Primary lymphoma of central nervous system in immunocompetent patients in south-east Scotland

Increasing incidence and continued dismal outcome of primary central nervous system lymphoma in Norway 1989-2003 : time trends in a 15-year national survey

BACKGROUND

The incidence of primary central nervous system lymphoma (PCNSL) appears to be increasing in some countries, whereas it is stable in others. Many reports the last decades have suggested that there have been improvements in the treatment of PCNSL. The objective of this study was to analyze time trends in the incidence, clinical features, histologic diagnosis, treatment, and outcome of nonacquired immunodeficiency syndrome (non-AIDS) PCNSL in Norway from 1989 to 2003.

METHODS

Patients were identified by a chart review of all patients who had a recorded diagnosis of PCNSL from 1989 to 2003 in The Norwegian Cancer Registry. The histologic and cytologic material from each patient was re-examined by pathologists. Time trends were analyzed according to year of diagnosis grouped into 3 5-year periods: 1989-1993, 1994-1998, and 1999-2003.

RESULTS

There were 98 patients who had confirmed, newly diagnosed non-AIDS PCNSL in Norway from 1989 to 2003. The incidence rate increased during the consecutive 5-year periods from 0.89 per million during 1989 to 1993, to 1.74 per million during 1994 to 1998, and to 1.82 per million during 1999 to 2003 (P = .013). Diagnostic delay and overall survival did not improve with time. Survival decreased from 1999 to 2003 compared with survival from 1994 to 1998, which was explained in part by reduced performance status and fewer patients receiving combined chemotherapy and radiotherapy during 1999 to 2003. In multivariate analysis, age </=50 years, a good performance status, and active treatment (especially combined chemotherapy and radiotherapy) significantly improved survival.

CONCLUSIONS

The incidence of PCNSL is increasing in Norway. Despite diagnostic and therapeutic advances over the last decades, neither a reduction in diagnostic delay nor any improvement in overall survival with time was observed. The search for improved understanding of etiology and treatment should be intensified.

Rising incidence of primary central nervous system lymphoma in Kumamoto, Japan

BACKGROUND

Primary central nervous system lymphoma is an extranodal form of non-Hodgkin lymphoma arising in the craniospinal axis. The incidence of PCNSL is reportedly on the increase in some parts of the world in the last 2 decades.

METHODS

We surveyed 4007 patients diagnosed with PIT between 1989 and 2004, with histologic diagnosis being obtained in 70% of the patients. Of these, the PCNSL cases were reviewed.

RESULTS

Of 4007, 136 (3.4%) carried a diagnosis of PCNSL. At 0.41 per 100,000 per year, the age-adjusted incidence rate for that period was higher than that for the period from 1989 to 1998 (0.29 per 100,000 per year). Moreover, the number of patients with PCNSL doubled from 45 (1989-1996) to 91 (1997-2004).

CONCLUSIONS

Our findings point to an increase in the incidence of PCNSL among immunocompetent individuals in Kumamoto Prefecture.

Primary CNS lymphoma in immunocompetent patients from 1989 to 2001: a retrospective analysis of 164 cases uniformly diagnosed by stereotactic biopsy

BACKGROUND

We present outcome data of a cohort of 164 immunocompetent PCNSL patients uniformly diagnosed at a single center for stereotactic neurosurgery, and evaluate the acceptance and impact of combination radiotherapy (RT) and chemotherapy (CHT) with high-dose methotrexate (HD-MTX) over time.

METHOD

We assessed choice of treatment and patient survival in a series of 164 PCNSL cases diagnosed from 1989 to 2001, and performed a re-evaluation of histopathology and pre-operative clinical data.

FINDINGS

From 1989 to 1993, RT was the predominant therapy, and additional CHT did not improve survival. After 1994, the use of combination CHT/RT increased continuously, consistently contained MTX, and was associated with longer survival than RT only: median survival was 14 months after CHT/RT (2-year survival 35.7%) and 10 months (2-year survival 26.2%) after RT only (not significant). Overall median survival remained poor, increasing from six (1989-1993) to nine months (1994-2001) (p = 0.008). Survival was variable, with a few patients surviving >4 years after diagnosis in the CHT/RT as well as in the RT only group.

