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Pertz M, Schlegel U, Thoma P. Sociocognitive Functioning and Psychosocial Burden in Patients with Brain Tumors. Cancers (Basel) 2022; 14:cancers14030767. [PMID: 35159034 PMCID: PMC8833643 DOI: 10.3390/cancers14030767] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/24/2022] [Accepted: 01/31/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary After years of gauging the efficacy of tumor-directed therapies primarily by means of survival, a broader perspective on therapeutic outcome also focusses on patients’ everyday functional abilities. Besides neurocognition, a matter of high clinical relevance, “social cognition” may also affect well-being and quality of life (QoL) in brain tumor patients. Abilities that enable individuals to establish and maintain social relationships are summarized under the umbrella term “sociocognitive functioning”. These abilities encompass the understanding and sharing of emotional and mental states of other individuals as well as skills to detect and resolve interpersonal problems. These sociocognitive abilities may be challenged in highly demanding life situations such as brain tumor diagnosis and treatment. Therefore, we summarize the literature on psychosocial burden and sociocognitive functioning in adult brain tumor patients. Abstract Brain tumors may represent devastating diseases and neuro-oncological research in the past solely focused on development of better treatments to achieve disease control. The efficacy of tumor-directed treatment was evaluated by progression-free and overall survival. However, as neuro-oncological treatment became more effective, preservation and improvement of quality of life (QoL) was noticed to represent an important additional outcome measure. The need to balance between aggressive tumor-directed treatment and preservation of QoL was increasingly acknowledged in brain tumor patients. QoL is comprised by many determinants; one of those may have been rather neglected so far: social cognition. Since diagnosis and treatment of brain tumors represent demanding life situations, patients may experience increased psychosocial burden and the negative consequences of illness on well-being may be buffered by intact social relationships. These skills to build and maintain supportive social relationships essentially depend on the ability to empathize with others and to recognize and appropriately address social conflicts, i.e., “sociocognitive functioning”. Therefore, sociocognitive functions may influence QoL and treatment outcome. In this article, we review the literature on psychosocial burden and sociocognitive functioning in adult brain tumor patients.
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Affiliation(s)
- Milena Pertz
- Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23–25, D-44892 Bochum, Germany;
- Correspondence:
| | - Uwe Schlegel
- Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23–25, D-44892 Bochum, Germany;
| | - Patrizia Thoma
- Neuropsychological Therapy Centre (NTC), Faculty of Psychology, Ruhr University Bochum, Universitätsstraße 150, D-44780 Bochum, Germany;
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Pertz M, Kowalski T, Thoma P, Schlegel U. What Is on Your Mind? Impaired Social Cognition in Primary Central Nervous System Lymphoma Patients Despite Ongoing Complete Remission. Cancers (Basel) 2021; 13:cancers13050943. [PMID: 33668180 PMCID: PMC7956780 DOI: 10.3390/cancers13050943] [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: 12/19/2020] [Revised: 02/05/2021] [Accepted: 02/20/2021] [Indexed: 12/30/2022] Open
Abstract
Simple Summary Prolonged survival after treatment of primary central nervous system lymphoma (PCNSL) led to considering patients’ everyday functional needs. Apart from cognitive functions (e.g., memory, attention), which have been investigated previously, social participation affects the quality of life (QoL). Although successful navigation in a social world is crucial for participation, social functioning in PCNSL patients has not been addressed so far. In this study, we investigated social abilities in PCNSL patients with ongoing complete remission for at least one year. PCNSL patients had difficulties in inferring others’ mental states and were impaired in providing optimal solutions for difficult social situations as compared to matched healthy controls. This demonstrates that PCNSL patients differ from healthy controls in their social functioning even in the absence of (residual) disease itself. Social difficulties may represent an additional burden affecting patients’ and caregivers’ QoL. Abstract Within the past decades, long-term survival was achieved in a substantial fraction of primary central nervous system lymphoma (PCNSL) patients, expanding the focus of research to their quality of life (QoL). Social relationships crucially contribute to well-being in the context of adversity. Therefore, abilities that facilitate social interactions essentially determine QoL. The present study specifically targeted those sociocognitive abilities. Forty-three PCNSL patients with ongoing complete remission to therapy for at least one year and 43 healthy controls matched for age, gender and education were examined with standardized self-report and behavioral measures of social cognition. An impaired ability to comprehend others’ feelings was found in patients for both positive and negative mental states. Patients had difficulties in identifying the awkward element in challenging social situations, whereas the degree of discomfort experienced in those situations was comparable between groups. Both the production of optimal solutions for social situations and the mere recognition of these among less optimal strategies were impaired in patients. Clinicians should be aware of possible sociocognitive impairment and ought to address this in additional supportive interventions. Impaired sociocognitive abilities may entail social conflicts at a time when patients rely on social support. This, in turn, could detrimentally affect QoL.
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Affiliation(s)
- Milena Pertz
- Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23–25, D-44892 Bochum, Germany; (T.K.); (U.S.)
- Correspondence: ; Tel.: +49-234-299-80312
| | - Thomas Kowalski
- Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23–25, D-44892 Bochum, Germany; (T.K.); (U.S.)
| | - Patrizia Thoma
- Neuropsychological Therapy Centre (NTC)/Clinical Neuropsychology, Faculty of Psychology, Ruhr University Bochum, Universitätsstraße 150, D-44780 Bochum, Germany;
| | - Uwe Schlegel
- Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23–25, D-44892 Bochum, Germany; (T.K.); (U.S.)
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Wang YX, Huang Y, Xu XP, Chen BB, Lin ZG, Ma Y, Ding TL, Wang Q. Curative effect of methotrexate combined with teniposide in the treatment of primary central nervous system lymphoma. Oncol Lett 2020; 19:2097-2106. [PMID: 32194707 PMCID: PMC7039052 DOI: 10.3892/ol.2020.11328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 03/07/2018] [Indexed: 12/23/2022] Open
Abstract
The present study aimed to investigate the curative effect of high-dose methotrexate (HD-MTX) combined with teniposide (Vm26) vs. HD-MTX alone in the treatment of primary central nervous system lymphoma (PCNSL), in order to provide data for assisting decisions associated with clinical treatment. Data from 56 patients with PCNSL admitted in Shanghai Huashan Hospital (Shanghai, China) from January 2009 to December 2014 were included into the present study. Clinical data, curative effects and prognosis of patients in these two groups were retrospectively analyzed using SPSS 20 statistical software. In the HD-MTX+Vm26 group, 12 patients (42.85%) achieved complete remission (CR) and 10 patients (35.71%) achieved partial remission (PR), while in the HD-MTX group 7 patients (25%) achieved CR and 11 patients (39.29%) achieved PR (P=0.158). The median progression-free survival (PFS) time was 22 months in the HD-MTX+Vm26 group and 12 months in the HD-MTX group (P=0.019). The median overall survival time was 57 months in the HD-MTX+Vm26 group, and 28 months in the HD-MTX group (P=0.013). Compared with HD-MTX alone, the combined treatment of HD-MTX+Vm26 had an improved curative effect in the treatment of PCNSL, effectively controlled tumor progression in patients, prolonged survival time and improved prognosis. Age was an independent prognostic factor in patients with PCNSL. Patients with an age of ≤60 years exhibited longer PFS compared with patients with an age of >60 years.
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Affiliation(s)
- Yi-Xia Wang
- Department of Hematology, Huashan Hospital Affiliated to Fudan University, Shanghai 200040, P.R. China.,Department of Hematology, The Second People's Hospital of Kashi, Xinjiang 844000, P.R. China
| | - Yan Huang
- Department of Hematology, The Second People's Hospital of Kashi, Xinjiang 844000, P.R. China
| | - Xiao-Ping Xu
- Department of Hematology, Huashan Hospital Affiliated to Fudan University, Shanghai 200040, P.R. China
| | - Bo-Bin Chen
- Department of Hematology, Huashan Hospital Affiliated to Fudan University, Shanghai 200040, P.R. China
| | - Zhi-Guang Lin
- Department of Hematology, Huashan Hospital Affiliated to Fudan University, Shanghai 200040, P.R. China
| | - Yan Ma
- Department of Hematology, Huashan Hospital Affiliated to Fudan University, Shanghai 200040, P.R. China
| | - Tian-Ling Ding
- Department of Hematology, Huashan Hospital Affiliated to Fudan University, Shanghai 200040, P.R. China
| | - Qian Wang
- Department of Hematology, Huashan Hospital Affiliated to Fudan University, Shanghai 200040, P.R. China
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Kim SK, Park JE, Kim KH, Cho JM, Moon J, Yoon WS, Kim SH, Kim YI, Kim YZ, Kim HS, Dho YS, Park JS, Yoon HI, Seo Y, Sung KS, Song JH, Wee CW, Lee SH, Lim DH, Im JH, Chang JH, Han MH, Hong JB, Hwang K, Park CK, Lee YS, Gwak HS. A National Consensus Survey for Current Practice in Brain Tumor Management III: Brain Metastasis and Primary Central Nervous System Lymphoma. Brain Tumor Res Treat 2020; 8:20-28. [PMID: 32390350 PMCID: PMC7221464 DOI: 10.14791/btrt.2020.8.e7] [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: 02/29/2020] [Revised: 03/02/2020] [Accepted: 03/16/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The Guideline Working Group of the Korean Society for Neuro-Oncology (KSNO) conducted the nationwide questionnaire survey for diverse queries facing to treat patients with brain tumor. As part III of the survey, the aim of this study is to evaluate the national patterns of clinical practice for patients with brain metastasis and primary central nervous system lymphoma (PCNSL). METHODS A web-based survey was sent to all members of the KSNO by email. The survey included 7 questions of brain metastasis and 5 questions of PCNSL, focused on the management strategies in specific situations. All questions were developed by consensus of the Guideline Working Group. RESULTS In the survey about brain metastasis, respondents preferred surgical resection with adjuvant treatment for patients with a surgically accessible single brain metastatic lesion less than 3 cm in size without extracranial systemic lesions. However, most respondents considered radiosurgery for surgically inaccessible lesions. As the preferred treatment of multiple brain metastases according to the number of brain lesions, respondents tended to choose radiotherapy with increasing number of lesions. Radiosurgery was mostly chosen for the brain metastases of less than or equal to 4. In the survey about PCNSL, a half of respondents choose high-dose methotrexate-based polychemotherapy as the first-line induction therapy for PCNSL. The consolidation and salvage therapy showed a little variation among respondents. For PCNSL patients with cerebrospinal fluid dissemination, intrathecal chemotherapy was most preferred. CONCLUSION The survey demonstrates the prevailing clinical practice patterns for patients with brain metastasis and PCNSL among members of the KSNO. This information provides a point of reference for establishing a practical guideline in the management of brain metastasis and PCNSL.
