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Wolf EB, Imperial R, Jiang L, Agarwal AK, Tun HW. Clinical and Genomic Profile of Primary Cranial Neurolymphomatosis. J Blood Med 2024; 15:291-303. [PMID: 38947230 PMCID: PMC11212808 DOI: 10.2147/jbm.s459123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 06/12/2024] [Indexed: 07/02/2024] Open
Abstract
Primary cranial neurolymphomatosis (PCNL) is a rare subtype of primary CNS lymphoma (PCNSL) in which infiltrative lymphomatous involvement is confined to cranial nerves. Here, we report a case of PCNL with successful genomic profiling. A 57-year-old male had a lengthy prediagnostic phase spanning approximately 30 months, characterized by multiple episodes of cranial neuropathies managed by steroids. At the time of diagnosis, the patient had right-sided cranial neuropathies involving cranial nerves (CN) V, VI, and VII. Pathological findings of the right cavernous lesion biopsy were consistent with large B-cell lymphoma-infiltrating nerve fibers. The clinical course was aggressive and refractory, characterized by relentless progression with the development of cervical spinal neurolymphomatosis, cerebrospinal fluid involvement, and ependymal and intraparenchymal cerebral involvement, despite multiple lines of therapy, including chemoimmunotherapy, Bruton's tyrosine kinase inhibitor, radiation, autologous stem cell transplant, chimeric antigen receptor T-cell therapy (CAR-T), and whole-brain radiation. The patient survived for 22 months from the time of the initial diagnosis and 52 months after the first episode of cranial neuropathy. Next-generation sequencing identified mutations (MYD88, CD79b, and PIM1) that are frequently observed in PCNSL. The unusual findings included a total of 22 mutations involving PIM1, indicating a highly active aberrant somatic hypermutation and two missense CXCR4 mutations. CXCR4 mutations have never been described in PCNSL and may have implications for disease biology and therapeutic interventions. We provide a literature review to further elucidate PCNL.
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Affiliation(s)
- Emily B Wolf
- Division of Hematology and Medical Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Robin Imperial
- Division of Hematology and Medical Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Liuyan Jiang
- Department of Laboratory Medicine and Pathology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Amit K Agarwal
- Department of Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Han W Tun
- Division of Hematology and Medical Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
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2
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Reinecke R, Jahnke K, Foltyn-Dumitru M, Lachner K, Armbrust M, Weber KJ, Zeiner PS, Czabanka M, Brunnberg U, Hartmann S, Steinbach JP, Ronellenfitsch MW. Intrathecal IgM synthesis as a diagnostic marker in patients with suspected CNS lymphoma. J Neurochem 2024; 168:1157-1167. [PMID: 38332527 DOI: 10.1111/jnc.16069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 01/19/2024] [Accepted: 01/23/2024] [Indexed: 02/10/2024]
Abstract
For CNS lymphomas (CNSL), there is a high need for minimally invasive and easily obtainable diagnostic markers. Intrathecal IgM synthesis can easily be determined in routine CSF diagnostics. The aim of this study was to systematically investigate the diagnostic potential of intrathecal IgM synthesis in primary and secondary CNSL (PCNSL and SCNSL). In this retrospective study, patients with a biopsy-proven diagnosis of PCNSL or SCNSL were compared with patients with other neurological diseases in whom CNSL was initially the primary radiological differential diagnosis based on MRI. Sensitivity and specificity of intrathecal IgM synthesis were calculated using receiver operating characteristic curves. Seventy patients with CNSL were included (49 PCNSL and 21 SCNSL) and compared to 70 control patients. The sensitivity and specificity for the diagnosis of CNSL were 49% and 87%, respectively, for the entire patient population and 66% and 91% after selection for cases with tumor access to the CSF system and isolated intrathecal IgM synthesis. In cases with MRI-based radiological suspicion of CNSL, intrathecal IgM synthesis has good specificity but limited sensitivity. Because of its low-threshold availability, analysis of intrathecal IgM synthesis has the potential to lead to higher diagnostic accuracy, especially in resource-limited settings, and deserves further study.
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Affiliation(s)
- Raphael Reinecke
- Dr. Senckenberg Institute of Neurooncology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- University Cancer Center (UCT), Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
| | - Kolja Jahnke
- Department of Neurology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
| | - Martha Foltyn-Dumitru
- Dr. Senckenberg Institute of Neurooncology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Karsten Lachner
- Institute of Neuroradiology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
| | - Moritz Armbrust
- Neurological Institute (Edinger Institute), Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
| | - Katharina J Weber
- University Cancer Center (UCT), Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- Neurological Institute (Edinger Institute), Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- German Cancer Consortium (DKTK), partner site Frankfurt/Mainz, a partnership between DKFZ and University Hospital Frankfurt, Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Pia S Zeiner
- Dr. Senckenberg Institute of Neurooncology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- University Cancer Center (UCT), Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- German Cancer Consortium (DKTK), partner site Frankfurt/Mainz, a partnership between DKFZ and University Hospital Frankfurt, Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Marcus Czabanka
- Department of Neurosurgery, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
| | - Uta Brunnberg
- University Cancer Center (UCT), Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- Department of Medicine, Hematology and Oncology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
| | - Sylvia Hartmann
- Dr. Senckenberg Institute of Pathology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
| | - Joachim P Steinbach
- Department of Neurology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- University Cancer Center (UCT), Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- German Cancer Consortium (DKTK), partner site Frankfurt/Mainz, a partnership between DKFZ and University Hospital Frankfurt, Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Michael W Ronellenfitsch
- Dr. Senckenberg Institute of Neurooncology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- University Cancer Center (UCT), Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
- German Cancer Consortium (DKTK), partner site Frankfurt/Mainz, a partnership between DKFZ and University Hospital Frankfurt, Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), Goethe University Frankfurt, Frankfurt am Main, Germany
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3
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Lim JX, Loh D, Tan L, Lee L. Use of fluorescein sodium to obtain histological diagnosis of primary Central nervous system lymphoma ghost tumour despite disappearance on intraoperative magnetic resonance imaging: technical note and review of the literature. Br J Neurosurg 2024; 38:244-248. [PMID: 33331187 DOI: 10.1080/02688697.2020.1859087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 11/19/2020] [Accepted: 11/30/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND IMPORTANCE Corticosteroid pre-treatment in patients with primary central nervous system lymphoma (PCNSL) can lead to the phenomenon of ghost tumours (GhT). This affects the diagnostic yield of biopsies and potentially causes misdiagnosis of the condition. The usual strategy of neuronavigation using preoperative magnetic resonance imaging (MRI) or localisation using intraoperative MRI (iMRI) can be rendered ineffective in this situation. CLINICAL PRESENTATION A middle-aged Chinese male with newly diagnosed human immunodeficiency virus infection was found to have an intracranial lesion suggestive of PCNSL. Preoperatively corticosteroid led to an attenuation of the contrast enhancing lesion on iMRI. However, intraoperative use of FS allowed the successful identification, biopsy and diagnosis of the condition. CONCLUSION FS is useful in the biopsy of PCNSL GhT even when the lesion is not seen in subsequent MRI imaging.
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Affiliation(s)
- Jia Xu Lim
- Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Daniel Loh
- Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Leanne Tan
- Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Lester Lee
- Neurosurgery, National Neuroscience Institute, Singapore, Singapore
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4
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Liu Y, Cai L, Zhou Y. A case of primary central-nervous system lymphoma with no obvious effect of hormone therapy. Asian J Surg 2024; 47:2008-2009. [PMID: 38212218 DOI: 10.1016/j.asjsur.2023.12.206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 12/29/2023] [Indexed: 01/13/2024] Open
Affiliation(s)
- Yongsheng Liu
- Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Lize Cai
- Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Youxin Zhou
- Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China.
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Mosteiro A, Hoyos JA, Ferres A, Topczewski T, Rivero A, Rivas A, Aldecoa I, Caballero GA, Morcos R, Balague O, Enseñat J, González JJ. The ghost tumour revisited. Corticosteroids in primary central nervous system lymphoma: diagnostic, prognostic and therapeutic implications. Br J Neurosurg 2023:1-8. [PMID: 37997350 DOI: 10.1080/02688697.2023.2283130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 11/08/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE The cytolytic effect of corticosteroids on primary central nervous system lymphoma (PCNSL) has established the clinical dogma of avoiding steroid therapy prior to surgery for diagnostic purposes. However, since steroids are very useful during the initial management of intracranial lesions with vasogenic oedema, it was our aim to determine whether they cause a drawback in the diagnosis and prognosis of PCNSL. METHODS A retrospective cohort study of patients diagnosed with PCNSL between 2000 and 2020 in our tertiary neurosurgical centre. Data on steroid administration, surgery type and complications, haematopathological findings and prognostic factors were compiled. A second cohort was used as a control group to compare the ratio of non-diagnostic biopsies; this series comprised patients who underwent stereotactic brain biopsy for any reason between 2019 and 2020. RESULTS Forty patients with PCNSL were included in the study, of which 28 (70%) had received steroids before surgery. The use of steroids was more prevalent in patients with poorer performance status at diagnosis. No relevant differences were found in the diagnostic accuracy regardless of steroid exposure (93% under steroids vs 100% without steroids) or type of surgery performed. Furthermore, steroid withdrawal did not seem to augment the diagnostic ratio. The notable diagnostic delay was not influenced by the use of steroids. CONCLUSIONS Novel imaging and surgical techniques might obviate the need to withhold corticosteroids from patients suffering from PCNSL prior to biopsy. Moreover, when steroids have been given, tapering them and delaying the surgery might not be justified. This could hold relevant therapeutic implications in the early clinical stages.
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Affiliation(s)
- Alejandra Mosteiro
- Department of Neurological Surgery, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Jhon A Hoyos
- Department of Neurological Surgery, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Abel Ferres
- Department of Neurological Surgery, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Thomaz Topczewski
- Department of Neurological Surgery, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Andrea Rivero
- Department of Haematology, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Alfredo Rivas
- Department of Haematology, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Iban Aldecoa
- Department of Pathology, Hospital Clinic of Barcelona, Barcelona, Spain
| | | | - Ricardo Morcos
- Department of Neurology, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Olga Balague
- Department of Pathology, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Joaquim Enseñat
- Department of Neurological Surgery, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Jose Juan González
- Department of Neurological Surgery, Hospital Clínic of Barcelona, Barcelona, Spain
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6
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Savary T, Fieux M, Douplat M, Tournegros R, Daubie S, Pavie D, Denoix L, Pialat JB, Tringali S. Incidence of Underlying Abnormal Findings on Routine Magnetic Resonance Imaging for Bell Palsy. JAMA Netw Open 2023; 6:e239158. [PMID: 37079301 PMCID: PMC10119737 DOI: 10.1001/jamanetworkopen.2023.9158] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 02/24/2023] [Indexed: 04/21/2023] Open
Abstract
Importance There is no consensus on the benefits of routine magnetic resonance imaging (MRI) of the facial nerve in patients with suspected idiopathic peripheral facial palsy (PFP) (ie, Bell palsy [BP]). Objectives To estimate the proportion of adult patients in whom MRI led to correction of an initial clinical diagnosis of BP; to determine the proportion of patients with confirmed BP who had MRI evidence of facial nerve neuritis without secondary lesions; and to identify factors associated with secondary (nonidiopathic) PFP at initial presentation and 1 month later. Design, Setting, and Participants This retrospective multicenter cohort study analyzed the clinical and radiological data of 120 patients initially diagnosed with suspected BP from January 1, 2018, to April 30, 2022, at the emergency department of 3 tertiary referral centers in France. Interventions All patients screened for clinically suspected BP underwent an MRI of the entire facial nerve with a double-blind reading of all images. Main Outcomes and Measures The proportion of patients in whom MRI led to a correction of the initial diagnosis of BP (any condition other than BP, including potentially life-threating conditions) and results of contrast enhancement of the facial nerve were described. Results Among the 120 patients initially diagnosed with suspected BP, 64 (53.3%) were men, and the mean (SD) age was 51 (18) years. Magnetic resonance imaging of the facial nerve led to a correction of the diagnosis in 8 patients (6.7%); among them, potentially life-threatening conditions that required changes in treatment were identified in 3 (37.5%). The MRI confirmed the diagnosis of BP in 112 patients (93.3%), among whom 106 (94.6%) showed evidence of facial nerve neuritis on the affected side (hypersignal on gadolinium-enhanced T1-weighted images). This was the only objective sign confirming the idiopathic nature of PFP. Conclusions and Relevance These preliminary results suggest the added value of the routine use of facial nerve MRI in suspected cases of BP. Multicentered international prospective studies should be organized to confirm these results.