CONCLUSIONS

Despite considerable improvement of PCNSL therapy, the overall benefit of combined CHT/RT versus RT only was lower than that expected from previous phase II clinical trials. The striking variability of survival in either treatment group may suggest a yet undefined biological heterogeneity of PCNSL, which may also include a more aggressive PCNSL subtype in the group of patients with rapidly progressive disease and not eligible for standard therapy.

Primary central nervous system lymphoma - A hospital based study of incidence and clinicopathological features from India (1983-2003)

Over the last two decades, an increase in the incidence of PCNSL cases has been reported in the West, both among immunosuppressed and immunocompetent patients. The present study was undertaken to assess the trend of incidence of PCNSL cases in India. To the best of our knowledge, only a single such report is available from India. All biopsy proven PCNSL cases obtained from the Neurosurgical databases of two large referral hospitals, one in Northern India (AIIMS, New Delhi) and another in Southern India (NIMHANS, Bangalore) from the period 1980 to 2003, were reviewed. Immunophenotyping was done and relevant clinical details collected. Appropriate statistical analysis was done to assess any change in trend of incidence or age at presentation. PCNSL cases constituted 0.95% and 0.92% of the total intracranial neoplasms at AIIMS and at NIMHANS, respectively. The mean age for cases diagnosed at AIIMS was 44.35 years, while that for NIMHANS was 39.51 years. Statistical analysis to evaluate any change in trend either of incidence or of age at presentation, over the study period, did not reveal any significant change. All the cases occurred in immunocompetent patients, except one case of HIV positive at NIMHANS, and one case of renal transplant at AIIMS. Frontal lobe was the most common site of involvement. Majority of the cases were diffuse, high grade, large cell lymphoma, B-cell immunophenotype. Thus, this multicentric hospital based study did not reveal any increase in incidence of PCNSL cases in India over the past 24 years. Further, in contrast to the West, majority of the cases in this Indian study were immunocompetent and a decade younger than in the West. The association of PCNSL with HIV/AIDS has been low in India, possibly due to early death in AIDS on account of opportunistic infections.

Incidence, clinical features, treatment and outcome of primary central nervous system lymphoma in Norway

The incidence of primary central nervous system lymphoma (PCNSL) has been reported to increase in some parts of the world, while being stable in other regions. In an attempt to characterize the incidence rate, clinical features, treatment, outcome, and prognostic factors of PCNSL in Norway, we report our experience in a large unselected series of patients. Clinical features, histological diagnosis, radiological findings, treatment, and outcome of all patients diagnosed with PCNSL in Norway in the years 1989-1998 were registered. During the 10-year period 58 new cases of histologically verified PCNSL were registered in Norway. The annual incidence rate of PCNSL was on average 1.34 cases per million people with a non-significant increasing trend (p=0.069). For patients diagnosed before death (n=45) the estimated survival following histological diagnosis was 55%, 47%, and 23% at 1, 2, and 5 years, respectively. In Cox-regression analysis age, WHO performance status and treatment had independent prognostic impact on survival. In the studied decade, there was a non-significant trend towards increased incidence of PCNSL, perhaps due to increased availability of diagnostic imaging, especially magnetic resonance imaging.

Primary central nervous system lymphoma

Primary central nervous system lymphoma (PCNSL) is a rare variant of non-Hodgkin's lymphoma that is increasing in incidence. Methotrexate-based chemotherapy in combination with whole-brain radiotherapy (WBRT) has dramatically improved the outcome of patients. However, treatment-related neurotoxicity is a significant complication, especially after radiotherapy in the elderly. Despite advances in therapy, several important questions remain regarding optimal methotrexate dose, dosing frequency, adjunct chemotherapy, and the impact of deferring WBRT. Advances in biologic therapy and strategies to intensify the delivery of chemotherapy may help to limit the use of radiotherapy, thus lessening potential neurotoxicity. Studies looking at oncogenic proteins as potential prognostic markers for PCNSL may help us to develop risk-adapted therapies.