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Affiliation(s)
- Sung Kwon Kim
- Department of Neurosurgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - Ji Eun Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Hwan Kim
- Department of Neurosurgery, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jin Mo Cho
- Department of Neurosurgery, International St. Mary's Hospital, Catholic Kwandong University, Incheon, Korea
| | - Jangsup Moon
- Department of Neurology, Rare Disease Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Wan Soo Yoon
- Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Se Hoon Kim
- Department of Pathology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Il Kim
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Young Zoon Kim
- Division of Neurooncology and Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Ho Sung Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yun Sik Dho
- Department of Neurosurgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Jae Sung Park
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hong In Yoon
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Youngbeom Seo
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, Daegu, Korea
| | - Kyoung Su Sung
- Department of Neurosurgery, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Jin Ho Song
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chan Woo Wee
- Department of Radiation Oncology, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Se Hoon Lee
- Division of Hematology/Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Do Hoon Lim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Ho Im
- Department of Radiation Oncology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Jong Hee Chang
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Myung Hoon Han
- Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Je Beom Hong
- Department of Neurosurgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kihwan Hwang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Chul Kee Park
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
| | - Youn Soo Lee
- Department of Hospital Pathology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
| | - Ho Shin Gwak
- Department of Cancer Control, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea.
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Pertz M, Okoniewski A, Schlegel U, Thoma P. Impairment of sociocognitive functions in patients with brain tumours. Neurosci Biobehav Rev 2019; 108:370-392. [PMID: 31786319 DOI: 10.1016/j.neubiorev.2019.11.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 09/24/2019] [Accepted: 11/25/2019] [Indexed: 12/30/2022]
Abstract
The ability to decode mental states and to come up with effective solutions for interpersonal problems aids successful initiation and maintenance of social interactions and contributes to participation and mental health. Since these abilities of social cognition are challenged in highly demanding situations, such as diagnosis and treatment of a life-threatening illness, this article reviews the literature on emotion recognition, empathy, Theory of Mind and socially skilled behaviour in brain tumour patients. The data available suggest that patients are affected by a slight but consistent impairment of emotion recognition, empathy and Theory of Mind before and immediately after brain tumour treatment, with the degree of impairment being influenced by tumour histology and localization. Impairments mostly decrease a few months after surgery due to assumed neuroplasticity. Future research may address more complex sociocognitive functions, such as social problem solving, and may investigate to which degree sociocognitive difficulties act as risk factors for poor or failed reintegration into occupational and social life following successful brain tumour treatment.
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Affiliation(s)
- Milena Pertz
- Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr-University Bochum, In der Schornau 23-25, D-44892 Bochum, Germany.
| | - Annalena Okoniewski
- Neuropsychological Treatment Centre (NTC)/ Clinical Neuropsychology, Faculty of Psychology, Ruhr-University Bochum, Universitätsstraße 150, D-44780 Bochum, Germany
| | - Uwe Schlegel
- Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr-University Bochum, In der Schornau 23-25, D-44892 Bochum, Germany
| | - Patrizia Thoma
- Neuropsychological Treatment Centre (NTC)/ Clinical Neuropsychology, Faculty of Psychology, Ruhr-University Bochum, Universitätsstraße 150, D-44780 Bochum, Germany
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van der Meulen M, Dirven L, Habets EJJ, van den Bent MJ, Taphoorn MJB, Bromberg JEC. Cognitive functioning and health-related quality of life in patients with newly diagnosed primary CNS lymphoma: a systematic review. Lancet Oncol 2019; 19:e407-e418. [PMID: 30102235 DOI: 10.1016/s1470-2045(18)30356-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 05/02/2018] [Accepted: 05/03/2018] [Indexed: 12/29/2022]
Abstract
Incidence of primary CNS lymphoma (PCNSL) is increasing, while prognosis is improving as treatments advance. However, declined cognitive functioning remains a major challenge in the treatment of PCNSL. This cognitive decline, in conjunction with other symptoms caused by the disease or its treatment, or both, can compromise health-related quality of life (HRQOL). The aim of this Review was to give a comprehensive overview on cognitive functioning and HRQOL for patients with PCNSL, including an evaluation of patient-related and treatment-related factors that can influence cognitive functioning and HRQOL. We reviewed the literature for studies on cognitive functioning and HRQOL in newly diagnosed adult patients with PCNSL using MEDLINE/PubMed, Embase, Web of Science, Scopus, Cochrane, PsycINFO, CINAHL EBSCO, and Google Scholar, up to Jan 4, 2018. Articles were selected using predetermined inclusion and exclusion criteria; 42 articles were eligible for inclusion. Findings show that the tumour itself has a great effect on cognitive functioning and HRQOL. Initially, induction chemotherapy results in improvement of cognition and HRQOL in most patients. In the long-term, the addition of whole-brain radiotherapy has a negative effect on cognitive functioning, but the magnitude of this effect is not always clinically relevant. HRQOL scores were worse compared with controls, and worse after combined chemotherapy and radiotherapy when compared with chemotherapy only, particularly in the long term. Therefore, combined chemotherapy and radiotherapy seems to have a negative effect on HRQOL and cognition in patients with PCNSL. Although prolonged progression-free survival is achieved with combined treatment, information on its effect on cognition and HRQOL should be included in clinical decision-making.
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Affiliation(s)
- Matthijs van der Meulen
- Department of Neuro-Oncology, Erasmus MC Cancer Institute, Brain Tumor Center, University Medical Center Rotterdam, Rotterdam, Netherlands.
| | - Linda Dirven
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands; Department of Neurology, Haaglanden Medical Center, The Hague, Netherlands
| | - Esther J J Habets
- Department of Neurology, Haaglanden Medical Center, The Hague, Netherlands; Department of Medical Psychology, Haaglanden Medical Center, The Hague, Netherlands
| | - Martin J van den Bent
- Department of Neuro-Oncology, Erasmus MC Cancer Institute, Brain Tumor Center, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Martin J B Taphoorn
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands; Department of Neurology, Haaglanden Medical Center, The Hague, Netherlands
| | - Jacoline E C Bromberg
- Department of Neuro-Oncology, Erasmus MC Cancer Institute, Brain Tumor Center, University Medical Center Rotterdam, Rotterdam, Netherlands
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Royer-Perron L, Hoang-Xuan K. Management of primary central nervous system lymphoma. Presse Med 2018; 47:e213-e244. [PMID: 30416008 DOI: 10.1016/j.lpm.2018.04.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 03/21/2018] [Accepted: 04/09/2018] [Indexed: 12/28/2022] Open
Abstract
A rare tumor, primary central nervous system lymphoma can affect immunocompetent and immunocompromised patients. While sensitive to radiotherapy or chemotherapy crossing the blood-brain barrier, it often recurs. Modern treatment consists of high-dose methotrexate-based induction chemotherapy, often followed by consolidation with either radiotherapy or further chemotherapy. Neurotoxicity is however a concern with radiotherapy, especially for patients older than 60 years. The benefit of the addition of rituximab to chemotherapy is unclear. Targeted therapies and immunotherapy have been effective in some patients and are tested on a larger scale. Survival has improved in the last decade, but remains poor in older patients.