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Affiliation(s)
- Thibault Savary
- Service d’ORL, d’Otoneurochirurgie et de Chirurgie Cervico-Faciale, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France
| | - Maxime Fieux
- Service d’ORL, d’Otoneurochirurgie et de Chirurgie Cervico-Faciale, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France
- Université de Lyon, Université Lyon 1, Lyon, France
- Université Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM), Mondor Institute for Biomedical Research (IMRB), Créteil, France
- Centre National de la Recherche Scientifique (CNRS) Equipe Mixte de Recherche 7000, Créteil, France
| | - Marion Douplat
- Université de Lyon, Université Lyon 1, Lyon, France
- Service des Urgences, Hospices Civils of Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France
- Research on Healthcare Performance, Université Claude Bernard Lyon 1, INSERM U1290, Lyon, France
- Unité Mixte de Recherche (UMR) Adés 7268, Aix-Marseille University, Etablissement Français du Sang–CNRS, Espace Éthique Méditerranéen, Marseille, France
| | - Romain Tournegros
- Service d’ORL, d’Otoneurochirurgie et de Chirurgie Cervico-Faciale, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France
| | - Sophie Daubie
- Service d’Imagerie Médicale, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France
| | - Dylan Pavie
- Service d’Imagerie Médicale, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France
| | - Luna Denoix
- Service d’ORL, d’Otoneurochirurgie et de Chirurgie Cervico-Faciale, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France
| | - Jean-Baptiste Pialat
- Université de Lyon, Université Lyon 1, Lyon, France
- Service d’Imagerie Médicale, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France
- Creatis CNRS UMR 5220, INSERM U1294, Université Lyon 1, Villeurbanne, France
| | - Stephane Tringali
- Service d’ORL, d’Otoneurochirurgie et de Chirurgie Cervico-Faciale, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France
- Université de Lyon, Université Lyon 1, Lyon, France
- UMR 5305, Laboratoire de Biologie Tissulaire et d’Ingénierie Thérapeutique, Institut de Biologie et Chimie des Protéines, CNRS Université Claude Bernard Lyon 1, Lyon, France
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7
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Mesoporous Materials as Elements of Modern Drug Delivery Systems for Anti-Inflammatory Agents: A Review of Recent Achievements. Pharmaceutics 2022; 14:pharmaceutics14081542. [PMID: 35893798 PMCID: PMC9331996 DOI: 10.3390/pharmaceutics14081542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/16/2022] [Accepted: 07/22/2022] [Indexed: 12/04/2022] Open
Abstract
Interest in the use of mesoporous materials as carriers of medicinal substances has been steadily increasing in the last two decades. Mesoporous carriers have application in the preparation of delivery systems for drugs from various therapeutic groups; however, their use as the carriers of anti-inflammatory agents is particularly marked. This review article, with about 170 references, summarizes the achievements in the application of mesoporous materials as the carriers of anti-inflammatory agents in recent years. This article will discuss a variety of mesoporous carriers as well as the characteristics of their porous structure that determine further use of these materials in the field of medical applications. Special attention will be paid to the progress observed in the construction of stimuli-responsive drug carriers and systems providing site-specific drug delivery. Subsequently, a review of the literature devoted to the use of mesoporous matrices as the carriers of anti-inflammatory drugs was carried out.
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8
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Vishnevetsky A, Anand P. Approach to Neurologic Complications in the Immunocompromised Patient. Semin Neurol 2021; 41:554-571. [PMID: 34619781 DOI: 10.1055/s-0041-1733795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Neurologic complications are common in immunocompromised patients, including those with advanced human immunodeficiency virus, transplant recipients, and patients on immunomodulatory medications. In addition to the standard differential diagnosis, specific pathogens and other conditions unique to the immunocompromised state should be considered in the evaluation of neurologic complaints in this patient population. A thorough understanding of these considerations is critical to the inpatient neurologist in contemporary practice, as increasing numbers of patients are exposed to immunomodulatory therapies. In this review, we provide a chief complaint-based approach to the clinical presentations and diagnosis of both infectious and noninfectious complications particular to immunocompromised patients.
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Affiliation(s)
- Anastasia Vishnevetsky
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pria Anand
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
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9
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Abstract
Central nervous system lymphoma (CNSL) is a rare form of extranodal non-Hodgkin lymphoma. Central nervous system lymphoma can be primary (isolated to the central nervous space) or secondary in the setting of systemic disease. Treatment of CNSL has improved since the introduction of high-dose methotrexate and aggressive consolidation regimens. However, results after treatment are durable in only half of patients, and long-term survivors may experience late neurotoxicity, impacting quality of life. Given the rarity of this disease, few randomized prospective trials exist. This leaves many questions unanswered regarding optimal first-line and salvage treatments. Recent advances in the knowledge of pathophysiology of CNSL will hopefully help the development of future treatments. This review gives an overview of the epidemiology, pathophysiology, clinical presentation, diagnosis, and treatment of immunocompetent patients with CNSL.
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10
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Abstract
Cancer and cancer therapies have the potential to affect the nervous system in a host of different ways. Cerebral edema, increased intracranial pressure, cerebrovascular events, status epilepticus, and epidural spinal cord compression are among those most often presenting as emergencies. Neurologic side-effects of cancer therapies are often mild, but occasionally result in serious illness. Immunotherapies cause autoimmune-related neurologic side-effects that are generally responsive to immunosuppressive therapies. Emergency management of neuro-oncologic problems benefits from early identification and close collaboration among interdisciplinary team members and patients or surrogate decision-makers.
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Affiliation(s)
- Zachary D Threlkeld
- Division of Neurocritical Care, Department of Neurology, Stanford University School of Medicine, 300 Pasteur Drive MC 5778, Stanford, CA 94305, USA
| | - Brian J Scott
- Division of Neurohospitalist Medicine, Department of Neurology, Stanford University School of Medicine, 453 Quarry Rd, 2nd Floor, Stanford, CA 94305, USA.
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11
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Lo YT, Ang YLS, Yang VS, Kanavathy DT, Liang S, Lee L. Motor deficits at presentation and predictors of overall survival in central nervous system lymphomas. J Neurooncol 2021; 151:295-306. [PMID: 33398535 DOI: 10.1007/s11060-020-03665-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/12/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Central nervous system lymphomas (CNSL) can present with motor and non-motor symptoms. In many central nervous system tumors, motor deficits are associated with significant morbidity and functional impairment, and correlate with worse prognosis. CNSLs however, often exhibit remarkable response to chemotherapy and radiotherapy with corresponding symptom improvement. We investigate the survival outcomes and trajectories of motor and functional recovery in a cohort of patients presenting with and without initial motor deficits. METHODS Patients who underwent biopsy and with a histologically confirmed CNSL between 2008 and 2019 were retrospectively identified. Baseline demographic variables, comorbidities, presenting symptoms, histological type, neuroimaging features (location and number of lesions), and treatment administered (pre- and post-operative steroid use and chemotherapy regime) were recorded. Dates of death were obtained from the National Registry of Births and Deaths. Motor power and performance status at admission, 1 month and 6 months were determined. RESULTS We identified 119 patients, of whom 34% presented with focal motor deficits. The median overall survival (OS) was 26.6 months. Those with focal motor deficits had longer OS (median 42.4 months) than those without (median 23.3 months; p = 0.047). In multivariate Cox analysis, age (HR 1.04 per year; p = 0.003), CCI (HR 1.31 per point; p < 0.001), leptomeningeal/ependymal involvement (HR 2.53; p = 0.016), thalamus involvement (HR 0.34; p = 0.019), neutrophil:lymphocyte ratio (HR 1.06 per point; p = 0.034), positive HIV status (HR 5.31; p = 0.003), preoperative steroids use (HR 0.49; p = 0.018), postoperative high-dose steroids (HR 0.26; p < 0.001) and postoperative low-dose steroids (HR 0.28; p = 0.010) were significant predictors of OS. By one month, 43% of surviving patients had full power, increasing to 61% by six months. CONCLUSION A significant proportion of patients with initial motor deficits recovered in motor strength by six months. In our population, those presenting with motor deficits had paradoxically better overall survival.
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Affiliation(s)
- Yu Tung Lo
- Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore. .,Department of Neurosurgery, Outram Road, Singapore, 169608, Singapore.
| | - Ya Lyn Samantha Ang
- Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.,Department of Neurosurgery, Outram Road, Singapore, 169608, Singapore
| | - Valerie Shiwen Yang
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore.,Translational Precision Oncology Lab, Institute of Molecular and Cell Biology, A*STAR, Singapore, Singapore
| | | | - Sai Liang
- Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Lester Lee
- Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.,Department of Neurosurgery, Outram Road, Singapore, 169608, Singapore.,Duke-NUS Medical School, Singapore, Singapore
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12
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Liang S, Lim JX, Lee HY, Low SY. Primary Central Nervous System Lymphoma Presenting as Multifocal Brain Abscesses. Cureus 2020; 12:e12068. [PMID: 33489486 PMCID: PMC7805420 DOI: 10.7759/cureus.12068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A previously well female presented with a history of progressive functional decline. She had a known history of generalized seropositive myasthenia gravis on long-term mycophenolate mofetil and pyridostigmine. MRI of her brain reported multiple cerebral abscesses based on radiological features. The patient was commenced on intravenous antibiotics, but there was no clinical or radiological response to treatment. Decision was made for a stereotactic biopsy. Intraoperative tissue cultures were negative for infection. However, histology reported B-cell lymphoma with morphological features changes typically seen in corticosteroid-treated lymphoma - an unexpected finding as no steroids were administered as part of her treatment. Owing to the unusual diagnosis, the case is presented in corroboration with current literature.
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Affiliation(s)
- Sai Liang
- Neurosurgery, National Neuroscience Institute, Singapore, SGP
| | - Jia Xu Lim
- Neurosurgery, National Neuroscience Institute, Singapore, SGP
| | - Hwei Yee Lee
- Pathology, Tan Tock Seng Hospital, Singapore, SGP
| | - Sharon Yy Low
- Neurosurgery, National Neuroscience Institute, Singapore, SGP
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13
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Nachtsheim L, Wittersheim M, Kreissl S, Klussmann JP, Grosheva M. Facial nerve paralysis caused by a T-cell lymphoma. Clin Case Rep 2020; 8:2965-2968. [PMID: 33363860 PMCID: PMC7752436 DOI: 10.1002/ccr3.3285] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/22/2020] [Accepted: 08/01/2020] [Indexed: 12/01/2022] Open
Abstract
Facial nerve paralysis due to the infiltration by a lymphoma is rare and the prognosis remains poor. If perineural spread and meningeosis are suspected, quick interdisciplinary diagnostic work-up is recommended. It should include magnetic resonance imaging, biopsy of the lesion, bone marrow biopsy, and lumbar puncture. Therapy should be initiated immediately.