Diagnostic advances and new trends for the treatment of primary central nervous system lymphoma

Primary central nervous system lymphoma (PCNSL) is a rare non-Hodgkin's lymphoma arising in the brain. Recent increase in its incidence has been noted both in immunocompetent individuals and patients with immunodeficiency. This review will focus on the epidemiology, pathogenesis, diagnosis and treatment of this aggressive extranodal lymphoma in immunocompetent patients. Stereotactic biopsy is usually required for diagnosis, while molecular biology and/or cytofluorimetric analysis may confirm the presence of clonal proliferation in the cerebrospinal fluid (CSF). Methotrexate-based chemotherapy plus whole-brain radiotherapy are the standard treatment for PCNSL and achieve a high rate of complete remissions (CR), but long-term neurotoxicity may heavily compromise the patient's quality of life. The metabolic rate of controversial gadolinium-enhancing lesions on magnetic resonance (MR) scans may be assessed with positron emission tomography (PET), which discriminates radiation necrosis from true recurrence. Withholding radiotherapy in patients achieving CR after first-line chemotherapy is a new and interesting treatment option, while the role of high-dose chemotherapy with stem cell rescue is still uncertain.

Primary central nervous system lymphomas: incidence and survival in the Southern and Eastern Netherlands

BACKGROUND

An excessive increase in the incidence of primary central nervous system lymphoma (PCNSL) has been reported since the mid-1980s in the U.S. and U.K. Clinical studies have shown that radiotherapy and chemotherapy may prolong survival. In the current study, the authors describe the incidence, treatment, and survival of an unselected group of patients with PCNSL in the southern and eastern Netherlands.

METHODS

Data regarding patients diagnosed between 1989-1994 were obtained from 4 population-based regional cancer registries in the southern and eastern Netherlands (n = 86) and the Eindhoven Cancer Registry for 1980-1988 (n = 6). Lymphomas were registered as PCNSL when a tissue diagnosis of CNS lymphoma was established for a patient with neurologic symptoms (i.e., lymphomas were not necessarily restricted to the CNS at the time of diagnosis). Only patients diagnosed during their lifetime with Stage I disease, Stage "IV" disease (i.e., diffuse CNS lymphoma), or disease of unknown stage were included (63 patients, 8 patients, and 15 patients, respectively, between 1989-1994). For 80 patients (93%) follow-up was complete until January 1, 1997.

RESULTS

Between 1989-1994, an average World Standardized Rate of 2.3 cases and 1.7 cases per 1 million person-years, respectively, was reported for males and females. The median age of the patients at the time of diagnosis was 62 years, and was 66 years for patients with an unknown disease stage. In the area of the Eindhoven Cancer Registry the occurrence of PCNSL more than doubled from < 2% of all histologically confirmed primary CNS malignancies diagnosed between 1980-1985 to approximately 4% of cases diagnosed between 1986-1994. The median survival of all the patients was 4.1 months; the median survival was 5.8 months for patients with limited (Stage I and Stage IV) disease and was 0.6 months for patients with an unknown stage of disease. Approximately 65% of the patients with limited disease received radiotherapy and approximately 35% of such patients received chemotherapy. Furthermore, chemotherapy was given more often to patients age < 60 years who tended to have a slightly better survival than patients age > or = 60 years.

CONCLUSIONS

The increase in the incidence of PCNSL in the 1980s may be explained in large part by changes in diagnostics and registration. The relatively high incidence and low survival rate of PCNSL in the southern and eastern Netherlands reported in the 1990s may be due in part to the inclusion of patients with systemic lymphoma and immunodeficiency disorders. However, a significant improvement in the prognosis of patients with PCNSL in the southern and eastern Netherlands diagnosed in the 1990s is unlikely.

A study of primary central nervous system lymphoma in northern India

BACKGROUND

Primary central nervous system lymphoma (PCNSL) is rare and accounts for 1 to 2% of all lymphomas. There are conflicting reports about the rise in incidence of PCNSL cases in the last two decades; this has largely been attributed to an increase in incidence of AIDS and other immunosuppressive states in some studies. This study was undertaken to view the trend of PCNSL at the Postgraduate Institute of Medical Education and Research, Chandigarh, which is a referral hospital in northern India.

METHODS

The PCNSL cases from our surgical material of 15 years (1985-1999) were reviewed. Slides were examined independently by three histopathologists. Immunophenotyping was done on paraffin-embedded tissue using indirect immunoperoxidase technique.

RESULTS

Out of a total of 3,325 intracranial tumors diagnosed during this period (1985-1999), there were 40 cases (1.2%) of PCNSL; gliomas accounted for 1,531 cases (46.04%). The age ranged from 24-75 years with the sex ratio (M:F) being 2:1. HIV serology, available in 14 cases, was negative in all. The parietal lobe was the most common site of involvement. Diffuse large cell lymphoma was the most common morphological type. Immunohistochemistry could be done in 31 cases; 28 cases were found to be B-cell type whereas 3 cases were T-cell type. No statistically significant increase was seen on comparing the number of cases at 5-year intervals.