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Affiliation(s)
- Louis Royer-Perron
- Hôpital Pierre-Boucher, Longueuil, Canada; AP-HP, Sorbonne universités, UPMC université Paris 06, hôpitaux Universitaires La Pitié Salpêtrière, Charles Foix, service de neurologie, 2, Mazarin, 75013, Paris, France; LOC network, 75561 Paris cedex 13, France.
| | - Khê Hoang-Xuan
- Institut du Cerveau et de la Moelle épinière (ICM), Inserm U 1127, CNRS UMR 7225, Paris, France; AP-HP, Sorbonne universités, UPMC université Paris 06, hôpitaux Universitaires La Pitié Salpêtrière, Charles Foix, service de neurologie, 2, Mazarin, 75013, Paris, France; LOC network, 75561 Paris cedex 13, France
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Han X, Ji Y, Ouyang M, Zhu T, Zhou D. Efficacy and safety of HD-MTX based systemic chemotherapy regimens: retrospective study of induction therapy for primary central nervous system lymphoma in Chinese. Sci Rep 2017; 7:17053. [PMID: 29213063 PMCID: PMC5719046 DOI: 10.1038/s41598-017-17359-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 11/22/2017] [Indexed: 12/15/2022] Open
Abstract
We performed a retrospective study of 49 patients with newly diagnosed primary central nervous system lymphoma (PCNSL), to compare the efficacy and safety of different high-dose methotrexate (HD-MTX) based systemic chemotherapy regimens as induction therapy. 25 patients received AB ± R alternative regimen (consist methotrexate, ifosfamide, vindesine, dexamethasone, carmustine and teniposide), while others received HD-MTX ± R regimen. The complete response rate and overall response rate of AB ± R group and HD-MTX ± R group were 36.83% vs. 33.33%, and 68.42% vs. 71.43%, while the 2-year OS and PFS rate were 71.43% vs. 74.62%, and 42.86% vs. 54.64%, respectively. In Age > 60 subgroup, the 2-year OS and PFS rate of AB ± R group and HD-MTX ± R group were 81.82% vs. 33.33%, and 54.55% vs. 33.33%. No significant differences were found in grade 3 or 4 toxicity rate. Generally, HD-MTX ± R regimen was not inferior to AB ± R alternative regimen, but AB ± R alternative regimen seemed achieving more survival benefits in the elderly. We suggest to adjust HD-MTX ± R regimen by changing the dose-reduction strategy especially in elderly patients and adding other powerful drugs that can well penetrate blood-brain barrier to improve the efficacy.
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Affiliation(s)
- Xiao Han
- Department of Haematology, Chinese Academy of Medical Science, Peking Union Medical College Hospital, Beijing, China
| | - Yali Ji
- Department of Haematology, Chinese Academy of Medical Science, Peking Union Medical College Hospital, Beijing, China
| | - Mingqi Ouyang
- Department of Haematology, Chinese Academy of Medical Science, Peking Union Medical College Hospital, Beijing, China
| | - Tienan Zhu
- Department of Haematology, Chinese Academy of Medical Science, Peking Union Medical College Hospital, Beijing, China
| | - Daobin Zhou
- Department of Haematology, Chinese Academy of Medical Science, Peking Union Medical College Hospital, Beijing, China.
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Zheng M, Perry AM, Bierman P, Loberiza F, Nasr MR, Szwajcer D, Del Bigio MR, Smith LM, Zhang W, Greiner TC. Frequency of MYD88 and CD79B mutations, and MGMT methylation in primary central nervous system diffuse large B-cell lymphoma. Neuropathology 2017; 37:509-516. [PMID: 28856744 DOI: 10.1111/neup.12405] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 06/29/2017] [Accepted: 06/29/2017] [Indexed: 12/24/2022]
Abstract
Primary CNS diffuse large B-cell lymphoma (PCNS-DLBCL) and systemic DLBCL harbor mutations in MYD88 and CD79B. DNA methyltransferase (MGMT) is methylated in some DLBCL. Our goal was to investigate the frequencies of these events, which have not been previously reported within the same series of patients with PCNS-DLBCL. Fifty-four cases of PCNS-DLBCL from two institutions were analyzed by Sanger sequencing for MYD88 and CD79B, and pyrosequencing for MGMT. MYD88 mutations were identified in 68.8% (35 of 51 cases), with L265P being the most frequent mutation. Mutations other than L265P were identified in 21.6% of cases, of which eight novel MYD88 mutations were identified. Of mutated cases, 17.6% had homozygous/hemizygous MYD88 mutations, which has not been previously reported in PCNS-DLBCL. CD79B mutations were found in six of 19 cases (31.6%), all in the Y196 mutation hotspot. MGMT methylation was observed in 37% (20 of 54 cases). There was no significant difference in median overall survival (OS) between the wild type and mutated MYD88 cases, or between methylated and unmethylated MGMT cases. However, a significant difference (P = 0.028) was noted in median OS between the wild type and mutated CD79B cases.
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Affiliation(s)
- Mei Zheng
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Anamarija M Perry
- Department of Pathology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Philip Bierman
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Fausto Loberiza
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Michel R Nasr
- Department of Pathology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Szwajcer
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Marc R Del Bigio
- Department of Pathology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lynette M Smith
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Weiwei Zhang
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Timothy C Greiner
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Kerbauy MN, Moraes FY, Lok BH, Ma J, Kerbauy LN, Spratt DE, Santos FPS, Perini GF, Berlin A, Chung C, Hamerschlak N, Yahalom J. Challenges and opportunities in primary CNS lymphoma: A systematic review. Radiother Oncol 2017; 122:352-361. [PMID: 28104300 DOI: 10.1016/j.radonc.2016.12.033] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 12/29/2016] [Accepted: 12/29/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Historically, high-dose methotrexate (HD-MTX) plus consolidation chemotherapy and/or whole brain radiotherapy (WBRT) has been the gold standard on Primary Central Nervous System Lymphoma (PCNSL) management. We sought to examine and summarize the data, on clinical trial (CT) setting, investigating multi-modality treatment to PCNSL. METHODS We performed a systematic review of electronic databases (Medline, EMBASE, Cochrane Database and clinicaltrials.gov) and a manual search to identify original PCNSL phase 2 and phase 3 CT from the last 10years. After a 4stage Prisma based selection process, 32 published (3 Randomized CT and 29 phases 2 CT) studies ultimately were selected for review. Four ongoing clinical trials found on clinicaltrial.gov were reviewed. Two investigators reviewed titles, abstracts, and articles independently. Two investigators abstracted data sequentially and evaluated each study independently. FINDINGS Treatment of PCNSL requires a multidisciplinary approach. HD-MTX represents the most accepted standard of care induction therapy for newly diagnosed PCNSL. When HD-MTX is given with WBRT for consolidation delayed neurotoxicity can be an important complication, particularly in elderly patients. Studies have suggested that WBRT may be deferred until relapse without compromising survival and deferring WBRT may be the best approach in elderly patients. Results from dose-reduced WBRT and consolidative HD-Ara-C are encouraging. High-dose chemotherapy in combination with autologous stem cell transplantation (HDC-ASCT) as chemotherapy alone has emerged as an important consolidative treatment for selected population. The optimal salvage therapy is still to be defined. CONCLUSION WBRT for consolidation is a well-studied modality; however emerging options to selected population such as HDC-ASCT, dose-reduced WBRT or chemotherapy alone are associated with similar survival outcome and less neurotoxicity in selected series. Ongoing and future clinical trials will better define the best approach on this rare disease.
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Affiliation(s)
- Mariana N Kerbauy
- Department of Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Fabio Y Moraes
- Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo, Brazil; Department of Radiation Oncology, University of Toronto, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.
| | - Benjamin H Lok
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Jennifer Ma
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Lucila N Kerbauy
- Department of Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan Medical Center, Ann Arbor, USA
| | - Fabio P S Santos
- Department of Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Guilherme F Perini
- Department of Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Caroline Chung
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, USA
| | - Nelson Hamerschlak
- Department of Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Joachim Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
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12
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Chen D, Gu W, Li W, Liu X, Yang X. Primary diffuse large B-cell lymphoma of the central nervous system: A case report and literature review. Oncol Lett 2016; 11:3085-3090. [PMID: 27123068 DOI: 10.3892/ol.2016.4365] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 12/14/2015] [Indexed: 12/13/2022] Open
Abstract
The present study reports the clinical diagnosis and management of a patient with primary diffuse large B-cell lymphoma (Bcl) of the central nervous system (CNS). Making an early diagnosis of primary diffuse large Bcl is challenging due to the variable and complicated clinical manifestations of the disease. The relevant literature was reviewed, and high-dose methotrexate, whole brain radiotherapy and highly active antiretroviral therapy was recommended for the patient. The present study elucidates the role of positron emission tomography-computed tomography scans for the diagnosis and management of primary diffuse large Bcl of the CNS, and demonstrates the importance of resection surgery in the management of the disease. Specifically, the present study proposes that resection surgery may be applied in the early stages of disease for patients with a single occupied lesion and increased intracranial pressure.
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Affiliation(s)
- Dawei Chen
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Weihong Gu
- Department of Surgery, The Second Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Wenzhong Li
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Xiaoliang Liu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Xiaoyu Yang
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
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13
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Hirono S, Iwadate Y, Higuchi Y, Serizawa T, Nagano O, Matsutani T, Saeki N. Stereotactic radiosurgery in combination with up-front high-dose methotrexate as a first-line treatment for newly diagnosed primary central nervous system lymphoma. J Neurooncol 2015; 123:237-44. [PMID: 25911295 DOI: 10.1007/s11060-015-1786-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 04/20/2015] [Indexed: 11/30/2022]
Abstract
The efficacy of stereotactic radiosurgery (SRS) instead of whole brain radiotherapy (WBRT) following high-dose methotrexate (HD-MTX) for primary central nervous system lymphoma (PCNSL) is unclear. To clarify whether SRS in combination with up-front HD-MTX supplements the effect of HD-MTX in remaining or refractory lesions after initial HD-MTX treatment. The authors conducted a retrospective review for newly diagnosed PCNSL patients who underwent SRS after HD-MTX as a first-line treatment. The local control (LC), the progression-free survival (PFS), the recurrence patterns, the salvage treatments, the overall survival (OS), the Karnofsky Performance Status (KPS), the activities of daily living (ADL) were analyzed as well as radiosurgical parameters. Twenty patients underwent SRS for 51 lesions with the median volume of 0.45 cm(3). The median age at SRS was 67 (range 37-82). The median KPS at SRS was 90. The LC rate at 2 years was 86.0 %, the median PFS after SRS was 17 months, necessitating additional SRS and chemotherapy. The median OS was 52 months. No significant side effects related to SRS were observed. During follow-up period, the good ADL preservation was achieved for 13 months from SRS. Patients with KPS ≥ 90 at SRS demonstrated longer ADL preservation (32 months from SRS). SRS following up-front HD-MTX without WBRT provided excellent LC, acceptable OS and the long ADL preservation period. These benefits may be more emphasized especially in patients with good KPS, but should be validated in a large patient population.
