CNS-International Prognostic Index (CNS-IPI) score has enabled risk stratification with risk ranging < 1% (low-risk group) compared to > 10% (high-risk group). The latter could be considered for CNS prophylaxis. CNS-IPI, however, is not perfect and may not capture patients with high-risk extra-nodal sites such as testicular DLBCL. Cell-of-origin and MYC/BCL2 expression can further build on CNS-IPI to narrow higher risk patients. CNS prophylaxis strategies are controversial. Common strategies include intrathecal (IT) chemotherapy and systemic CNS penetrants such as methotrexate. IT chemotherapy does not adequately penetrate the brain parenchyma and hence it is insufficient in preventing parenchymal CNS recurrences. Most experts promote systemic methotrexate for high-risk groups, which penetrates both the leptomeningeal and parenchymal CNS compartments. Even though systemic CNS prophylaxis is widely promoted over IT alone, its efficacy is unclear. Ongoing efforts in search for appropriate CNS prophylaxis strategies are warranted. My personal practice is to administer systemic high-dose methotrexate in conjunction with R-CHOP chemotherapy for eligible patients deemed at a high risk of CNS recurrence, especially those with high-risk CNS-IPI and extra-nodal involvement.
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Affiliation(s)
- Roopesh Kansara
- Department of Internal Medicine, Section of Medical Oncology/Hematology, CancerCare Manitoba, University of Manitoba, 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada.
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Abstract
PURPOSE Cancer remains a significant cause of morbidity and mortality across the globe. A recent report suggests around 14.1 million new cases and 8.2 million cancer-related deaths, which are expected to reach 21.7 million and 13 million by 2030 worldwide, respectively. MATERIALS AND METHODS Because of highly complex mechanisms of cancer progression, it is important to explore and develop new innovative technologies which are more efficient compared with presently available treatment options. RESULTS Currently, chemotherapy, radiation and surgery are the most commonly used cancer treatment methods. In the last decade, nanomedicine emerged as an alternative treatment option that uses specific drug-delivery systems, improves efficacy of drugs and reduces detrimental side effects to normal tissues. CONCLUSION In this review, we have summarized cancer nanomedicines (active and passive drug delivery) available in the market. We have also discussed other nanomedicines that are at different stages of clinical trials.
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Affiliation(s)
- Nasimudeen R Jabir
- a King Fahd Medical Research Center , King Abdulaziz University , Jeddah , Saudi Arabia
| | - Khalid Anwar
- b School of Life Sciences , Jawaharlal Nehru University , New Delhi , India
| | - Chelapram K Firoz
- a King Fahd Medical Research Center , King Abdulaziz University , Jeddah , Saudi Arabia
| | - Mohammad Oves
- c Center of Excellence in Environmental Studies , King Abdulaziz University , Jeddah , Saudi Arabia
| | - Mohammad Amjad Kamal
- a King Fahd Medical Research Center , King Abdulaziz University , Jeddah , Saudi Arabia
| | - Shams Tabrez
- a King Fahd Medical Research Center , King Abdulaziz University , Jeddah , Saudi Arabia
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García-Recio M, Cladera A, Bento L, Dominguez J, Ruiz de Gracia S, Sartori F, Del Campo R, García L, Ballester C, Gines J, Bargay J, Sampol A, Gutiérrez A. Analysis of the role of intratecal liposomal cytarabine in the prophylaxis and treatment of central nervous system lymphomatosis: The Balearic Lymphoma Group experience. PLoS One 2017; 12:e0179595. [PMID: 28665999 PMCID: PMC5493300 DOI: 10.1371/journal.pone.0179595] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 06/01/2017] [Indexed: 01/18/2023] Open
Abstract
Central nervous system (CNS) lymphomatosis is a fatal complication of aggressive non-Hodgkin lymphoma (NHL). In lymphoblastic or Burkitt lymphoma, without specific CNS prophylaxis the risk of CNS relapse is 20–30%. DLBCL has a lower risk of relapse (around 5%) but several factors increase its incidence. There is no consensus or trials to conclude which is the best CNS prophylaxis. Best results seem to be associated with the use of intravenous (iv) high-dose methotrexate (HDMTX) but with a significant toxicity. Other options are the administration of intrathecal (IT) MTX, cytarabine or liposomal cytarabine (ITLC). Our aim is to analyze the experience of the centers of the Balearic Lymphoma Group (BLG) about the toxicity and efficacy of ITLC in the prophylaxis and therapy of CNS lymphomatosis. We retrospectively reviewed cases from 2005 to 2015 (n = 58) treated with ITLC. Our toxicity results were: 33% headache, 20% neurological deficits, 11% nausea, 9% dizziness, 4% vomiting, 4% fever, 2% transient blindness and 2% photophobia. In the prophylactic cohort (n = 26) with a median follow-up of 55 months (17–81) only 3 CNS relapses (11%) were observed (testicular DLBCL, Burkitt and plasmablastic lymphoma, with a cumulative incidence of 8%, 14% and 20% respectively). In the treatment cohort (n = 32), CSF complete clearance was obtained in 77% cases. Median OS was 6 months (0–16). Death causes were lymphoma progression (19 patients, 79%), treatment toxicity (2 patients) and non-related (3 patients, 12%). Toxicity profile was good especially when concomitant dexamethasone was administered. In the prophylactic cohort the incidence of CNS relapse in DLBCL group was similar to previously reported for HDMTX and much better than IT MTX. A high number of ITLC injections was associated with better rates of CSF clearance, clinical responses, PFS and lower relapses. Survival is still poor in CNS lymphomatosis and new therapeutic approaches are still needed.