CONCLUSION

This study revealed that there has been no significant increase in PCNSL cases over the last 15 years.

Malignant neoplasms subsequent to treatment of inflammatory bowel disease with 6-mercaptopurine

OBJECTIVE

Most complications of 6-mercaptopurine (6MP) used in the treatment of inflammatory bowel disease (IBD) occur early, whereas neoplasms occur late in the course. Concern persists that the risk is increased when 6MP is used. We report our experience with malignant tumors developing over 27 yr of treating IBD patients with 6MP.

METHODS

A total of 591 patients with IBD treated with 6MP between 1969 and 1997 were followed or traced until present to identify all malignant tumors and blood dyscrasias that had developed to determine the type, distribution, and duration of the IBD, the dose and duration of 6MP therapy, the concurrent versus previous use of 6MP, the incidence and probable relationship of 6MP to specific neoplasms, and whether the 6MP had been effective in treatment.

RESULTS

A total of 550 patients (93%) fulfilled the criteria for follow-up; these included 380 with Crohn's disease (CD) and 170 with ulcerative colitis (UC). Twenty-five patients had developed neoplasms (16 of 380 CD and nine of 170 UC) (p = 0.66). In half of the cases, the goal of therapy had been achieved with 6MP. In 10 patients, the neoplasm was diagnosed while the patients were taking 6MP (40%) and in 15, many years after the 6MP had been terminated (60%). The incidence of neoplasms (25 of 550) was 2.7/1000 patient-years of follow-up. The most common neoplasms were found in the bowel (eight of 550, 1.6%; five CD, and three UC), and breast (three, 0.5%; two CD, and one UC). Non-Hodgkins lymphomas occurred in two patients with CD; one was cerebral and the other abdominal. One patient with CD developed leukemia. The duration of 6MP therapy ranged from 5 months to 22 yr, with a mean of 5 yr. The dose of 6MP ranged from a quarter of a tablet/day (12.5 mg) to 100 mg/day, with the majority in a range from 50 to 75 mg/day.

CONCLUSION

In no instance could a neoplasm be attributed to the use of 6MP. The incidence of colon cancer is not greater than that with long standing colitis. Suspicion of a relationship between 6MP and leukemia/lymphoma persists, but the incidence is low. This must be weighed against the improved quality of life due to 6MP for patients with IBD.

Is primary CNS lymphoma really becoming more common? A population-based study of incidence, clinicopathological features and outcomes in Alberta from 1975 to 1996

BACKGROUND

The incidence of primary CNS lymphoma (PCNSL) is believed to be increasing in immunocompetent patients but this may not be universally true. The objective of this study was to determine in a population if the incidence of PCNSL is increasing, if the histologic subtypes are changing, and to describe the clinicopathologic and outcome characteristics of PCNSL.

PATIENTS AND METHODS

We identified all Alberta residents with a histologic diagnosis of PCNSL from 1 January 1975 to 31 December 1996 using the Alberta Cancer Registry. Annual age-standardized incidence rates (ASIR), clinicopathologic and outcome characteristics were determined.

RESULTS

There were 50 immunocompetent PCNSL patients; the median age was 64 and 30 were male. Their median survival was 10.15 months. Histology was available for review in 37 (74%) patients: 19 (51%) were diffuse large cell, 16 (43%) were immunoblastic and 2 (5%) were unclassifiable malignant lymphomas. The ASIR ranged from 0.178-1.631/10(6) and no change in ASIR was found (test for trend, P = 0.26) for gender or age. The ASIR of malignant gliomas did not change either but increased for all other non-Hodgkin's lymphoma (94.95-138.7610(6); test for trend, P = 0.0001) The number of brain biopsies increased from 1979-1985 (test for trend, P < 0.0001) but remained stable from 1986-1996 (test for trend, P = 0.99).

CONCLUSIONS

Unlike several other populations, PCNSL is not becoming significantly more common in Alberta. If this difference is real (i.e., not due to differences in cancer registry coding practices etc.) comparisons between Albertans and other populations in whom the incidence is rising may provide clues regarding the etiology of PCNSL.