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Affiliation(s)
- Seiichiro Hirono
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuoku, Chiba, 260-8670, Japan,
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14
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Reduced neurotoxicity with combined treatment of high-dose methotrexate, cyclophosphamide, doxorubicin, vincristine and prednisolone (M-CHOP) and deferred radiotherapy for primary central nervous system lymphoma. Clin Neurol Neurosurg 2014; 127:106-11. [DOI: 10.1016/j.clineuro.2014.10.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 10/05/2014] [Accepted: 10/10/2014] [Indexed: 11/21/2022]
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15
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Nakajima H, Motomura M, Yamaguchi M, Katoh T, Abe K. [Leptomeningeal infiltlation of primary CNS B-cell lymphoma diagnosed by the biopsy of cauda equina: a case report]. Rinsho Shinkeigaku 2014; 53:803-8. [PMID: 24225563 DOI: 10.5692/clinicalneurol.53.803] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 49-year-old man was admitted to our hospital with progressive gait disturbance. Our examination revealed a low grade fever, weight loss derived muscle weakness, sensory disturbance and loss of deep tendon reflex of the lower extremities. Magnetic resonance imaging (MRI) detected an abnormal intensity and gadolinium enhancement in the cauda equina. Two weeks after admission, disturbance of consciousness and bladder appeared. Cerebrospinal fluid examination showed pleocytosis, elevated protein and soluble IL-2R, but cytological examination was class II negative. We performed a cauda equina biopsy urgently and diagnosed malignant lymphoma, of a diffuse large B-cell type. We selected combined MTX-based chemoradiotherapy and his symptoms significantly improved after a month. He achieved complete remission and remains recurrence-free after 10 months post treatment although he remains with light paraparesis and sensory disturbance of the lower extremities. He has already gone back to a normal life. An examination of cauda equina biopsy led to quick diagnosis and treatment.
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Affiliation(s)
- Hideki Nakajima
- Unit of Translational Medicine, Department of Clinical Neuroscience and Neurology, Nagasaki University Graduate School of Biomedical Science
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16
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Upfront autologous stem-cell transplantation with melphalan, cyclophosphamide, etoposide, and dexamethasone (LEED) in patients with newly diagnosed primary central nervous system lymphoma. Int J Hematol 2014; 100:152-8. [PMID: 24947495 DOI: 10.1007/s12185-014-1608-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 05/22/2014] [Accepted: 05/28/2014] [Indexed: 10/25/2022]
Abstract
Treatment of primary central nervous system lymphoma (PCNSL) improved in recent years. However, the high neurotoxicity and low survival rates associated with this condition remain unresolved. We report 13 consecutive patients with PCNSL for whom upfront melphalan, cyclophosphamide, etoposide, and dexamethasone (known as LEED) followed by autologous stem-cell transplantation (ASCT) was planned at the Anjo Kosei Hospital. All patients were pathologically diagnosed with diffuse large B-cell lymphoma and were negative for human immunodeficiency virus. All patients were to receive three cycles of high-dose methotrexate-based induction chemotherapy, two cycles of high-dose AraC-based chemotherapy, and LEED followed by ASCT. All 13 patients achieved a partial response, and the 3-year overall survival (OS) rate was 76.2 %. Seven of the 13 patients were alive at the last follow-up, without any adverse events, including neurotoxicity. Six of the 13 (46.2 %) patients underwent ASCT and the 3-year OS rate was 80.0 %. Although this study included only a limited number of patients, these preliminary signs of efficacy and tolerability merit further consideration. To make further improvements in survival, the rate of patients undergoing ASCT should be increased. Other prospective studies involving greater numbers of patients are required to confirm these findings.
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17
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Prica A, Chan K, Cheung M. Combined modality therapy versus chemotherapy alone as an induction regimen for primary central nervous system lymphoma: a cost-effectiveness analysis. Neuro Oncol 2014; 16:1384-91. [PMID: 24799455 DOI: 10.1093/neuonc/nou057] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In immunocompetent patients with primary central nervous system lymphoma (PCNSL), combined modality therapy (CMT) using high-dose methotrexate and radiotherapy (WBRT) has improved response rates compared with chemotherapy alone. The trade-off is delayed and potentially devastating treatment-related neurotoxicity (NT). METHODS A cost-effectiveness analysis using a Markov model compared CMT with chemotherapy alone in age-stratified patients with PCNSL. Baseline probabilities were derived from a systematic literature review. Direct and lost productivity costs were collected from a Canadian perspective and presented in Can$ in 2011. Outcomes were life expectancy, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio. RESULTS The quality-adjusted life expectancy was 1.55 QALYs for CMT and 1.53 QALYs for chemotherapy alone. In younger patients (aged <60 years), CMT yielded 2.44 QALYs, compared with 1.89 QALYs for chemotherapy alone, yielding an expected benefit with CMT of 0.55 QALYs or 6.6 quality-adjusted months. The CMT strategy dominated in younger patients, as it was Can$11 951 less expensive than chemotherapy alone. The chemotherapy-alone strategy dominated in older patients, as it was Can$11 244 less expensive than CMT, and there was no difference in QALYs between the strategies. The model was robust in sensitivity analyses of key variables tested through the plausible ranges obtained from costing sources and published literature. CONCLUSION The preferred induction strategy for younger patients with PCNSL appears to be CMT, which minimized cost while maximizing life expectancy and QALYs. This analysis confirms that the preferred strategy for older patients is chemotherapy alone.
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Affiliation(s)
- A Prica
- Division of Hematology, Department of Medicine, Sunnybrook Health Science Centre, University of Toronto, Toronto, Canada (A.P., M.C.); Division of Medical Oncology, Department of Medicine, Sunnybrook Health Science Centre and Princess Margaret Hospital, University of Toronto, Toronto, Canada (K.C.)
| | - K Chan
- Division of Hematology, Department of Medicine, Sunnybrook Health Science Centre, University of Toronto, Toronto, Canada (A.P., M.C.); Division of Medical Oncology, Department of Medicine, Sunnybrook Health Science Centre and Princess Margaret Hospital, University of Toronto, Toronto, Canada (K.C.)
| | - M Cheung
- Division of Hematology, Department of Medicine, Sunnybrook Health Science Centre, University of Toronto, Toronto, Canada (A.P., M.C.); Division of Medical Oncology, Department of Medicine, Sunnybrook Health Science Centre and Princess Margaret Hospital, University of Toronto, Toronto, Canada (K.C.)
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18
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Prognostic impact of completion of initial high-dose methotrexate therapy on primary central nervous system lymphoma: a single institution experience. Int J Clin Oncol 2014; 20:29-34. [DOI: 10.1007/s10147-014-0692-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 03/26/2014] [Indexed: 10/25/2022]
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19
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Primary B-cell CNS lymphoma clinicopathologic and treatment outcomes in 89 patients from a single tertiary care center. Int J Hematol 2014; 99:450-6. [DOI: 10.1007/s12185-014-1540-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 02/12/2014] [Accepted: 02/13/2014] [Indexed: 10/25/2022]
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20
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Non-deep-seated primary CNS lymphoma: therapeutic responses and a molecular signature. J Neurooncol 2014; 117:261-8. [DOI: 10.1007/s11060-014-1379-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 01/19/2014] [Indexed: 10/25/2022]
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21
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Schäfer N, Glas M, Herrlinger U. Primary CNS lymphoma: a clinician's guide. Expert Rev Neurother 2013; 12:1197-206. [PMID: 23082736 DOI: 10.1586/ern.12.120] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Primary CNS lymphoma is a high malignant disease of the brain which can lead rapidly to death if diagnosis and/or the start of treatment is delayed. The age at time of diagnosis is a strong factor influencing prognosis so that in younger patients <65 years of age long-term survival may be achieved in a substantial percentage of patients, while in elderly patients long-term survival is seen much more rarely. First-line therapy consists of high-dose methotrexate-based (poly)chemotherapy. This review provides an overview of clinical presentation, steps to diagnosis, detailed information about current treatment concepts and specific information for particular clinical situations.