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Affiliation(s)
- Lisa Nachtsheim
- Department of Otorhinolaryngology, Head and Neck SurgeryMedical FacultyUniversity of CologneCologneGermany
| | - Maike Wittersheim
- Department of PathologyMedical FacultyUniversity of CologneCologneGermany
| | - Stefanie Kreissl
- Department I of Internal Medicine and Center of Integrated OncologyMedical FacultyUniversity of CologneCologneGermany
| | - Jens Peter Klussmann
- Department of Otorhinolaryngology, Head and Neck SurgeryMedical FacultyUniversity of CologneCologneGermany
| | - Maria Grosheva
- Department of Otorhinolaryngology, Head and Neck SurgeryMedical FacultyUniversity of CologneCologneGermany
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14
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Choi YS. Recent advances in the management of primary central nervous system lymphoma. Blood Res 2020; 55:S58-S62. [PMID: 32719178 PMCID: PMC7386887 DOI: 10.5045/br.2020.s010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 06/02/2020] [Accepted: 06/02/2020] [Indexed: 12/21/2022] Open
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare subtype of extranodal lymphoma primarily involving the brain, spinal cord, or leptomeninges. PCNSL is associated with a relatively poor prognosis compared to other extranodal diffuse large B-cell lymphomas. However, methotrexate-based induction chemotherapy followed by consolidative chemotherapy or high-dose therapy and autologous stem cell transplantation has improved the survival outcome, together with reduced neurotoxicity. Recent studies found that aberrant activation of the B-cell receptor-signaling pathway and activation of the NF-κB are frequent genetic alterations and could be good targets for the treatment of PCNSL. Herein, we have reviewed the current status and recent advances in the biology and management of PCNSL.
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Affiliation(s)
- Yoon Seok Choi
- Department of Hematology-Oncology, Ajou University School of Medicine, Suwon, Korea
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15
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Uneda A, Hirashita K, Kanda T, Yunoki M, Yoshino K, Kurozumi K, Date I. Primary Central Nervous System Methotrexate-associated Lymphoproliferative Disorder in a Patient with Rheumatoid Arthritis: Case Report and Review of Literature. NMC Case Rep J 2020; 7:121-127. [PMID: 32695560 PMCID: PMC7363643 DOI: 10.2176/nmccrj.cr.2019-0241] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 12/24/2019] [Indexed: 11/20/2022] Open
Abstract
Methotrexate (MTX) is an immunosuppressor that is widely used to treat autoimmune diseases, including rheumatoid arthritis (RA). However, it can have serious adverse effects including a lymphoma: MTX-associated lymphoproliferative disorder (MTX-LPD). Extranodal lesions are common in MTX-LPD patients. However, MTX-LPD in the central nervous system (CNS) is extremely rare with few reported cases. Here, we describe a case of primary CNS MTX-LPD in a patient with RA, with a review of the literature. A 68-year-old woman who had received MTX for her RA for more than 10 years was referred to our hospital. Head magnetic resonance imaging (MRI) showed multiple lesions with heterogeneous contrast enhancement scattered throughout both hemispheres. As immunosuppression caused by MTX was suspected, MTX was discontinued, based on a working diagnosis of MTX-LPD. We performed an open biopsy of her right temporal lesion. Histopathologic examination showed atypical CD20+ lymphoid cells, leading to a definitive diagnosis of diffuse large B-cell lymphoma (DLBCL). In situ hybridization of an Epstein-Barr virus-encoded small RNA (EBER) was positive. Sanger sequencing confirmed that both MYD88 L265 and CD79B Y196 mutations were absent. The LPD regressed after stopping MTX. Follow-up head MRI at 8 months after surgery showed no evidence of recurrence. Although primary CNS MTX-LPD is extremely rare, it should be included in the differential diagnosis when a patient receiving MTX develops CNS lesions. Diagnosis by biopsy and MTX discontinuation are required as soon as possible.
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Affiliation(s)
- Atsuhito Uneda
- Department of Neurosurgery, Kagawa Rosai Hospital, Marugame, Kagawa, Japan.,Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Koji Hirashita
- Department of Neurosurgery, Kagawa Rosai Hospital, Marugame, Kagawa, Japan
| | - Takahiro Kanda
- Department of Neurosurgery, Kagawa Rosai Hospital, Marugame, Kagawa, Japan
| | - Masatoshi Yunoki
- Department of Neurosurgery, Kagawa Rosai Hospital, Marugame, Kagawa, Japan
| | - Kimihiro Yoshino
- Department of Neurosurgery, Kagawa Rosai Hospital, Marugame, Kagawa, Japan
| | - Kazuhiko Kurozumi
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Isao Date
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
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16
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Velasco R, Mercadal S, Vidal N, Alañá M, Barceló MI, Ibáñez-Juliá MJ, Bobillo S, Caldú Agud R, García Molina E, Martínez P, Cacabelos P, Muntañola A, García-Catalán G, Sancho JM, Camro I, Lado T, Erro ME, Gómez-Vicente L, Salar A, Caballero AC, Solé-Rodríguez M, Gállego Pérez-Larraya J, Huertas N, Estela J, Barón M, Barbero-Bordallo N, Encuentra M, Dlouhy I, Bruna J, Graus F. Diagnostic delay and outcome in immunocompetent patients with primary central nervous system lymphoma in Spain: a multicentric study. J Neurooncol 2020; 148:545-554. [PMID: 32524392 DOI: 10.1007/s11060-020-03547-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 05/26/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION To assess the management of immunocompetent patients with primary central nervous system lymphomas (PCNSL) in Spain. METHODS Retrospective analysis of 327 immunocompetent patients with histologically confirmed PCNSL diagnosed between 2005 and 2014 in 27 Spanish hospitals. RESULTS Median age was 64 years (range: 19-84; 33% ≥ 70 years), 54% were men, and 59% had a performance status (PS) ≥ 2 at diagnosis. Median delay to diagnosis was 47 days (IQR 24-81). Diagnostic delay > 47 days was associated with PS ≥ 2 (OR 1.99; 95% CI 1.13-3.50; p = 0.016) and treatment with corticosteroids (OR 2.47; 95% CI 1.14-5.40; p = 0.023), and it did not improve over the years. Patients treated with corticosteroids (62%) had a higher risk of additional biopsies (11.7% vs 4.0%, p = 0.04) but corticosteroids withdrawal before surgery did not reduce this risk and increased the diagnostic delay (64 vs 40 days, p = 0.04). Median overall survival (OS) was 8.9 months [95% CI 5.9-11.7] for the whole series, including 52 (16%) patients that were not treated, and 14.1 months (95%CI 7.7-20.5) for the 240 (73.4%) patients that received high-dose methotrexate (HD-MTX)-based chemotherapy. Median OS was shorter in patients ≥ 70 years (4.1 vs. 13.4 months; p < 0.0001). Multivariate analysis identified age ≥ 65 years, PS ≥ 2, no treatment, and cognitive/psychiatric symptoms at diagnosis as independent predictors of short survival. CONCLUSIONS Corticosteroids withdrawal before surgery does not decrease the risk of a negative biopsy but delays diagnosis. In this community-based study, only 73.4% of patients could receive HD-MTX-based chemotherapy and OS remains poor, particularly in elderly patients ≥ 70 years.
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Affiliation(s)
- R Velasco
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-ICO Duran i Reynals, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain. .,Department of Cell Biology, Physiology and Immunology, Institute of Neurosciences, Universitat Autònoma de Barcelona, and Centro de Investigación Biomédica en Red Sobre Enfermedades Neurodegenerativas (CIBERNED), Bellaterra, Spain. .,Department of Neurology, Neuro-Oncology Unit, Hospital Universitari de Bellvitge and ICO L'Hospitalet, C/Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain.
| | - S Mercadal
- Department of Hematology, Catalan Institute of Oncology-Hospital Duran i Reynals, IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - N Vidal
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-ICO Duran i Reynals, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.,Department of Pathology, Unit of Neuro-Oncology. Hospital Universitari de Bellvitge-ICO Duran i Reynals, IDIBELL, L'Hospitalet del Llobregat, Barcelona, Spain
| | - M Alañá
- Department of Neurology, Complejo Asistencial Universitario, Salamanca, Spain
| | - M I Barceló
- Department of Neurology, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - M J Ibáñez-Juliá
- Department of Neurology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - S Bobillo
- Department of Hematology, Vall d'Hebron Institute of Oncology (VHIO), University Hospital Vall d'Hebron, Barcelona, Spain
| | - R Caldú Agud
- Department of Neurology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - E García Molina
- Department of Neurology, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | - P Martínez
- Department of Hematology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - P Cacabelos
- Department of Neurology, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, La Coruña, Spain
| | - A Muntañola
- Department of Hematology, Hospital Universitario Mutua de Terrassa, Terrassa, Spain
| | - G García-Catalán
- Department of Neurosurgery, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - J M Sancho
- Department of Hematology, ICO-IJC-Hospital Germans Trias i Pujol, Badalona, Spain
| | - I Camro
- Department of Neurology, Hospital Universitario Cruces, Barakaldo, Vizcaya, Spain
| | - T Lado
- Department of Hematology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - M E Erro
- Neurology Department, Complejo Hospitalario de Navarra, Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
| | - L Gómez-Vicente
- Department of Neurology, Hospital Universitario Quirónsalud Madrid, Pozuelo de Alarcón, Madrid, Spain
| | - A Salar
- Department of Hematology, Hospital del Mar, Barcelona, Spain
| | - A C Caballero
- Department of Hematology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - M Solé-Rodríguez
- Department of Hematology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - J Gállego Pérez-Larraya
- Departament of Neurology, Clínica Universidad de Navarra, IdiSNA, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - N Huertas
- Department of Neurology, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain
| | - J Estela
- Department of Neurology, Hospital Parc Taulí, Sabadell, Spain
| | - M Barón
- Unit of Neurology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - N Barbero-Bordallo
- Department of Neurology, Hospital Universitario Rey Juan Carlos, HURJC-HUIE-HCV, Madrid, Spain
| | - M Encuentra
- Department of Hematology, Catalan Institute of Oncology-Hospital Duran i Reynals, IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - I Dlouhy
- Department of Hematology and Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - J Bruna
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-ICO Duran i Reynals, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.,Department of Cell Biology, Physiology and Immunology, Institute of Neurosciences, Universitat Autònoma de Barcelona, and Centro de Investigación Biomédica en Red Sobre Enfermedades Neurodegenerativas (CIBERNED), Bellaterra, Spain
| | - F Graus
- Department of Hematology and Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
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17
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Grommes C, Rubenstein JL, DeAngelis LM, Ferreri AJM, Batchelor TT. Comprehensive approach to diagnosis and treatment of newly diagnosed primary CNS lymphoma. Neuro Oncol 2020; 21:296-305. [PMID: 30418592 DOI: 10.1093/neuonc/noy192] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare form of non-Hodgkin lymphoma that affects the brain parenchyma, spinal cord, eyes, and cerebrospinal fluid without evidence of systemic, non-CNS involvement. PCNSL is uncommon and only a few randomized trials have been completed in the first-line setting. Over the past decades, the prognosis of PCNSL has improved, mainly due to the introduction and widespread use of high-dose methotrexate, which is now the backbone of all first-line treatment polychemotherapy regimens. Despite this progress, durable remission is recorded in only 50% of patients, and therapy can be associated with significant late neurotoxicity. Here, we overview the epidemiology, clinical presentation, staging evaluation, prognosis, and current up-to-date treatment of immunocompetent PCNSL patients.