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Affiliation(s)
- Marta García-Recio
- Hematology department, Son Espases University Hospital, Palma de Mallorca, Balearic Islands, Spain
| | - Antonia Cladera
- Hematology department, Hospital Son Llatzer, Palma de Mallorca, Balearic Islands, Spain
| | - Leyre Bento
- Hematology department, Son Espases University Hospital, Palma de Mallorca, Balearic Islands, Spain
| | - Julia Dominguez
- Hematology department, Hospital Son Llatzer, Palma de Mallorca, Balearic Islands, Spain
| | - Silvia Ruiz de Gracia
- Hematology department, Son Espases University Hospital, Palma de Mallorca, Balearic Islands, Spain
| | - Francesca Sartori
- Hematology department, Son Espases University Hospital, Palma de Mallorca, Balearic Islands, Spain
| | - Raquel Del Campo
- Hematology department, Hospital Son Llatzer, Palma de Mallorca, Balearic Islands, Spain
| | - Lucia García
- Hematology department, Son Espases University Hospital, Palma de Mallorca, Balearic Islands, Spain
| | - Carmen Ballester
- Hematology department, Son Espases University Hospital, Palma de Mallorca, Balearic Islands, Spain
| | - Jordi Gines
- Pharmacy department, Son Espases University Hospital, Palma de Mallorca, Balearic Islands, Spain
| | - Joan Bargay
- Hematology department, Hospital Son Llatzer, Palma de Mallorca, Balearic Islands, Spain
| | - Antonia Sampol
- Hematology department, Son Espases University Hospital, Palma de Mallorca, Balearic Islands, Spain
| | - Antonio Gutiérrez
- Hematology department, Son Espases University Hospital, Palma de Mallorca, Balearic Islands, Spain
- * E-mail:
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Pardo-Moreno J, Fernández C, Arroyo R, Ruiz-Ocaña C, Aláez C, Cuadrado ML. Safety of intra-cerebrospinal fluid chemotherapy in onco-haematological patients: a retrospective analysis of 627 interventions. J Neurooncol 2015; 125:351-8. [PMID: 26342710 DOI: 10.1007/s11060-015-1922-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 08/29/2015] [Indexed: 01/30/2023]
Abstract
Intra-cerebrospinal fluid chemotherapy (ICC) is used widely to treat or prevent neoplastic meningitis (NM), although its safety has not been thoroughly assessed. We aimed to analyse the incidence, severity and cause of the adverse reactions provoked by ICC in a cohort of onco-haematological patients. We retrospectively reviewed all the adverse reactions related to ICC procedures performed by the same researcher over a 5-year period. We classified them according to their severity and cause, and examined their association with certain characteristics of the patients and interventions. A total of 627 procedures were performed on 124 patients, in which 59 adverse reactions were documented (9.4 %). Thirty-two (54 %) of these were considered severe and 30 (51 %) were due to the drug itself. NM was associated with a higher incidence of adverse reactions (p = 0.002) and severe adverse reactions (p < 0.001). Adverse reactions were more common (p = 0.028) and more often severe (p = 0.008) when an Ommaya reservoir was used, as opposed to the lumbar puncture procedure. The use of liposomal cytarabine was also associated with a higher incidence of adverse reactions (p < 0.001) and serious adverse reactions (p < 0.001) than immediate-release drugs. Liposomal cytarabine provoked more adverse reactions attributable to the drug when administered by lumbar puncture (p = 0.192), whereas the remaining drugs had higher risk when administered via Ommaya reservoir (p = 0.015). ICC seems a relatively safe procedure. Adverse reactions appear to be more frequent when NM is already present. Lumbar puncture seems to be safer than the Ommaya reservoir, except when liposomal cytarabine is administered.
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Affiliation(s)
- Javier Pardo-Moreno
- Department of Neurology, Hospital Rey Juan Carlos, Universidad Rey Juan Carlos, C/Gladiolo s/n, Móstoles, 28933, Madrid, Spain.
| | - Cristina Fernández
- Department of Preventive Medicine, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos, Universidad Complutense, Madrid, Spain
| | - Rafael Arroyo
- Department of Neurology, Hospital Quirón Madrid, Pozuelo de Alarcón, Madrid, Spain.,Department of Neurology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos, Universidad Complutense, Madrid, Spain
| | - Carlos Ruiz-Ocaña
- Department of Neurosurgery, Hospital Quirón Madrid, Pozuelo de Alarcón, Madrid, Spain
| | - Concepción Aláez
- Department of Haematology, Hospital Quirón Madrid, Pozuelo de Alarcón, Madrid, Spain
| | - María-Luz Cuadrado
- Department of Neurology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos, Universidad Complutense, Madrid, Spain
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