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Affiliation(s)
- Niklas Schäfer
- Division of Clinical Neurooncology, Department of Neurology, University Hospital of Bonn, Bonn, Germany
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22
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Bergner N, Monsef I, Illerhaus G, Engert A, Skoetz N. Role of chemotherapy additional to high-dose methotrexate for primary central nervous system lymphoma (PCNSL). Cochrane Database Syst Rev 2012; 11:CD009355. [PMID: 23152274 DOI: 10.1002/14651858.cd009355.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Primary central nervous system lymphoma (PCNSL) is a variant of extranodal non-Hodgkin lymphoma (NHL) that accounts for about 2% to 5% of all primary intracranial tumours with immunocompetent patients. It appears at a median age of 62 years. A standard of care for PCNSL patients has not been defined yet, but high-dose methotrexate (HD-MTX) is considered to be a beneficial chemotherapy in PCNSL treatment. Currently, HD-MTX is combined with numerous other chemotherapy drugs to improve outcomes of HD-MTX monotherapy. However, the impact of additional chemotherapy remains unclear, as there is evidence of a higher risk of adverse events (AEs) such as infective complications. OBJECTIVES We performed a systematic review of randomised controlled trials (RCTs) to assess the efficacy and safety of additional chemotherapy to HD-MTX in the treatment of immunocompetent PCNSL patients. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 5) and MEDLINE (from 1950 to May 2012) as well as conference proceedings for RCTs. Two review authors (NB, NS) independently screened search results. SELECTION CRITERIA We included RCTs comparing HD-MTX in combination with additional chemotherapy to mono-chemotherapy with HD-MTX in immunocompetent patients off all ages in first-line treatment of PCNSL. DATA COLLECTION AND ANALYSIS As an effect measure we used hazard ratios (HR) and 95% confidence intervals (CI) for overall survivals (OS) and progression-free survival (PFS). For effect measure of complete remission rate (CRR), partial response rate (PRR), treatment-related mortality (TRM) and AEs we used risk ratios (RR). Two review authors (NB, NS) independently extracted data and assessed the quality of trials. MAIN RESULTS Our search strategies led to 699 potentially relevant references. Of these, one RCT involving 79 patients was included. We judged the quality of the trial as moderate. The study was reported as a randomised open-label study and published as a full-text article.Even though PFS was statistically significantly improved for patients treated with HD-MTX plus cytarabine (HR 0.54; 95% CI 0.31 to 0.92; P = 0.01), this did not translate to a statistical significant OS benefit (HR 0.65; 95% CI 0.38 to 1.13; P = 0.07). AEs, especially infective complications, hepatotoxicity and haematological toxicities, were assessed more often in patients undergoing HD-MTX therapy combined with cytarabine. However, there were no statistically significant differences in terms of TRM (RR 3.08; 95% CI 0.33 to 28.32; P = 0.35). AUTHORS' CONCLUSIONS Owing to the small number of included trials and patients, the findings in this review remain uncertain. In summary, the presently available evidence (one small trial) showed a benefit in terms of PFS, ORR and CRR but no statistically significant difference regarding OS for patients with PCNSL treated with HD-MTX plus cytarabine compared to HD-MTX alone. However, the risk of severe infections and toxicity was significantly higher in patients treated with combined chemotherapy. More RCTs with additional chemotherapy to HD-MTX therapy with higher numbers of patients and longer follow-up periods are needed to confirm the results of this review and determine whether the PFS benefit will translate into an OS advantage. At least the one included study shows that RCTs of moderate quality and with valuable outcomes for this malignant disease are feasible.
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Affiliation(s)
- Nicole Bergner
- Cochrane Haematological Malignancies Group, Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
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23
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Brastianos PK, Batchelor TT. Primary Central Nervous System Lymphoma. Hematol Oncol Clin North Am 2012; 26:897-916. [DOI: 10.1016/j.hoc.2012.05.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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24
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Prica A, Chan K, Cheung MC. Combined modality therapy versus chemotherapy alone as an induction regimen for primary central nervous system lymphoma: a decision analysis. Br J Haematol 2012; 158:600-7. [PMID: 22734565 DOI: 10.1111/j.1365-2141.2012.09208.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Accepted: 05/15/2012] [Indexed: 11/29/2022]
Abstract
In immunocompetent patients with primary central nervous system (CNS) lymphoma, combined modality therapy (CMT) using high-dose methotrexate and whole brain radiotherapy has improved response rates compared to chemotherapy alone. The trade-off is delayed and potentially devastating treatment-related neurotoxicity. A Markov decision-analytic model compared CMT to chemotherapy alone in patients with primary CNS lymphoma. Baseline probabilities were derived from a systematic literature review. Outcomes were life expectancy and quality-adjusted life expectancy. Sensitivity analyses were performed. The life expectancy was 2·69 years for CMT and 2·77 years for chemotherapy alone. The quality-adjusted life expectancies for the two strategies were 1·70 and 1·67 quality-adjusted life years (QALYs) respectively. In younger patients <60 years of age, CMT yielded a quality-adjusted life expectancy of 2·71 QALYs, compared to 2·09 QALYs for chemotherapy alone, yielding an expected benefit with CMT of 0·62 QALYs or 7·4 quality-adjusted months. There was no difference between the strategies in the older group. The model was robust to key variables for the younger group. The preferred induction strategy for younger patients appears to be CMT, maximizing life expectancy, and QALYs. This analysis confirms that the preferred strategy for older patients is chemotherapy alone.
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Affiliation(s)
- Anca Prica
- Division of Haematology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.
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25
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Joerger M, Huitema ADR, Illerhaus G, Ferreri AJM. Rational administration schedule for high-dose methotrexate in patients with primary central nervous system lymphoma. Leuk Lymphoma 2012; 53:1867-75. [PMID: 22530664 DOI: 10.3109/10428194.2012.676177] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Methotrexate (MTX) at a dose of ≥1 g/m(2) remains the most efficient treatment against primary central nervous system lymphoma (PCNSL), and is the most widely used drug in prospective clinical trials. MTX is a folate analog that inhibits dihydrofolate reductase, thereby blocking de novo purine synthesis. MTX as well as 7-hydroxy-MTX, its main metabolite in serum, are both eliminated by the kidneys. The elimination of MTX is prolonged in patients with renal impairment and third-space fluid collections, and in patients receiving concurrent non-steroidal antirheumatic drugs, benzimidazoles and sulfonamides, among others. Main adverse events with high-dose MTX include severe myelosuppression, renal dysfunction and stomatitis. Supportive measures such as rigorous hydration, urine alkalinization and careful drug monitoring with supplemental leucovorin rescue are crucial to avoid significant toxicity. Strategies to optimize clinical efficacy of high-dose MTX in patients with PCNSL include administration of 3 h instead of longer infusions, potentially supplemented with an additional intravenous MTX bolus, and maintaining MTX dose intensity over the course of four treatment cycles. Some pharmacological studies suggest that achieving an MTX area under the plasma concentration-time curve (AUC(MTX)) of between 1000 and 1100 μmol.h/L may improve clinical outcome, but clinical data are not conclusive at present. In this review, we analyze the impact of patient, lymphoma and pharmacokinetic variables on the antitumor activity of high-dose MTX in patients with PCNSL, summarize recommendations for daily clinical practice and give some suggestions for future trials.
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Affiliation(s)
- M Joerger
- Department of Oncology and Hematology, Cantonal Hospital, St. Gallen, Switzerland.
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26
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Prodduturi P, Bierman PJ. Current and emerging pharmacotherapies for primary CNS lymphoma. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2012; 6:219-31. [PMID: 22654527 PMCID: PMC3362327 DOI: 10.4137/cmo.s7752] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Primary central nervous system lymphoma (PCNSL) constitutes a rare group of extranodal non-Hodgkin's lymphoma (NHL) primarily of B cell origin. It occurs in both immuno-competent and immune-compromised patients. High dose m ethotrexate (HD-MTX) based chemotherapy is the standard therapy. Chemotherapy with whole brain radiation therapy (WBRT) improves response rates and survival compared with WBRT alone. However, due to the increased risk for neurotoxicity with WBRT, recent studies have focused on using chemotherapy alone. Methotrexate based multi-agent chemotherapy without WBRT is associated with similar t reatment rates and survival compared with regimens that include WBRT although controlled trials have not been performed. Because of the low incidence of this disease, it is difficult to conduct randomized controlled trials. In this article we have discussed about the past, present and emerging treatment options in patients with PCNSL.
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Affiliation(s)
- Prathima Prodduturi
- University of Nebraska Medical Center, Division of Hematology and Oncology, Omaha, NE, USA 68198-7680
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27
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Fakhry C, Bajaj G, Aygun N, Westra W, Gillison M. Long-term survival of a patient with leptomeningeal involvement by nasopharyngeal carcinoma after treatment with high-dose intravenous methotrexate. Head Neck 2012; 34:296-300. [PMID: 20737501 PMCID: PMC3715067 DOI: 10.1002/hed.21516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Revised: 04/30/2010] [Accepted: 05/13/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nasopharyngeal carcinoma with leptomeningeal involvement is rare and typically has poor prognosis. METHODS AND RESULTS We present a case report of a patient with nasopharyngeal carcinoma who was treated with high-dose intravenous methotrexate and remains asymptomatic and without clinical evidence of disease 6 years later. CONCLUSIONS Systemic high-dose methotrexate should be evaluated in the treatment of advanced nasopharyngeal carcinoma with central nervous involvement.