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Affiliation(s)
- Christian Grommes
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - James L Rubenstein
- Helen Diller Comprehensive Cancer Center, University of California, San Francisco, California, USA
| | - Lisa M DeAngelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Andres J M Ferreri
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Tracy T Batchelor
- Departments of Neurology and Radiation Oncology, Division of Hematology and Oncology, Boston, Massachusetts
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18
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Komakech A, Im JH, Gwak HS, Lee KY, Kim JH, Yoo BC, Cheong H, Park JB, Kwon JW, Shin SH, Yoo H. Dexamethasone Interferes with Autophagy and Affects Cell Survival in Irradiated Malignant Glioma Cells. J Korean Neurosurg Soc 2020; 63:566-578. [PMID: 32272509 PMCID: PMC7477145 DOI: 10.3340/jkns.2019.0187] [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: 09/08/2019] [Accepted: 12/08/2019] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Radiation is known to induce autophagy in malignant glioma cells whether it is cytocidal or cytoprotective. Dexamethasone is frequently used to reduce tumor-associated brain edema, especially during radiation therapy. The purpose of the study was to determine whether and how dexamethasone affects autophagy in irradiated malignant glioma cells and to identify possible intervening molecular pathways. METHODS We prepared p53 mutant U373 and LN229 glioma cell lines, which varied by phosphatase and tensin homolog (PTEN) mutational status and were used to make U373 stable transfected cells expressing GFP-LC3 protein. After performing cell survival assay after irradiation, the IC50 radiation dose was determined. Dexamethasone dose (10 μM) was determined from the literature and added to the glioma cells 24 hours before the irradiation. The effect of adding dexamethasone was evaluated by cell survival assay or clonogenic assay and cell cycle analysis. Measurement of autophagy was visualized by western blot of LC3-I/LC3-II and quantified by the GFP-LC3 punctuated pattern under fluorescence microscopy and acridine orange staining for acidic vesicle organelles by flow cytometry. RESULTS Dexamethasone increased cell survival in both U373 and LN229 cells after irradiation. It interfered with autophagy after irradiation differently depending on the PTEN mutational status : the autophagy decreased in U373 (PTEN-mutated) cells but increased in LN229 (PTEN wild-type) cells. Inhibition of protein kinase B (AKT) phosphorylation after irradiation by LY294002 reversed the dexamethasone-induced decrease of autophagy and cell death in U373 cells but provoked no effect on both autophagy and cell survival in LN229 cells. After ATG5 knockdown, radiation-induced autophagy decreased and the effect of dexamethasone also diminished in both cell lines. The diminished autophagy resulted in a partial reversal of dexamethasone protection from cell death after irradiation in U373 cells; however, no significant change was observed in surviving fraction LN229 cells. CONCLUSION Dexamethasone increased cell survival in p53 mutated malignant glioma cells and increased autophagy in PTEN-mutant malignant glioma cell but not in PTEN-wildtype cell. The difference of autophagy response could be mediated though the phosphatidylinositol 3-kinase/AKT/mammalian target of rapamycin signaling pathway.
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Affiliation(s)
- Alfred Komakech
- Department of Cancer Control, National Cancer Center Graduate School of Cancer Science and Policy, Goyang, Korea
| | - Ji-Hye Im
- Department of Cancer Control, National Cancer Center Graduate School of Cancer Science and Policy, Goyang, Korea
| | - Ho-Shin Gwak
- Department of Cancer Control, National Cancer Center Graduate School of Cancer Science and Policy, Goyang, Korea
| | - Kyue-Yim Lee
- Department of Cancer Control, National Cancer Center Graduate School of Cancer Science and Policy, Goyang, Korea
| | - Jong Heon Kim
- Department of Cancer Biomedical Science, National Cancer Center Graduate School of Cancer Science and Policy, Goyang, Korea
| | - Byong Chul Yoo
- Department of Cancer Biomedical Science, National Cancer Center Graduate School of Cancer Science and Policy, Goyang, Korea
| | - Heesun Cheong
- Department of Cancer Biomedical Science, National Cancer Center Graduate School of Cancer Science and Policy, Goyang, Korea
| | - Jong Bae Park
- Department of Cancer Biomedical Science, National Cancer Center Graduate School of Cancer Science and Policy, Goyang, Korea
| | - Ji Woong Kwon
- Neuro-oncology Clinic, National Cancer Center, Goyang, Korea
| | - Sang Hoon Shin
- Neuro-oncology Clinic, National Cancer Center, Goyang, Korea
| | - Heon Yoo
- Neuro-oncology Clinic, National Cancer Center, Goyang, Korea
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19
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Bullis CL, Maldonado-Perez A, Bowden SG, Yaghi N, Munger D, Wood MD, Barajas RF, Ambady P, Neuwelt EA, Han SJ. Diagnostic impact of preoperative corticosteroids in primary central nervous system lymphoma. J Clin Neurosci 2020; 72:287-291. [PMID: 31648968 DOI: 10.1016/j.jocn.2019.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 10/04/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE High dose corticosteroids are an effective tool for rapidly alleviating neurologic symptoms caused by intracranial mass lesions. However, there is concern that preoperative corticosteroids limit the ability to obtain a definitive pathologic diagnosis, particularly if imaging features suggest primary central nervous system lymphoma (PCNSL). METHODS To explore the impact of preoperative corticosteroids in newly diagnosed PCNSL patients, from 2009 to 2018 treated at our institution. RESULTS We identified 54 patients; 18 had received corticosteroids prior to biopsy or resection. Only in one case did the patient have a prior non-diagnostic biopsy, requiring a second procedure. The cumulative doses of preoperative dexamethasone ranged from 4 mg to 120 mg (mean 32 mg, median 24 mg), given over 1-14 days (mean 2 days, median 1 day), and the majority had received corticosteroids for only 1-2 days. There was a trend for a larger diameter of lesional T1 contrast enhancement for patients who received steroids (39 mm vs. 34 mm, p = 0.11). In this series of cases with pathologically and clinically proven PCNSL, preoperative corticosteroids had been given in a third of cases, suggesting that they may be given for symptomatic relief without compromising pathologic diagnosis. CONCLUSIONS Despite the commonly held tenet that preoperative corticosteroids can obscure the pathologic diagnosis in PCNSL, this is likely not the case in the majority of patients who receive a short course preoperatively. Obtaining a second stereotactic scan to confirm continued presence of the lesion prior to tissue sampling may also mitigate these concerns.
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Affiliation(s)
- C L Bullis
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, United States
| | - A Maldonado-Perez
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, United States; Ponce Health Sciences University, Ponce, PR, United States
| | - S G Bowden
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, United States
| | - N Yaghi
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, United States
| | - D Munger
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, United States
| | - M D Wood
- Department of Pathology (Neuropathology), Oregon Health & Science University, Portland, OR, United States
| | - R F Barajas
- Department of Radiology, Oregon Health & Science University, Portland, OR, United States
| | - P Ambady
- Department of Neurology, Oregon Health & Science University, Portland, OR, United States
| | - E A Neuwelt
- Department of Neurology, Oregon Health & Science University, Portland, OR, United States
| | - S J Han
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, United States.
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20
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Maragkos GA, Penumaka A, Ahrendsen JT, Salem MM, Nelton EB, Alterman RL. Factors Affecting the Diagnostic Yield of Frame-Based Stereotactic Intracranial Biopsies. World Neurosurg 2019; 135:e695-e701. [PMID: 31883483 DOI: 10.1016/j.wneu.2019.12.102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Frame-based stereotactic biopsy (FSB) remains the "gold standard" for obtaining diagnostic samples of intracranial lesions to guide therapy. Nevertheless, diagnostic yield is highly variable. This study aims to provide an analysis of diagnostic yield, surgical complications, and factors associated with obtaining nondiagnostic samples in a contemporary FSB series. METHODS A retrospective cohort study was conducted of all adult patients with imaging-documented lesions undergoing FSB at our institution between 2013 and 2018. Diagnostic accuracy, lesion characteristics associated with nondiagnostic biopsy, and surgical complications were evaluated. A biopsy was considered nondiagnostic if all frozen samples and the final pathology yielded normal brain tissue or nonspecific reactive tissue unless the "reactive" pathology was consistent with radiation injury from prior therapy. RESULTS Our search identified 198 FSB patients. Mean (standard deviation) age was 62 ± 17 years, and 44.2% were female. Median procedure time was 32 minutes. A definitive histologic diagnosis was established in 187 cases (94.4% diagnostic yield). Mean lesion diameter was 31.9 ± 16.8 mm. Multivariable logistic regression revealed only lesion diameter to be significantly associated with diagnostic result (odds ratio for nondiagnostic result: 0.94 per mm diameter decrease, 95% confidence interval 0.87-0.99, P = 0.028). On univariable analysis, diagnosis of central nervous system lymphoma appeared to increase the risk of a nondiagnostic biopsy (P = 0.025), but this association disappeared when controlling for lesion size and steroid administration before biopsy. Eight patients (4.0%) developed postoperative hemorrhagic complications, 3 of whom required reoperation, and another expired. CONCLUSIONS This study demonstrates that diagnostic yield from contemporary FSB is high and depends predominantly on lesion size.
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Affiliation(s)
- Georgios A Maragkos
- Neurosurgery Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Department of Neurological Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Anirudh Penumaka
- Neurosurgery Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Department of Neurological Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Jared T Ahrendsen
- Neurosurgery Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Neurological Pathology Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Mohamed M Salem
- Neurosurgery Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Department of Neurological Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Emmalin B Nelton
- Neurosurgery Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Department of Neurological Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Ron L Alterman
- Neurosurgery Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Department of Neurological Surgery, Harvard Medical School, Boston, Massachusetts, USA.
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21
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Morell AA, Shah AH, Cavallo C, Eichberg DG, Sarkiss CA, Benveniste R, Ivan ME, Komotar RJ. Diagnosis of primary central nervous system lymphoma: a systematic review of the utility of CSF screening and the role of early brain biopsy. Neurooncol Pract 2019; 6:415-423. [PMID: 31832211 DOI: 10.1093/nop/npz015] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Because less-invasive techniques can obviate the need for brain biopsy in the diagnosis of primary central nervous system lymphoma (PCNSL), it is common practice to wait for a thorough initial work-up, which may delay treatment. We conducted a systematic review and reviewed our own series of patients to define the role of LP and early brain biopsy in the diagnosis of PCNSL. Methods Our study was divided into 2 main sections: 1) systematic review assessing the sensitivity of cerebrospinal fluid (CSF) analysis on the diagnosis of PCNSL, and 2) a retrospective, single-center patient series assessing the diagnostic accuracy and safety of early biopsy in immunocompetent PCNSL patients treated at our institution from 2012 to 2018. Results Our systematic review identified 1481 patients with PCNSL. A preoperative LP obviated surgery in 7.4% of cases. Brain biopsy was the preferred method of diagnosis in 95% of patients followed by CSF (3.1%). In our institutional series, brain biopsy was diagnostic in 92.3% of cases (24/26) with 2 cases that required a second procedure for diagnosis. Perioperative morbidity was noted in 7.6% of cases (n = 2) due to hemorrhages after stereotactic brain biopsy that improved at follow-up. Conclusions The diagnostic yield of CSF analyses for PCNSL in immunocompetent patients remains exceedingly low. Our institutional series demonstrates that early biopsy for PCNSL is safe and accurate, and may avert protracted work-ups. We conclude that performing an early brain biopsy in a suspected case of PCNSL is a valid, safe option to minimize diagnostic delay.
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Affiliation(s)
- Alexis A Morell
- Department of Neurological Surgery, University of Miami Miller School of Medicine, FL
| | - Ashish H Shah
- Department of Neurological Surgery, University of Miami Miller School of Medicine, FL
| | - Claudio Cavallo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Daniel G Eichberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine, FL
| | - Christopher A Sarkiss
- Department of Neurological Surgery, University of Miami Miller School of Medicine, FL
| | - Ronald Benveniste
- Department of Neurological Surgery, University of Miami Miller School of Medicine, FL
| | - Michael E Ivan
- Department of Neurological Surgery, University of Miami Miller School of Medicine, FL
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, FL
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22
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Nagano M, Ayaki T, Koita N, Kitano T, Nishikori M, Goda N, Minamiguchi S, Ikeda A, Takaori-Kondo A, Takahashi R. Recurrent Epstein-Barr Virus-positive (EBV+) Primary Central Nervous System Lymphoma (PCNSL) in a Patient with Clinical Features of Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS). Intern Med 2019; 58:849-854. [PMID: 30880301 PMCID: PMC6465023 DOI: 10.2169/internalmedicine.1246-18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 07/16/2018] [Indexed: 12/19/2022] Open
Abstract
Primary central nervous system lymphoma (PCNSL) and chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) can share clinical features and may be indistinguishable, even after brain biopsy. We encountered a case of Epstein-Barr virus-positive (EBV+) PCNSL recurrence in a patient with clinical features of CLIPPERS, and repeat brain biopsy was required to reach the correct diagnosis. Four years after the initial diagnosis and treatment of PCNSL, "peppering" punctate enhanced lesions with transient steroid responsiveness were detected during brain magnetic resonance imaging (MRI). A second brain biopsy supported a diagnosis of CLIPPERS, while a third biopsy confirmed the diagnosis of recurrent PCNSL.
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Affiliation(s)
- Masahiro Nagano
- Department of Neurology, Kyoto University Graduate School of Medicine, Japan
| | - Takashi Ayaki
- Department of Neurology, Kyoto University Graduate School of Medicine, Japan
| | - Natsuko Koita
- Department of Neurology, Kyoto University Graduate School of Medicine, Japan
| | - Toshiyuki Kitano
- Department of Hematology and Oncology, Kyoto University Graduate School of Medicine, Japan
| | - Momoko Nishikori
- Department of Hematology and Oncology, Kyoto University Graduate School of Medicine, Japan
| | - Naoki Goda
- Department of Diagnostic Pathology, Kyoto University Graduate School of Medicine, Japan
| | - Sachiko Minamiguchi
- Department of Diagnostic Pathology, Kyoto University Graduate School of Medicine, Japan
| | - Akio Ikeda
- Department of Neurology, Kyoto University Graduate School of Medicine, Japan
- Department of Epilepsy, Movement Disorders and Physiology, Kyoto University Graduate School of Medicine, Japan
| | - Akifumi Takaori-Kondo
- Department of Hematology and Oncology, Kyoto University Graduate School of Medicine, Japan
| | - Ryosuke Takahashi
- Department of Neurology, Kyoto University Graduate School of Medicine, Japan
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23
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Laybourne J, Masri I, Ivanova T. Bilateral sequential vitrectomies and intravitreal dexamethasone for pediatric acute lymphoblastic leukemia. Can J Ophthalmol 2018; 53:e186-e188. [PMID: 30340738 DOI: 10.1016/j.jcjo.2017.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 11/26/2017] [Accepted: 12/05/2017] [Indexed: 11/25/2022]
Affiliation(s)
- James Laybourne
- Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Ibrahim Masri
- Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Tsveta Ivanova
- Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom; Manchester Royal Eye Hospital, Manchester, United Kingdom.
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24
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Limaye K, Samaniego EA, Adams HP. Diagnosis and Treatment of Primary Central Nervous System Angiitis. Curr Treat Options Neurol 2018; 20:38. [PMID: 30076478 DOI: 10.1007/s11940-018-0522-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Primary central nervous system angiitis (PCNSA) is a rare disease. Varying clinical pictures coupled with lack of sensitive and specific diagnostic tests lead to challenges in management of these patients. This unfortunately may lead to both under- or over-diagnosis and unnecessary treatment. It is important to recognize the different conditions that may mimic the clinical and radiologic presentation. We present a contemporary literature review that should update physicians who encounter this patient population. RECENT FINDINGS Recent additions to the literature in form of case reports and single-center series show that digital subtraction angiography was the most widely used test to diagnose PCNSA. It is also important to note that brain biopsy is still considered "gold standard" and should be pursued as it not only has information that establishes the diagnosis but also may help in ruling out the diagnosis from mimics. In around 39% of suspected cases, an alternate diagnosis was eventually confirmed highlighting the importance of a comprehensive work-up. For treatment, almost all the literature supports the use of glucocorticoids as the initial treatment and if the patient has a relapse or develops steroid toxicity then the second most commonly used agent was cyclophosphamide. There are increasing reports of benefits with other agents such as methotrexate, azathioprine, mycophenolate, infliximab, and etanercept. The diagnosis and management of PCNSA continues to be a challenge. Formation of prospective patient registries with continued immunologic research for novel targets and immunomodulatory modalities may hold promise for future care of these patients.
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Affiliation(s)
- Kaustubh Limaye
- Cerebrovascular Diseases, University of Iowa, Iowa City, IA, USA
| | - Edgar A Samaniego
- Neurology, Neurosurgery and Radiology, University of Iowa, Iowa City, IA, USA
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25
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Mendez JS, Grommes C. Treatment of Primary Central Nervous System Lymphoma: From Chemotherapy to Small Molecules. Am Soc Clin Oncol Educ Book 2018; 38:604-615. [PMID: 30231317 DOI: 10.1200/edbk_200829] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare form of extranodal non-Hodgkin lymphoma that is typically confined to the brain, eyes, and cerebrospinal fluid (CSF) without evidence of systemic spread. PCNSL is an uncommon tumor, and only four randomized trials and one phase III trial have been completed so far, all in the first-line setting. The prognosis of patients with PCNSL has improved during the past few decades with the introduction of high-dose methotrexate (HD-MTX), which now serves as the backbone of all first-line treatment regimens. Despite recent progress, results after treatment are durable in half of patients, and therapy can be associated with late neurotoxicity. Novel insights into the pathophysiology of PCNSL have identified the B-cell receptor (BCR) pathway as a key mechanism in the pathogenesis of PCNSL. The use of novel agents targeting components of the BCR pathway, namely the Bruton tyrosine kinase (BTK) inhibitor ibrutinib, and immunomodulatory drugs (IMIDs) like lenalidomide and pomalidomide, has so far been limited to patients who have recurrent/refractory PCNSL with promising high response rates. Within the past 5 years, there has been a peak in clinical trials investigating small molecules and novel reagents in the recurrent/refractory setting, including immune checkpoint inhibitors, IMIDs, and BTK and PI3K/AKT/mTOR inhibitors.
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Affiliation(s)
- Joe S Mendez
- From the Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Neurology, Weill Cornell Medical College, New York, NY
| | - Christian Grommes
- From the Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Neurology, Weill Cornell Medical College, New York, NY
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26
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Abstract
PURPOSE OF REVIEW Primary central nervous system lymphoma (PCNSL) is an aggressive malignancy confined to the brain, spinal cord, leptomeninges, and eyes. Due to its rarity, there is a paucity of randomized trials and a varied approach to its management in the oncologic community. This review summarizes recent literature guiding current clinical practice. RECENT FINDINGS The presentation, work up, and management of PCNSL are discussed. Induction therapy incorporates a methotrexate-based chemotherapy regimen and is generally followed by a consolidation regimen including high dose chemotherapy (with or without autologous stem cell rescue). Whole brain radiation therapy (WBRT) is a potential additional consolidation strategy. Management of relapsed and refractory disease poses a special challenge due to poor outcomes. Immunotherapy and targeted treatments are promising novel strategies for recurrent/refractory patients. Currently, there is little consensus in the management of PCNSL. Treatment recommendations should be tailored to the individual patient, with consideration for risk of neurotoxicity. New, exciting strategies are in development and when feasible, enrollment in a clinical trial should be considered.
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Affiliation(s)
- Lauren R Schaff
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Christian Grommes
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- , New York, USA.
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Abstract
Primary CNS lymphoma (PCNSL) has been designated an acquired immune deficiency syndrome (AIDS)-defining disease since 1983 and accounts for up to 15% of non-Hodgkin lymphomas in human immunodeficiency virus (HIV) patients. The majority of HIV patients are Epstein-Barr virus (EBV)-related. The most likely etiology is ineffective immunoregulation of EBV, inducing oncogenic protein expression, and subsequent loss of apoptosis and increased proliferation of lymphocytes. PCNSL generally presents with supratentorial, single or multiple, contrast-enhancing lesions. Neurologic symptoms can be headache, cognitive function disorders, focal neurologic, deficit and epilepsy. Differential diagnosis includes other oncologic or infectious causes, with cerebral toxoplasmosis being the most important. Magnetic resonance imaging characteristics, activity on 201thallium single-photon emission computed tomography, presence of EBV DNA in the cerebrospinal fluid, and toxoplasmosis serology can make either PCNSL or cerebral toxoplasmosis more or less likely. However, definitive diagnosis of PCNSL relies on histopathologic confirmation. First-choice treatment is combination antiretroviral therapy in combination with high-dose methotrexate(-based) chemotherapy in patients in whom this is feasible. Combination antiretroviral therapy combined with whole-brain radiotherapy may be an alternative. Treatment of EBV with antiviral agents such as ganciclovir or zidovudine may be beneficial, but this needs further study. Prognosis of HIV-related PCNSL is poor, with median survival varying from 2 to 4 months, but patients treated with chemotherapy do better (median survival 1.5 years).
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Affiliation(s)
- Dieta Brandsma
- Department of Neuro-Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Jacoline E C Bromberg
- Department of Neuro-Oncology, Erasmus MC University Medical Center Cancer Center Daniel den Hoed, Rotterdam, The Netherlands.
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28
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Prasad SN, Lal H, Jaiswal S, Das KK. Primary dural diffuse large B cell lymphoma mimicking parafalcine meningioma. BMJ Case Rep 2017; 2017:bcr-2016-219126. [PMID: 28978572 PMCID: PMC5652401 DOI: 10.1136/bcr-2016-219126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2017] [Indexed: 11/04/2022] Open
Abstract
A 58-year-old immunocompetent woman presented with complaints of recent onset recurrent generalised tonic-clonic seizures and left hemiparesis. On MRI a dural-based heterogeneously enhancing mass was seen along the falx cerebri mimicking parafalcine meningioma, causing brain parenchymal compression and vasogenic oedema in the right frontal and parietal lobes. The tumour was completely excised and on subsequent investigation it was diagnosed as diffuse large B cell type primary dural lymphoma. Chemotherapy with CHOP (cyclophosphamide, hydroxyl doxorubicin, vincristine and prednisone) regimen was started; however, the patient later died from episodes of acute pulmonary thromboembolism, aspiration pneumonia and septic shock.