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Affiliation(s)
- Carole Fakhry
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Gopal Bajaj
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nafi Aygun
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - William Westra
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Maura Gillison
- Department of Medicine, Division of Hematology and Oncology, Ohio State University, Columbus, Ohio
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28
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Gonzalez-Aguilar A, Houillier C, Soussain C, Hoang-Xuan K. [Management of primary central nervous system lymphoma]. Rev Neurol (Paris) 2011; 167:721-8. [PMID: 21906768 DOI: 10.1016/j.neurol.2011.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 08/02/2011] [Indexed: 11/18/2022]
Abstract
Primary CNS lymphoma is the malignant brain tumor whose prognosis has improved the most the two past decades. The majority of the patients achieve a complete remission with treatment and a substantial minority may hope to be cured. The treatment includes high-dose methotrexate polychemotherapy combined or not with whole brain radiotherapy (WBRT). Elderly patients who are exposed to a high risk of treatment induced neurotoxicity need a specific management avoiding or defering WBRT. In young patients, the main questions concerning the treatment are the role of consolidation WBRT and intensive chemotherapy with peripheral blood stem cell rescue in the initial treatment of PCNSL. As recently shown, national and international collaborative efforts make now possible randomized trials for this rare disease, which would contribute to better define the treatment strategy. New insights in PCNSL tumorigenesis would help to better understand the heterogeneity of outcome and to develop efficient targeted therapies.
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Affiliation(s)
- A Gonzalez-Aguilar
- UPMC, Service de neurologie Mazarin, groupe hospitalier Pitié-Salpêtrière, 47 boulevard de l'Hôpital, Paris cedex 13, France
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Deckert M, Engert A, Brück W, Ferreri AJM, Finke J, Illerhaus G, Klapper W, Korfel A, Küppers R, Maarouf M, Montesinos-Rongen M, Paulus W, Schlegel U, Lassmann H, Wiestler OD, Siebert R, DeAngelis LM. Modern concepts in the biology, diagnosis, differential diagnosis and treatment of primary central nervous system lymphoma. Leukemia 2011; 25:1797-807. [PMID: 21818113 DOI: 10.1038/leu.2011.169] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Recent studies addressing the molecular characteristics of PCNSL, which is defined as malignant B-cell lymphoma with morphological features of DLBCL, have significantly improved our understanding of the pathogenesis of this lymphoma entity, which is associated with an inferior prognosis as compared with DLBCL outside the CNS. This unfavorable prognosis stimulated intense efforts to improve therapy and induced recent series of clinical studies, which addressed the role of radiotherapy and various chemotherapeutic regimens. This review combines the discussion of diagnosis, differential diagnosis and recent progress in studies addressing the molecular pathogenesis as well as therapeutic options in PCNSL.
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Affiliation(s)
- M Deckert
- Department of Neuropathology, University Hospital of Cologne, Cologne, Germany.
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Salvage treatment with temozolomide in refractory or relapsed primary central nervous system lymphoma and assessment of the MGMT status. J Neurooncol 2011; 106:155-60. [PMID: 21720808 DOI: 10.1007/s11060-011-0652-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2011] [Accepted: 06/20/2011] [Indexed: 10/18/2022]
Abstract
High-dose methotrexate (HD-MTX) is effective in the initial treatment of primary central nervous system lymphoma (PCNSL). Because treatment options in patients with progressive or recurrent PCNSL are limited, prognosis is poor. Temozolomide, a well-tolerated oral alkylating agent that permeates the blood brain barrier (BBB), is effective against malignant glioma and recurrent PCNSL. The gene for the deoxyribonucleic acid (DNA) repair enzyme O(6)-methylguanine-DNA methyltransferase (MGMT), which is closely related to cellular sensitivity to alkylating agents, is inactivated by promoter hypermethylation. We evaluated the results of temozolomide treatment and the methylation status of the promoter region of the MGMT gene in 17 patients (median age 68 years) with refractory or relapsed PCNSL. They were immunocompetent and had received initial treatment with HD-MTX (3.5 g/m(2)) with or without irradiation. All were treated with temozolomide 150-200 mg/m(2), for 5 days in the course of 28 days; treatment was continued until disease progression. We observed five complete remissions, five partial responses (PRs) with stable disease (SD), and seven with disease progression. Median overall survival after the temozolomide treatment was 6.7 months. One patient manifested grade 3 neutropenia and thrombocytopenia. Eleven tumor specimens were available for MGMT analysis. MGMT promoter methylation (mMGMT) in the tumor tissue was found in 4 (36.4%), the other seven harbored a non-methylated MGMT promoter (nmMGMT). There was no statistically significant difference in median overall survival between patients with mMGMT (11.1 months) and nmMGMT (6.7 months) (P = 0.63). Although some patients were elderly and had been heavily pre-treated, temozolomide resulted in a complete response (CR) in 29% and was well tolerated without any major toxicity.
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Gerard LM, Imrie KR, Mangel J, Buckstein R, Doherty M, Mackenzie R, Cheung MC. High-dose methotrexate based chemotherapy with deferred radiation for treatment of newly diagnosed primary central nervous system lymphoma. Leuk Lymphoma 2011; 52:1882-90. [DOI: 10.3109/10428194.2011.584004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Thiel E, Korfel A, Martus P, Kanz L, Griesinger F, Rauch M, Röth A, Hertenstein B, von Toll T, Hundsberger T, Mergenthaler HG, Leithäuser M, Birnbaum T, Fischer L, Jahnke K, Herrlinger U, Plasswilm L, Nägele T, Pietsch T, Bamberg M, Weller M. High-dose methotrexate with or without whole brain radiotherapy for primary CNS lymphoma (G-PCNSL-SG-1): a phase 3, randomised, non-inferiority trial. Lancet Oncol 2010; 11:1036-47. [PMID: 20970380 DOI: 10.1016/s1470-2045(10)70229-1] [Citation(s) in RCA: 402] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND High-dose methotrexate is the standard of care for patients with newly diagnosed primary CNS lymphoma. The role of whole brain radiotherapy is controversial because delayed neurotoxicity limits its acceptance as a standard of care. We aimed to investigate whether first-line chemotherapy based on high-dose methotrexate was non-inferior to the same chemotherapy regimen followed by whole brain radiotherapy for overall survival. METHODS Immunocompetent patients with newly diagnosed primary CNS lymphoma were enrolled from 75 centres and treated between May, 2000, and May, 2009. Patients were allocated by computer-generated block randomisation to receive first-line chemotherapy based on high-dose methotrexate with or without subsequent whole brain radiotherapy, with stratification by age (<60 vs ≥60 years) and institution (Berlin vs Tübingen vs all other sites). The biostatistics centre assigned patients to treatment groups and informed local centres by fax; physicians and patients were not masked to treatment group after assignment. Patients enrolled between May, 2000, and August, 2006, received high-dose methotrexate (4 g/m(2)) on day 1 of six 14-day cycles; thereafter, patients received high-dose methotrexate plus ifosfamide (1·5 g/m(2)) on days 3-5 of six 14-day cycles. In those assigned to receive first-line chemotherapy followed by radiotherapy, whole brain radiotherapy was given to a total dose of 45 Gy, in 30 fractions of 1·5 Gy given daily on weekdays. Patients allocated to first-line chemotherapy without whole brain radiotherapy who had not achieved complete response were given high-dose cytarabine. The primary endpoint was overall survival, and analysis was per protocol. Our hypothesis was that the omission of whole brain radiotherapy does not compromise overall survival, with a non-inferiority margin of 0·9. This trial is registered with ClinicalTrials.gov, number NCT00153530. FINDINGS 551 patients (median age 63 years, IQR 55-69) were enrolled and randomised, of whom 318 were treated per protocol. In the per-protocol population, median overall survival was 32·4 months (95% CI 25·8-39·0) in patients receiving whole brain radiotherapy (n=154), and 37·1 months (27·5-46·7) in those not receiving whole brain radiotherapy (n=164), hazard ratio 1·06 (95% CI 0·80-1·40; p=0·71). Thus our primary hypothesis was not proven. Median progression-free survival was 18·3 months (95% CI 11·6-25·0) in patients receiving whole brain radiotherapy, and 11·9 months (7·3-16·5; p=0·14) in those not receiving whole brain radiotherapy. Treatment-related neurotoxicity in patients with sustained complete response was more common in patients receiving whole brain radiotherapy (22/45, 49% by clinical assessment; 35/49, 71% by neuroradiology) than in those who did not (9/34, 26%; 16/35, 46%). INTERPRETATION No significant difference in overall survival was recorded when whole brain radiotherapy was omitted from first-line chemotherapy in patients with newly diagnosed primary CNS lymphoma, but our primary hypothesis was not proven. The progression-free survival benefit afforded by whole brain radiotherapy has to be weighed against the increased risk of neurotoxicity in long-term survivors.
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Affiliation(s)
- Eckhard Thiel
- Department of Hematology and Oncology, Charité Berlin, Berlin, Germany
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Hashemi-Sadraei N, Peereboom DM. Chemotherapy in newly diagnosed primary central nervous system lymphoma. Ther Adv Med Oncol 2010; 2:273-92. [PMID: 21789140 PMCID: PMC3126018 DOI: 10.1177/1758834010365330] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Primary central nervous system lymphoma (PCNSL) accounts for only 3% of brain tumors. It can involve the brain parenchyma, leptomeninges, eyes and the spinal cord. Unlike systemic lymphoma, durable remissions remain uncommon. Although phase III trials in this rare disease are difficult to perform, many phase II trials have attempted to define standards of care. Treatment modalities for patients with newly diagnosed PCNSL include radiation and/or chemotherapy. While the role of radiation therapy for initial management of PCNSL is controversial, clinical trials will attempt to improve the therapeutic index of this modality. Routes of chemotherapy administration include intravenous, intraocular, intraventricular or intra-arterial. Multiple trials have outlined different methotrexate-based chemotherapy regimens and have used local techniques to improve drug delivery. A major challenge in the management of patients with PCNSL remains the delivery of aggressive treatment with preservation of neurocognitive function. Because PCNSL is rare, it is important to perform multicenter clinical trials and to incorporate detailed measurements of long-term toxicities. In this review we focus on different chemotherapeutic approaches for immunocompetent patients with newly diagnosed PCNSL and discuss the role of local drug delivery in addition to systemic therapy. We also address the neurocognitive toxicity of treatment.