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Affiliation(s)
- Surya Nandan Prasad
- Department of Radiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Hira Lal
- Department of Radiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sushila Jaiswal
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kuntal Kanti Das
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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29
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Qian L, Tomuleasa C, Florian IA, Shen J, Florian IS, Zdrenghea M, Dima D. Advances in the treatment of newly diagnosed primary central nervous system lymphomas. Blood Res 2017; 52:159-166. [PMID: 29043230 PMCID: PMC5641507 DOI: 10.5045/br.2017.52.3.159] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 08/29/2017] [Indexed: 12/18/2022] Open
Abstract
Primary central nervous system lymphoma (PCNSL) is a type of highly invasive non-Hodgkin lymphoma. With a growing number of organ transplantation and immunosuppressant therapy, the incidence of PCNSL has been growing rapidly in recent years, which is attributed to the increased incidence of HIV/AIDS, a prominent risk factor for developing PCNSL. The rising rate of PCNSL incidence is the highest among the intracranial tumors. In the past 20 years, dozens of clinical trials related to PCNSL have been registered, but adequate therapeutics are still challenging. Currently, the chemotherapy regimens based on high-dose methotrexate and whole-brain radiotherapy are the two main therapeutic options; however, the toxicity associated with those is the main problem that challenges medical researchers. Novel agents and therapeutic strategies have been developed in recent years. In the current review, we describe advances in the treatment of PCNSL and discuss novel therapeutic approaches currently in development, such as the use of rituximab, disruption of the blood-brain barrier, and state-of-the-art radiotherapy.
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Affiliation(s)
- Liren Qian
- Department of Hematology, Navy General Hospital of PLA, Beijing, China
| | - Ciprian Tomuleasa
- Department of Hematology, Iuliu Hatieganu University, Cluj Napoca, Romania.,Department of Hematology, Ion Chiricuta Oncology Institute, Cluj Napoca, Romania
| | | | - Jianliang Shen
- Department of Hematology, Navy General Hospital of PLA, Beijing, China
| | - Ioan-Stefan Florian
- Department of Neurosurgery, Emergency University Hospital, Cluj Napoca, Romania
| | - Mihnea Zdrenghea
- Department of Hematology, Iuliu Hatieganu University, Cluj Napoca, Romania.,Department of Hematology, Ion Chiricuta Oncology Institute, Cluj Napoca, Romania
| | - Delia Dima
- Department of Hematology, Ion Chiricuta Oncology Institute, Cluj Napoca, Romania
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30
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Brett FM, Flavin R, Chen D, Loftus T, Looby S, McCarthy A, de Gascun C, Jaffe ES, Nor N, Javadpour M, McCabe D. EBV driven natural killer cell disease of the central nervous system presenting as subacute cognitive decline. HUMAN PATHOLOGY: CASE REPORTS 2017; 10:64-68. [PMID: 28845389 PMCID: PMC5568754 DOI: 10.1016/j.ehpc.2017.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Brain biopsy in patients presenting with subacute encephalopathyis never straightforward and only undertaken when a ‘treatable condition’ is a realistic possibility. This 63 year old right handed, immunocompetent Caucasian woman presented with an 8 month history of rapidly progressive right-sided hearing impairment, a 4 month history of intermittent headaches, tinnitus, ‘dizziness’, dysphagia, nausea and vomiting, with the subsequent evolution of progressive gait ataxia and a subacute global encephalopathy. The possibility of CJD was raised. Brain biopsy was carried out. Western blot for prion protein was negative. She died 9 days later and autopsy brain examination confirmed widespread subacute infarction due to an EBV positive atypical NK/T-cell infiltrate with positivity for CD3, CD56, granzyme B, perforin and EBER with absence of CD4, CD5 and CD8 expression. Molecular studies for T-cell clonality were attempted but failed due to insufficient DNA quality. Serology was consistent with past EBV infection (EBV VCA and EBNA IgG Positive). There was no evidence of disease outside the CNS. Primary central nervous system NK/T-cell lymphoma is extremely rare. The rare reported cases all present with a discrete intracranial mass, unlike the diffuse infiltrative pattern in this case. Whilst the diffuse interstitial pattern is reminiscent of chronic active EBV infection (CAEBV) seen in other organ systems such as the liver and bone marrow, the clinical presentation and epidemiologic profile are not typical for CAEBV.
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Affiliation(s)
- Francesca M Brett
- Department of Clinical Neurological Sciences, RCSI, Beaumont Hospital Dublin, Ireland
| | - Richard Flavin
- Department of Histopathology, St James's Hospital Dublin, Ireland
| | - Daphne Chen
- Department of Clinical Neurological Sciences, RCSI, Beaumont Hospital Dublin, Ireland
| | - Teresa Loftus
- Department of Clinical Neurological Sciences, RCSI, Beaumont Hospital Dublin, Ireland
| | - Seamus Looby
- Department of Clinical Neurological Sciences, RCSI, Beaumont Hospital Dublin, Ireland
| | - Allan McCarthy
- Department of Neurology, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital, Dublin, Ireland.,Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital, Dublin, Ireland
| | | | | | - Nurul Nor
- Midland Regional Hospital, Tullamore, Ireland
| | - Mohsen Javadpour
- Department of Clinical Neurological Sciences, RCSI, Beaumont Hospital Dublin, Ireland
| | - Dominick McCabe
- Department of Neurology, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital, Dublin, Ireland.,Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital, Dublin, Ireland.,Vascular Neurology Research Foundation, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital, Dublin, Ireland.,Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, UK.,Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland
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31
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Primary central nervous system lymphoma as a neurosurgical problem. Neurol Neurochir Pol 2017; 51:319-323. [DOI: 10.1016/j.pjnns.2017.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 04/10/2017] [Indexed: 11/21/2022]
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32
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Abstract
Primary central nervous system lymphoma (PCNSL) is a rare aggressive high-grade type of extranodal lymphoma. PCNSL can have a variable imaging appearance and can mimic other brain disorders such as encephalitis, demyelination, and stroke. In addition to PCNSL, the CNS can be secondarily involved by systemic lymphoma. Computed tomography and conventional MRI are the initial imaging modalities to evaluate these lesions. Recently, however, advanced MRI techniques are more often used in an effort to narrow the differential diagnosis and potentially inform diagnostic and therapeutic decisions.
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33
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Alcaide-Leon P, Dufort P, Geraldo AF, Alshafai L, Maralani PJ, Spears J, Bharatha A. Differentiation of Enhancing Glioma and Primary Central Nervous System Lymphoma by Texture-Based Machine Learning. AJNR Am J Neuroradiol 2017; 38:1145-1150. [PMID: 28450433 DOI: 10.3174/ajnr.a5173] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 02/01/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE Accurate preoperative differentiation of primary central nervous system lymphoma and enhancing glioma is essential to avoid unnecessary neurosurgical resection in patients with primary central nervous system lymphoma. The purpose of the study was to evaluate the diagnostic performance of a machine-learning algorithm by using texture analysis of contrast-enhanced T1-weighted images for differentiation of primary central nervous system lymphoma and enhancing glioma. MATERIALS AND METHODS Seventy-one adult patients with enhancing gliomas and 35 adult patients with primary central nervous system lymphomas were included. The tumors were manually contoured on contrast-enhanced T1WI, and the resulting volumes of interest were mined for textural features and subjected to a support vector machine-based machine-learning protocol. Three readers classified the tumors independently on contrast-enhanced T1WI. Areas under the receiver operating characteristic curves were estimated for each reader and for the support vector machine classifier. A noninferiority test for diagnostic accuracy based on paired areas under the receiver operating characteristic curve was performed with a noninferiority margin of 0.15. RESULTS The mean areas under the receiver operating characteristic curve were 0.877 (95% CI, 0.798-0.955) for the support vector machine classifier; 0.878 (95% CI, 0.807-0.949) for reader 1; 0.899 (95% CI, 0.833-0.966) for reader 2; and 0.845 (95% CI, 0.757-0.933) for reader 3. The mean area under the receiver operating characteristic curve of the support vector machine classifier was significantly noninferior to the mean area under the curve of reader 1 (P = .021), reader 2 (P = .035), and reader 3 (P = .007). CONCLUSIONS Support vector machine classification based on textural features of contrast-enhanced T1WI is noninferior to expert human evaluation in the differentiation of primary central nervous system lymphoma and enhancing glioma.
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Affiliation(s)
| | - P Dufort
- Department of Medical Imaging (P.D., A.F.G.) Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - A F Geraldo
- Department of Medical Imaging (P.D., A.F.G.) Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - L Alshafai
- Department of Medical Imaging (L.A.), Mount Sinai Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - P J Maralani
- Department of Medical Imaging (P.J.M.), Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - J Spears
- Neurosurgery (J.S.), St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - A Bharatha
- From the Departments of Medical Imaging (P.A.-L., A.B.)
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34
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Minnema MC, Kimby E, D'Sa S, Fornecker LM, Poulain S, Snijders TJ, Kastritis E, Kremer S, Fitsiori A, Simon L, Davi F, Lunn M, Castillo JJ, Patterson CJ, Le Garff-Tavernier M, Costopoulos M, Leblond V, Kersten MJ, Dimopoulos MA, Treon SP. Guideline for the diagnosis, treatment and response criteria for Bing-Neel syndrome. Haematologica 2016; 102:43-51. [PMID: 27758817 DOI: 10.3324/haematol.2016.147728] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 10/06/2016] [Indexed: 12/31/2022] Open
Abstract
Bing Neel syndrome is a rare disease manifestation of Waldenström's macroglobulinemia that results from infiltration of the central nervous system by malignant lymphoplasmacytic cells. In this guideline we describe the clinical symptoms, as well as the appropriate laboratory and radiological studies, that can aid in the diagnosis. The presentation of Bing Neel syndrome may be very diverse, and includes headaches, cognitive deficits, paresis, and psychiatric symptoms. The syndrome can present in patients with known Waldenström's macroglobulinemia, even in the absence of systemic progression, but also in previously undiagnosed patients. Diagnostic work-up should include cerebral spinal fluid analysis with multiparameter flow cytometry to establish B-cell clonality, protein electrophoresis and immunofixation for the detection and classification of a monoclonal protein as well as molecular diagnostic testing for immunoglobulin gene rearrangement and mutated MYD88. MRI of the brain and spinal cord is also essential. The second challenge is to expand our knowledge of prognosis and treatment outcome. Prospective clinical trials on Bing Neel syndrome patients that employ uniform treatment along with appropriate laboratory cerebral spinal fluid assessments and standardized MRI protocols will be invaluable, constituting a significant step forward in delineating treatment outcome for this intriguing disease manifestation.
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Affiliation(s)
- Monique C Minnema
- Department of Hematology, UMC Utrecht Cancer Center, the Netherlands
| | - Eva Kimby
- Hematology Center, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Shirley D'Sa
- Cancer Division, University College London Hospitals NHS Foundation Trust, UK
| | - Luc-Matthieu Fornecker
- Department of Oncology and Hematology, Hôpital Universitaires de Strasbourg and Université de Strasbourg, France
| | - Stéphanie Poulain
- Service d'Hématologie-Immunologie-Cytogénétique, Centre Hospitalier de Valenciennes/Laboratoire d'Hématologie, Centre de Biologie et Pathologie, CHRU de Lille/INSERM, France
| | - Tom J Snijders
- Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, UMC Utrecht, The Netherlands
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Greece
| | - Stéphane Kremer
- Pôle d'Imagerie-Neuroradiologie, Hôpital de Hautepierre/CHU Strasbourg, France
| | - Aikaterini Fitsiori
- Pôle d'Imagerie-Neuroradiologie, Hôpital de Hautepierre/CHU Strasbourg, France
| | - Laurence Simon
- Department of Oncology and Hematology, Hôpital Universitaires de Strasbourg and Université de Strasbourg, France
| | - Frédéric Davi
- Laboratory of Hematology, Hôpital Pitié Salpêtrière, Paris, France
| | - Michael Lunn
- Centre for Neuromuscular Disease, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Jorge J Castillo
- Bing Center for Waldenstrom's Macroglobulinemia, Dana Farber Cancer Institute and Harvard Medical; School, Boston, MA, USA
| | - Christopher J Patterson
- Bing Center for Waldenstrom's Macroglobulinemia, Dana Farber Cancer Institute and Harvard Medical; School, Boston, MA, USA
| | | | | | | | - Marie-José Kersten
- Department of Hematology, Academic Medical Center, Amsterdam, the Netherlands
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Greece
| | - Steven P Treon
- Bing Center for Waldenstrom's Macroglobulinemia, Dana Farber Cancer Institute and Harvard Medical; School, Boston, MA, USA
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35
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The Influence of Corticosteroids on Diagnostic Accuracy of Biopsy for Primary Central Nervous System Lymphoma. Can J Neurol Sci 2016; 43:721-5. [DOI: 10.1017/cjn.2016.255] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractClassical neurosurgical teaching suggests that corticosteroid administration reduces the diagnostic yield of stereotactic brain biopsy for primary central nervous system lymphoma (PCNSL). In a single-center series spanning 6 years, we reviewed 155 consecutive biopsy patients, 135 treated with prebiopsy corticosteroids. PCNSL was correctly diagnosed on initial biopsy in 15 of 16 steroid-treated patients; in the single nondiagnostic specimen, polymerase chain reaction reanalysis by an outside institution showed evidence of lymphoproliferative disease consistent with PCNSL. Our data challenge the notion that it is necessary to withhold corticosteroid therapy for cerebral edema in patients awaiting stereotactic biopsy for suspected PCNSL.
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36
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Performance of Apparent Diffusion Coefficient Values and Conventional MRI Features in Differentiating Tumefactive Demyelinating Lesions From Primary Brain Neoplasms. AJR Am J Roentgenol 2016; 205:1075-85. [PMID: 26496556 DOI: 10.2214/ajr.14.13970] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Tumefactive demyelinating lesions (TDLs) remain one of the most common brain lesions to mimic a brain tumor, particularly primary CNS lymphoma (PCNSL) and high-grade gliomas. The purpose of our study was to evaluate the ability of apparent diffusion coefficient (ADC) values and conventional MRI features to differentiate TDLs from PCNSLs and high-grade gliomas. MATERIALS AND METHODS Seventy-five patients (24 patients with TDLs, 28 with PCNSLs, and 23 with high-grade gliomas) with 168 brain lesions (70 TDLs, 68 PCNSLs, and 30 high-grade gliomas) who underwent DWI before surgery or therapy were included in the study. Minimum ADC (ADC(min)) and average ADC (ADC(avg)) values were calculated for each lesion. ANOVA and ROC analyses were performed. ROC analyses were also performed for the presence of incomplete rim enhancement and for the number of lesions. Multiple-variable logistic regression with ROC analysis was then performed to evaluate performance in multiple-variable models. RESULTS ADC(min) was statistically significantly higher (p < 0.01) in TDLs (mean, 0.886; 95% CI, 0.802-0.931) than in PCNSLs (0.547; 95% CI, 0.496-0.598) and high-grade gliomas (0.470; 95% CI, 0.385-0.555). (All ADC values in this article are reported in units of × 10(-3) mm(2)/s.) ADC(avg) was statistically significantly higher (p < 0.01) in TDLs (mean, 1.362; 95% CI, 1.268-1.456) than in PCNSLs (0.990; 95% CI, 0.919-1.061) but not in high-grade gliomas (1.216; 95% CI, 1.074-1.356). Multiple-variable models showed statistically significant individual effects and superior diagnostic performance on ROC analysis. CONCLUSION TDLs can be diagnosed on preoperative MRI with a high degree of specificity; MRI features of incomplete rim enhancement, high ADC values, and a large number of lesions individually increase the probability and diagnostic confidence that a lesion is a TDL.
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37
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Mabray MC, Barajas RF, Villanueva-Meyer JE, Zhang CA, Valles FE, Rubenstein JL, Cha S. The Combined Performance of ADC, CSF CXC Chemokine Ligand 13, and CSF Interleukin 10 in the Diagnosis of Central Nervous System Lymphoma. AJNR Am J Neuroradiol 2016; 37:74-9. [PMID: 26381553 DOI: 10.3174/ajnr.a4450] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 05/12/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE CXC chemokine ligand 13 and interleukin 10 have emerged as CSF biomarkers for the diagnosis of CNS lymphoma. Our hypothesis is that the combined use of ADC, CXC chemokine ligand 13, and interleukin 10 will result in increased diagnostic performance compared with the use of ADC values alone. MATERIALS AND METHODS Eighty-seven patients were included in this study, including 43 with CNS lymphoma and 44 without CNS lymphoma (21 metastases, 14 high-grade gliomas, 9 tumefactive demyelinating lesions) who had undergone CSF proteomic analysis and had a new enhancing mass on brain MR imaging. Average ADC was derived by contouring the contrast-enhancing tumor volume. Group means were compared via t tests for average ADC, CXC chemokine ligand 13, and interleukin 10. Receiver operating characteristic analysis was performed for each individual variable. Multiple-variable logistic regression with receiver operating characteristic analysis was performed, and the multiple-variable receiver operating characteristic was compared with single-variable receiver operating characteristics. RESULTS The average ADC was lower and CSF CXC chemokine ligand 13 and interleukin 10 values were higher in CNS lymphoma (P < .001). Areas under the curve ranged from 0.739 to 0.832 for single-variable ROC. Multiple-variable logistic regression yielded statistically significant individual effects for all 3 variables in a combined model. Multiple-variable receiver operating characteristics (area under the curve, 0.928) demonstrated statistically significantly superior diagnostic performance compared with the use of single variables alone. CONCLUSIONS The combined use of ADC, CSF CXC chemokine ligand 13, and interleukin 10 results in increased diagnostic performance for the diagnosis of CNS lymphoma. This finding highlights the importance of CSF analysis when the diagnosis of CNS lymphoma is considered on the basis of MR imaging.
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Affiliation(s)
- M C Mabray
- From the Departments of Radiology and Biomedical Imaging (M.C.M., R.F.B., J.E.V.-M., C.A.Z., F.E.V., S.C.)
| | - R F Barajas
- From the Departments of Radiology and Biomedical Imaging (M.C.M., R.F.B., J.E.V.-M., C.A.Z., F.E.V., S.C.)
| | - J E Villanueva-Meyer
- From the Departments of Radiology and Biomedical Imaging (M.C.M., R.F.B., J.E.V.-M., C.A.Z., F.E.V., S.C.)
| | - C A Zhang
- From the Departments of Radiology and Biomedical Imaging (M.C.M., R.F.B., J.E.V.-M., C.A.Z., F.E.V., S.C.) Epidemiology and Biostatistics (C.A.Z.)
| | - F E Valles
- From the Departments of Radiology and Biomedical Imaging (M.C.M., R.F.B., J.E.V.-M., C.A.Z., F.E.V., S.C.)
| | | | - S Cha
- From the Departments of Radiology and Biomedical Imaging (M.C.M., R.F.B., J.E.V.-M., C.A.Z., F.E.V., S.C.) Neurological Surgery (S.C.), University of California San Francisco, San Francisco, California
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Madle M, Krämer I, Lehners N, Schwarzbich M, Wuchter P, Herfarth K, Egerer G, Ho AD, Witzens-Harig M. The influence of rituximab, high-dose therapy followed by autologous stem cell transplantation, and age in patients with primary CNS lymphoma. Ann Hematol 2015; 94:1853-7. [PMID: 26268792 DOI: 10.1007/s00277-015-2470-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 08/03/2015] [Indexed: 10/23/2022]
Abstract
For patients with diffuse large B cell lymphoma without the involvement of the CNS, the addition of rituximab to standard chemotherapy has significantly improved survival. In this single-center, retrospective analysis, a total of 81 primary CNS lymphoma (PCNSL) patients treated in our institution between 2000 and 2011 were included. Beside first-line chemotherapy with or without rituximab, we evaluated the impact of age (≤/>60 years), autologous stem cell transplantation (ASCT +/-), and other factors upon overall survival (OS) and progression-free survival (PFS). In patients treated with rituximab (n = 27), 3-year OS was 77.8 % (95 % confidence interval (CI) 62-93 %). In contrast, in patients treated without rituximab (n = 52), 3-year OS was only 39.9 % (CI 27-53 %, Fig. 1). The difference in OS was significant in the univariate (p = 0.002) as well as in the multivariate analysis (p = 0.049, hazard ratio (HR) = 0.248). Patients ≤60 years of age (n = 28) had a 3-year OS of 78.2 % (CI 63-94 %); in patients >60 years (n = 51), 3-year OS was 38.7 % (CI 25-52 %). Patients who received high-dose therapy and ASCT had a 3-year OS of 85.2 % (CI 72-99 %), and 65.1 % were alive up to the time of analysis (range 9-131 months). Without ASCT, median OS was only 16 months (CI 11-21) and 3-year OS was 35.2 % (CI 22-48 %). Age and ASCT were significantly associated with better OS in univariate (p = 0.002 and p < 0.001) as well in multivariate analysis (p = 0.004, HR = 0.023 and p = 0.001, HR = 0.014). Rituximab treatment, ASCT, and age are independent prognostic factors for OS in the first-line treatment of PCNSL.
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Affiliation(s)
- M Madle
- Department of Hematology and Oncology, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - I Krämer
- Department of Hematology and Oncology, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
| | - N Lehners
- Department of Hematology and Oncology, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - M Schwarzbich
- Department of Hematology and Oncology, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - P Wuchter
- Department of Hematology and Oncology, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - K Herfarth
- Department of Radiation Oncology, University of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - G Egerer
- Department of Hematology and Oncology, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - A D Ho
- Department of Hematology and Oncology, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - M Witzens-Harig
- Department of Hematology and Oncology, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
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Varadarajan S, Breda C, Smalley JL, Butterworth M, Farrow SN, Giorgini F, Cohen GM. The transrepression arm of glucocorticoid receptor signaling is protective in mutant huntingtin-mediated neurodegeneration. Cell Death Differ 2015; 22:1388-96. [PMID: 25656655 PMCID: PMC4495362 DOI: 10.1038/cdd.2015.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 12/15/2014] [Accepted: 01/07/2015] [Indexed: 02/07/2023] Open
Abstract
The unfolded protein response (UPR) occurs following the accumulation of unfolded proteins in the endoplasmic reticulum (ER) and orchestrates an intricate balance between its prosurvival and apoptotic arms to restore cellular homeostasis and integrity. However, in certain neurodegenerative diseases, the apoptotic arm of the UPR is enhanced, resulting in excessive neuronal cell death and disease progression, both of which can be overcome by modulating the UPR. Here, we describe a novel crosstalk between glucocorticoid receptor signaling and the apoptotic arm of the UPR, thus highlighting the potential of glucocorticoid therapy in treating neurodegenerative diseases. Several glucocorticoids, but not mineralocorticoids, selectively antagonize ER stress-induced apoptosis in a manner that is downstream of and/or independent of the conventional UPR pathways. Using GRT10, a novel selective pharmacological modulator of glucocorticoid signaling, we describe the importance of the transrepression arm of the glucocorticoid signaling pathway in protection against ER stress-induced apoptosis. Furthermore, we also observe the protective effects of glucocorticoids in vivo in a Drosophila model of Huntington's disease (HD), wherein treatment with different glucocorticoids diminished rhabdomere loss and conferred neuroprotection. Finally, we find that growth differentiation factor 15 has an important role downstream of glucocorticoid signaling in antagonizing ER stress-induced apoptosis in cells, as well as in preventing HD-mediated neurodegeneration in flies. Thus, our studies demonstrate that this novel crosstalk has the potential to be effectively exploited in alleviating several neurodegenerative disorders.