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Carrabba MG, Reni M, Foppoli M, Chiara A, Franzin A, Politi LS, Villa E, Ciceri F, Ferreri AJM. Treatment approaches for primary CNS lymphomas. Expert Opin Pharmacother 2010; 11:1263-76. [DOI: 10.1517/14656561003767456] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Matteo G Carrabba
- San Raffaele Scientific Institute, Haematology and Bone Marrow Transplantation Unit, Department of Oncology, Milan, Italy
- San Raffaele Scientific Institute, Unit of Lymphoid Malignancies, Medical Oncology Unit, Department of Oncology, Milan, Italy
| | - Michele Reni
- San Raffaele Scientific Institute, Medical Oncology Unit, Department of Oncology, Milan, Italy
| | - Marco Foppoli
- San Raffaele Scientific Institute, Unit of Lymphoid Malignancies, Medical Oncology Unit, Department of Oncology, Milan, Italy
| | - Anna Chiara
- San Raffaele Scientific Institute, Radiotherapy Unit, Department of Oncology, Milan, Italy
| | - Alberto Franzin
- San Raffaele Scientific Institute, Neurosurgery Unit, Department of Head and Neck, Milan, Italy
| | | | - Eugenio Villa
- San Raffaele Scientific Institute, Medical Oncology Unit, Department of Oncology, Milan, Italy
| | - Fabio Ciceri
- San Raffaele Scientific Institute, Haematology and Bone Marrow Transplantation Unit, Department of Oncology, Milan, Italy
| | - Andrés JM Ferreri
- San Raffaele Scientific Institute, Unit of Lymphoid Malignancies, Medical Oncology Unit, Department of Oncology, Milan, Italy
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Kawai N, Zhen HN, Miyake K, Yamamaoto Y, Nishiyama Y, Tamiya T. Prognostic value of pretreatment 18F-FDG PET in patients with primary central nervous system lymphoma: SUV-based assessment. J Neurooncol 2010; 100:225-32. [DOI: 10.1007/s11060-010-0182-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Accepted: 03/31/2010] [Indexed: 12/13/2022]
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Chimienti E, Spina M, Vaccher E, Tirelli U. Management of immunocompetent patients with primary central nervous system lymphoma. ACTA ACUST UNITED AC 2010; 9:353-64. [PMID: 19858054 DOI: 10.3816/clm.2009.n.070] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Primary central nervous system (CNS) lymphoma (PCNSL) is a non-Hodgkin lymphoma that arises within and is confined to the CNS. Recent data have suggested an increasing incidence in immunocompetent individuals, with a peak of incidence between 60 and 70 years of age. Patients with PCNSL present mostly with symptoms of increased intracranial pressure. The clinical management of these patients remains controversial, and the optimal treatment for patients with PCNSL has not yet been defined. Surgery, even if macroscopically radical, does not improve survival because of the multifocal and infiltrative nature of PCNSL; furthermore, the deep location of most of these tumors makes patients susceptible to serious and irreversible neurologic sequelae. Corticosteroids have a specific role in the treatment of patients with PCNSL, whose disease is sensitive to them as a chemotherapeutic agent. PCNSL is an extremely radiation-sensitive neoplasm; whole-brain radiation therapy plus corticosteroids was the first modality of treatment for patients with this neoplasm until 10 years ago, with a low cure rate and a high local recurrence rate. PCNSL is also a chemosensitive neoplasm; while the optimal choice, sequence, and combination of appropriate agents for efficacious treatment of patients with PCNSL has yet to be determined. An essential component of therapy must include an adequate drug delivery behind a normal blood-brain barrier. Methotrexate is the agent with the most proven activity in PCNSL. Combined-modality therapy has improved survival, but relapse is still common, and late neurologic toxicity is a significant complication, especially in older patients, who represent the majority of immunocompetent patients with PCNSL.
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Juergens A, Pels H, Rogowski S, Fliessbach K, Glasmacher A, Engert A, Reiser M, Diehl V, Vogt-Schaden M, Egerer G, Schackert G, Reichmann H, Kroschinsky F, Bode U, Herrlinger U, Linnebank M, Deckert M, Fimmers R, Schmidt-Wolf IGH, Schlegel U. Long-term survival with favorable cognitive outcome after chemotherapy in primary central nervous system lymphoma. Ann Neurol 2010; 67:182-9. [DOI: 10.1002/ana.21824] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Monotherapy with methotrexate for primary central nervous lymphoma has single agent activity in the absence of radiotherapy: a single institution cohort. J Neurooncol 2009; 98:385-93. [PMID: 20020180 PMCID: PMC2883931 DOI: 10.1007/s11060-009-0090-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2009] [Accepted: 11/30/2009] [Indexed: 01/09/2023]
Abstract
We have retrospectively reviewed toxicities and response of a cohort of primary central nervous system lymphoma (PCNSL) patients treated with high dose parenteral methotrexate (MTX) monotherapy without whole brain radiation. From The Massachusetts General Hospital (MGH) Cancer Registry, active since 1946, we selected all immunocompetent patients with histologic and/or radiographic PCNSL diagnosed between 1980 and 2007. We identified the recipients of MTX with leucovorin rescue as sole therapy. No patient received radiation therapy (XRT). We analyzed this cohort for toxicity, response and patterns of recurrence. The cohort of 121 patients received on average 11 cycles of intravenous MTX at a median dose of 8 g/m2. Median interval between cycles was 10 days. After 3 months of therapy, the overall response rate was 85% (58% CR, 27% PR). The overall survival (OS) for the cohort was 7 years and progression-free survival (PFS) was 3.14 years. A trend toward a higher PFS was seen in patients who continued to receive MTX (3.48 years) every three months as compared to patients who ceased MTX after one year (2.86 years). Of 68 patients who achieved initial CR, there were 40 recurrences. Twenty-six of the 40 were re-induced with MTX as above; Sixty-nine percent again achieved CR. Eighty-one treatment-related toxicities occurred in 1316 MTX cycles. These toxicities included MRI white matter changes (N = 8) and lead to MTX cessation in 16 patients. High-dose MTX monotherapy of PCNSL is well-tolerated and provides PFS of >3 years and OS >7 years.
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Ferreri AJM, Reni M, Foppoli M, Martelli M, Pangalis GA, Frezzato M, Cabras MG, Fabbri A, Corazzelli G, Ilariucci F, Rossi G, Soffietti R, Stelitano C, Vallisa D, Zaja F, Zoppegno L, Aondio GM, Avvisati G, Balzarotti M, Brandes AA, Fajardo J, Gomez H, Guarini A, Pinotti G, Rigacci L, Uhlmann C, Picozzi P, Vezzulli P, Ponzoni M, Zucca E, Caligaris-Cappio F, Cavalli F. High-dose cytarabine plus high-dose methotrexate versus high-dose methotrexate alone in patients with primary CNS lymphoma: a randomised phase 2 trial. Lancet 2009; 374:1512-20. [PMID: 19767089 DOI: 10.1016/s0140-6736(09)61416-1] [Citation(s) in RCA: 453] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Chemotherapy with high-dose methotrexate is the conventional approach to treat primary CNS lymphomas, but superiority of polychemotherapy compared with high-dose methotrexate alone is unproven. We assessed the effect of adding high-dose cytarabine to methotrexate in patients with newly diagnosed primary CNS lymphoma. METHODS This open, randomised, phase 2 trial was undertaken in 24 centres in six countries. 79 patients with non-Hodgkin lymphoma exclusively localised into the CNS, cranial nerves, or eyes, aged 18-75 years, and with Eastern Cooperative Oncology Group performance status of 3 or lower and measurable disease were centrally randomly assigned by computer to receive four courses of either methotrexate 3.5 g/m(2) on day 1 (n=40) or methotrexate 3.5 g/m(2) on day 1 plus cytarabine 2 g/m(2) twice a day on days 2-3 (n=39). Both regimens were administered every 3 weeks and were followed by whole-brain irradiation. The primary endpoint was complete remission rate after chemotherapy. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00210314. FINDINGS All randomly assigned participants were analysed. After chemotherapy, seven patients given methotrexate and 18 given methotrexate plus cytarabine achieved a complete remission, with a complete remission rate of 18% (95% CI 6-30) and 46% (31-61), respectively, (p=0.006). Nine patients receiving methotrexate and nine receiving methotrexate plus cytarabine achieved a partial response, with an overall response rate of 40% (25-55) and 69% (55-83), respectively, (p=0.009). Grade 3-4 haematological toxicity was more common in the methotrexate plus cytarabine group than in the methotrexate group (36 [92%] vs six [15%]). Four patients died of toxic effects (three vs one). INTERPRETATION In patients aged 75 years and younger with primary CNS lymphoma, the addition of high-dose cytarabine to high-dose methotrexate provides improved outcome with acceptable toxicity compared with high-dose methotrexate alone. FUNDING Swiss Cancer League.
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Affiliation(s)
- Andrés J M Ferreri
- Unit of Lymphoid Malignancies, San Raffaele Scientific Institute, Milan, Italy.
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Herrlinger U, Glantz M, Schlegel U, Gisselbrecht C, Cavalli F. Should Intra-cerebrospinal Fluid Prophylaxis Be Part of Initial Therapy for Patients With Non-Hodgkin Lymphoma: What We Know, and How We Can Find Out More. Semin Oncol 2009; 36:S25-34. [DOI: 10.1053/j.seminoncol.2009.05.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Uhm JE, Kim KH, Yi SY, Chang MH, Park KW, Kong DS, Lee JI, Nam DH, Park W, Lim DH, Kim SJ, Kim K, Ko YH, Kim WS. A retrospective study to compare two methotrexate-based regimens for primary central nervous system lymphoma. Leuk Lymphoma 2009; 50:1110-8. [PMID: 19557631 DOI: 10.1080/10428190902964776] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Algazi AP, Kadoch C, Rubenstein JL. Biology and treatment of primary central nervous system lymphoma. Neurotherapeutics 2009; 6:587-97. [PMID: 19560747 PMCID: PMC4942275 DOI: 10.1016/j.nurt.2009.04.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Revised: 04/17/2009] [Accepted: 04/28/2009] [Indexed: 12/17/2022] Open
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare variant of extranodal non-Hodgkin lymphoma that is restricted in distribution to the brain, leptomeninges, spinal cord, and intraocular compartments. Although PCNSL shares overlapping features with systemic lymphoma, recent studies also reveal a unique pattern of gene and protein expression in PCNSL. These findings have yielded new insights into the pathophysiology of the disease, as well as the identification of novel prognostic biomarkers. Immune system compromise, such as is seen in acquired immune deficiency syndrome (AIDS), is the best established known risk factor for PCNSL. Like other lesions of the brain, meninges, and eye, the presenting symptoms associated with PCNSL typically include focal neurological deficits related to the site of disease or more global consequences of increased intracranial pressure. Diagnosis of PCNSL typically includes gadolinium-enhanced MRI and pathologic tissue analysis, as well as additional studies aimed at excluding concurrent systemic disease. PCNSL typically has a worse overall prognosis than systemic lymphoma. High-dose chemotherapy, particularly with methotrexate-based regimens, is the backbone of therapy for most patients, and chemotherapy is associated with much lower rates of treatment-related morbidity and mortality than whole-brain irradiation. Autologous stem cell transplantation is an emerging treatment modality, particularly in younger patients with relapsed disease, but high rates of treatment-related mortality are observed in older patients. Immunotherapy, including treatment with intrathecal rituximab, is another area of active research that may have promise in refractory or relapsed disease. Treatment options for intraocular lymphoma parallel those for PCNSL elsewhere in the brain: systemic chemotherapy, radiation, and local delivery of cytotoxic and immunologically active agents such as anti-CD20 antibody.
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Affiliation(s)
- Alain P. Algazi
- grid.266102.10000000122976811Division of Hematology and Oncology, University of California, San Francisco, 505 Parnassus Avenue, Suite M1286, Box 1270, 94143 San Francisco, CA
| | - Cigall Kadoch
- grid.266102.10000000122976811Division of Hematology and Oncology, University of California, San Francisco, 505 Parnassus Avenue, Suite M1286, Box 1270, 94143 San Francisco, CA
| | - James L. Rubenstein
- grid.266102.10000000122976811Division of Hematology and Oncology, University of California, San Francisco, 505 Parnassus Avenue, Suite M1286, Box 1270, 94143 San Francisco, CA
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Abstract
Optimum treatment for patients with primary CNS lymphoma remains challenging because there have not been any large randomised clinical trials of this rare tumour. Drugs used in treating systemic non-Hodgkin lymphoma have mostly proven ineffective because of difficulties crossing the blood-brain barrier. The recognition of the efficacy of high-dose methotrexate was a substantial therapeutic breakthrough and further advances, such as the development of polychemotherapy regimens, have built on this. Whole-brain radiotherapy can consolidate response to chemotherapy, but the associated toxic effects of chemoradiation can be unacceptable. Other effective approaches include disruption of the blood-brain barrier and the use of high-dose chemotherapy. Recently, there have been attempts to optimise multi-drug chemotherapy regimens by focusing on improving survival and reducing toxic effects. A promising area of research is the incorporation of novel targeted drugs into standard treatment frameworks. In the future, greater cooperation between research groups should hopefully lead to further therapeutic advances.
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Affiliation(s)
- Patrick G Morris
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
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Principes de traitement des lymphomes primitifs du système nerveux central chez l’immunocompétent. ONCOLOGIE 2009. [DOI: 10.1007/s10269-008-1026-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Yang SH, Lee KS, Kim IS, Hong JT, Sung JH, Son BC, Lee SW, Hong YK. Long-term survival in primary CNS lymphoma treated by high-dose methotrexate monochemotherapy: role of STAT6 activation as prognostic determinant. J Neurooncol 2008; 92:65-71. [DOI: 10.1007/s11060-008-9736-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2008] [Accepted: 11/03/2008] [Indexed: 10/21/2022]
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Coping with illness and subjective theories of illness in adult patients with haematological malignancies: systematic review. Crit Rev Oncol Hematol 2008; 69:237-57. [PMID: 19004639 DOI: 10.1016/j.critrevonc.2008.09.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2007] [Revised: 07/25/2008] [Accepted: 09/17/2008] [Indexed: 11/21/2022] Open
Abstract
In parallel to development of individualised antineoplastic treatment, scientific interest in patients' subjective theories of illness (STOI) has emerged in the oncological community. STOI depend decisively on patients' information about their disease. Coping with illness is dependent from the individual situation and context, and it is generally modulated by patients' STOI. The purpose is fivefold: (1) to provide a thorough literature review about coping and about STOI in adult haematological patients, (2) to survey through which indicators the topics were operationalized in studies, (3) to clarify the kind of coherence between these two topics, (4) to explicate the interaction between STOI and other variables, and (5) to verify the clinical relevance of both topics. We searched 19 electronic databanks for English biomedical literature manuscripts (1995-2008) on this subject. Twenty-six studies met our criteria and varied in haematological entity, treatment concept, sample size and methodological design. We conclude that a subjective-individual regulation of patient's mental stability during a cytotoxic chemotherapy is important. Successful coping strategies develop not only based on objective, but also subjective evaluation mechanisms. We deduce consequences for doctor-patient communication and psychosocial care in haematology. The newly developed process model of subjective regulation in cancer patients, in general, views the oncological treatment process as a procedural mental evaluation.
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Illerhaus G, Marks R, Müller F, Ihorst G, Feuerhake F, Deckert M, Ostertag C, Finke J. High-dose methotrexate combined with procarbazine and CCNU for primary CNS lymphoma in the elderly: results of a prospective pilot and phase II study. Ann Oncol 2008; 20:319-25. [PMID: 18953065 DOI: 10.1093/annonc/mdn628] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND To improve survival of elderly patients with primary central nervous system lymphoma (PCNSL), we conducted a phase II study with high-dose methotrexate (MTX) combined with procarbazine and CCNU. To reduce neurotoxicity, whole-brain irradiation was reserved for patients not responding to chemotherapy. PATIENTS AND METHODS High-dose MTX was applied on days 1, 15, and 30, procarbazine on days 1-10, and CCNU on day 1. Study treatment comprised up to three 45-day cycles. There was no lower limit of Karnofsky performance status (KPS). RESULTS Thirty patients with PCNSL (n = 29) or primary ocular lymphoma (n = 1) were included (median age 70 years, range 57-79 years). The median initial KPS was 60% (range 30%-90%). Best documented response in 27 assessable patients were 12 of 27 (44.4%) complete remissions, 7 of 27 (25.9%) partial remissions, and 8 of 27 (29.6%) disease progressions. Two patients died of probable treatment-related causes. With a median follow-up of 78 months (range 34-105), the 5-year overall survival is 33%. Eight of 30 patients (26.7%) are currently alive and well, six without signs of leukoencephalopathy. CONCLUSION The combination of high-dose MTX with procarbazine and CCNU is feasible and effective and results in a low rate of leukoencephalopathy. Comorbidity and toxicity remain of concern when treating PCNSL in elderly patients.
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Affiliation(s)
- G Illerhaus
- Department of Haematology, University Medical Center Freiburg, Freiburg, Germany
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Pels H, Juergens A, Glasmacher A, Schulz H, Engert A, Linnebank M, Schackert G, Reichmann H, Kroschinsky F, Vogt-Schaden M, Egerer G, Bode U, Schaller C, Lamprecht M, Hau P, Deckert M, Fimmers R, Bangard C, Schmidt-Wolf IGH, Schlegel U. Early relapses in primary CNS lymphoma after response to polychemotherapy without intraventricular treatment: results of a phase II study. J Neurooncol 2008; 91:299-305. [DOI: 10.1007/s11060-008-9712-4] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2008] [Accepted: 09/25/2008] [Indexed: 11/28/2022]
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Traitement des lymphomes primitifs du système nerveux central chez l’immunocompétent. Rev Neurol (Paris) 2008; 164:569-74. [DOI: 10.1016/j.neurol.2008.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2008] [Accepted: 04/09/2008] [Indexed: 11/19/2022]
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