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Affiliation(s)
- S Varadarajan
- Department of Molecular and Clinical Cancer Medicine and Pharmacology, University of Liverpool, Liverpool, UK
| | - C Breda
- Department of Genetics, University of Leicester, Leicester, UK
| | - J L Smalley
- MRC Toxicology Unit, University of Leicester, Leicester, UK
| | - M Butterworth
- MRC Toxicology Unit, University of Leicester, Leicester, UK
| | - S N Farrow
- Respiratory Therapy Area, GlaxoSmithKline, Stevenage, UK
| | - F Giorgini
- Department of Genetics, University of Leicester, Leicester, UK
| | - G M Cohen
- Department of Molecular and Clinical Cancer Medicine and Pharmacology, University of Liverpool, Liverpool, UK
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Bittar J, Kamiya-Matsuoka C, Barata PC, Lee-Kim SH, Olar A, Tremont-Lukats IW. Corticosteroid sensitivity in gliomatosis cerebri delays diagnosis. Pract Neurol 2015; 15:309-11. [PMID: 25922538 DOI: 10.1136/practneurol-2015-001125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2015] [Indexed: 11/04/2022]
Affiliation(s)
- Jan Bittar
- Department of Neuro-Oncology, The University of Texas-M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Carlos Kamiya-Matsuoka
- Department of Neuro-Oncology, The University of Texas-M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Pedro C Barata
- Department of Neuro-Oncology, The University of Texas-M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Soo-Hyun Lee-Kim
- Department of Neuro-Oncology, The University of Texas-M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Adriana Olar
- Department of Pathology, The University of Texas-M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Ivo W Tremont-Lukats
- Department of Neuro-Oncology, The University of Texas-M.D. Anderson Cancer Center, Houston, Texas, USA
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Sakata A, Okada T, Yamamoto A, Kanagaki M, Fushimi Y, Dodo T, Arakawa Y, Takahashi JC, Miyamoto S, Togashi K. Primary central nervous system lymphoma: is absence of intratumoral hemorrhage a characteristic finding on MRI? Radiol Oncol 2015; 49:128-34. [PMID: 26029023 PMCID: PMC4387988 DOI: 10.1515/raon-2015-0007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 01/06/2015] [Indexed: 12/15/2022] Open
Abstract
Background. Previous studies have shown that intratumoral hemorrhage is a common finding in glioblastoma multi-forme, but is rarely observed in primary central nervous system lymphoma. Our aim was to reevaluate whether intratumoral hemorrhage observed on T2-weighted imaging (T2WI) as gross intratumoral hemorrhage and on susceptibility-weighted imaging as intratumoral susceptibility signal can differentiate primary central nervous system lymphoma from glioblastoma multiforme. Patients and methods. A retrospective cohort of brain tumors from August 2008 to March 2013 was searched, and 58 patients (19 with primary central nervous system lymphoma, 39 with glioblastoma multiforme) satisfied the inclusion criteria. Absence of gross intratumoral hemorrhage was examined on T2WI, and an intratumoral susceptibility signal was graded using a 3-point scale on susceptibility-weighted imaging. Results were compared between primary central nervous system lymphoma and glioblastoma multiforme, and values of P < 0.05 were considered significant. Results. Gross intratumoral hemorrhage on T2WI was absent in 15 patients (79%) with primary central nervous system lymphoma and 23 patients (59%) with glioblastoma multiforme. Absence of gross intratumoral hemorrhage could not differentiate between the two disorders (P = 0.20). However, intratumoral susceptibility signal grade 1 or 2 was diagnostic of primary central nervous system lymphoma with 78.9% sensitivity and 66.7% specificity (P < 0.001), irrespective of gross intratumoral hemorrhage. Conclusions. Low intratumoral susceptibility signal grades can differentiate primary central nervous system lymphoma from glioblastoma multiforme. However, specificity in this study was relatively low, and primary central nervous system lymphoma cannot be excluded based solely on the presence of an intratumoral susceptibility signal.
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Affiliation(s)
- Akihiko Sakata
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tomohisa Okada
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Correspondence to: Tomohisa Okada, M.D., Ph.D., Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawaharacho, Sakyo-ku, Kyoto, 606–8507, Japan. Phone: +81 75 751 4215; Fax: +81 75 751 4216; E-mail:
| | - Akira Yamamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Mitsunori Kanagaki
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yasutaka Fushimi
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Toshiki Dodo
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoshiki Arakawa
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Jun C Takahashi
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kaori Togashi
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Ambroise MM, Ghosh M, Mallikarjuna V, Annapurneswari S, Kurian A, Chakravarthy R. Primary central nervous system lymphoma: a clinicopathological and cytomorpholgical study from a tertiary care centre in Chennai, India. Asian Pac J Cancer Prev 2013; 14:727-31. [PMID: 23621227 DOI: 10.7314/apjcp.2013.14.2.727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study was to analyze the clinicopathological and immunohistochemical features of primary central nervous system lymphoma (PCNSL) cases occurring in Indian patients and also study the utility of the crush smear preparation in intraoperative diagnosis. MATERIALS AND METHODS The immune status, clinical, radiological details, immunohistochemical profile, histopathological findings and cytological features in smear preparation of 32 cases of PCNSL were analyzed. Patients with systemic NHL and skull-base lymphomas were excluded. RESULTS The mean age of our patients was 52 years with a male: female ratio 1:1. A periventricular location was found in 62.5% of patients. None of our PCNSL cases were associated with AIDS. All cases except one were diffuse large B-cell lymphomas. Intraoperative diagnosis using crush smears allowed correct prediction in 93% of cases. CONCLUSIONS Our study shows that PCNSL is seen predominantly in immunocompetent patients in India .The age of presentation is relatively young as compared to the West. Our study also stresses the utility of crush smear preparation in establishing an intraoperative diagnosis.
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Scott BJ, Douglas VC, Tihan T, Rubenstein JL, Josephson SA. A systematic approach to the diagnosis of suspected central nervous system lymphoma. JAMA Neurol 2013; 70:311-9. [PMID: 23319132 DOI: 10.1001/jamaneurol.2013.606] [Citation(s) in RCA: 113] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Central nervous system (CNS) lymphoma can present a diagnostic challenge. Currently, there is no consensus regarding what presurgical evaluation is warranted or how to proceed when lesions are not surgically accessible. We conducted a review of the literature on CNS lymphoma diagnosis (1966 to October 2011) to determine whether a common diagnostic algorithm can be generated. We extracted data regarding the usefulness of brain and body imaging, serum and cerebrospinal fluid (CSF) studies, ophthalmologic examination, and tissue biopsy in the diagnosis of CNS lymphoma. Contrast enhancement on imaging is highly sensitive at the time of diagnosis: 98.9% in immunocompetent lymphoma and 96.1% in human immunodeficiency virus-related CNS lymphoma. The sensitivity of CSF cytology is low (2%-32%) but increases when combined with flow cytometry. Cerebrospinal fluid lactate dehydrogenase isozyme 5, β2-microglobulin, and immunoglobulin heavy chain rearrangement studies have improved sensitivity over CSF cytology (58%-85%) but have only moderate specificity (85%). New techniques of proteomics and microRNA analysis have more than 95% specificity in the diagnosis of CNS lymphoma. Positive CSF cytology, vitreous biopsy, or brain/leptomeningeal biopsy remain the current standard for diagnosis. A combined stepwise systematic approach outlined here may facilitate an expeditious, comprehensive presurgical evaluation for cases of suspected CNS lymphoma.
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Affiliation(s)
- Brian J Scott
- Department of Neurology, University of California-San Francisco, 505 Parnassus Ave, San Francisco, CA 94143, USA.
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Ohe M, Hashino S, Hattori A. Successful treatment of diffuse large B-cell lymphoma with clarithromycin and prednisolone. THE KOREAN JOURNAL OF HEMATOLOGY 2012; 47:293-7. [PMID: 23320009 PMCID: PMC3538802 DOI: 10.5045/kjh.2012.47.4.293] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Revised: 05/11/2012] [Accepted: 10/09/2012] [Indexed: 11/17/2022]
Abstract
We report a case of diffuse large B-cell lymphoma (DLBCL) treated successfully with clarithromycin (CAM) and prednisolone (PSL). A 71-year-old woman presented with fever and cervical pain. DLBCL was diagnosed based on histological results from lymph node biopsy. Cervical pain was thought to be caused by the invasion of lymphoma cells into the cervical vertebrae. She initially received radiotherapy for the cervical lesion. She did not receive conventional chemotherapy because of the risk of recurrent non-tuberculous mycobacteria infection; therefore, she was treated with 20 mg/day PSL and 800 mg/day CAM to induce apoptosis in lymphoma cells. Complete remission was achieved after 6 months. The present findings suggest that CAM and PSL may be effective in some cases of DLBCL.
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Affiliation(s)
- Masashi Ohe
- Department of General Medicine, Hokkaido Social Insurance Hospital, Sapporo, Japan
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Teo MK, Mathieson C, Carruthers R, Stewart W, Alakandy L. Cauda equina lymphoma--a rare presentation of primary central nervous system lymphoma: case report and literature review. Br J Neurosurg 2012; 26:868-71. [PMID: 22768968 DOI: 10.3109/02688697.2012.697225] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The spinal cord is an extremely rare site for primary central nervous system (CNS) lymphoma (< 1%). Very few cases of primary cauda equina (including conus) lymphoma were previously reported. We report such a case, and with literature review, discuss their clinical features, operative and histopathological findings. Although rare, with an increasing incidence of CNS lymphoma, they should be considered in the differential diagnosis of intradural lesions. Furthermore, with intraoperative smear to establish diagnosis, extensive surgery can be avoided. The controversial role of glucocorticoids in the management of these patients is also discussed.
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Affiliation(s)
- Mario K Teo
- Department of Neurosurgery, Institute of Neurological Sciences, Glasgow, UK.
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Conservative management of post-transplant central nervous system lymphoma. Int Urol Nephrol 2012; 45:1219-22. [PMID: 22476860 DOI: 10.1007/s11255-012-0146-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Accepted: 02/14/2012] [Indexed: 01/11/2023]
Abstract
Primary CNS lymphoma (PCNSL) is a rare B cell variant non-Hodgkins lymphoma that is confined to the brain, leptomeninges, spinal cord and eyes. Its incidence is increasing, primarily due to increase in the number of organ transplantations being undertaken. The majority of the PTLD (post-transplant lymphoproliferative disorder) is seen in kidney transplant recipients simply because they constitute a larger group of transplant recipients each year as compared to other solid organ transplantations. Primary infection of previously infected EBV seronegative patients and immunosuppression are found to be the main etiologic factors in the development of PTLD-PCNSL. There are no clear guidelines on treatment regimens, and it should be individualized according to patient comorbidities. We report a case of PCNS lymphoproliferative disorder in a kidney transplant recipient, which underwent complete remission with decreasing immunosuppression. The patient could not undergo chemotherapy/radiotherapy due to underlying comorbidities. We highlight the available treatment modalities for PTLD-PCNSL.
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Taniguchi E. Primary lymphoma of the central nervous system: a clinicopathologic study. Brain Tumor Pathol 2012; 18:101-8. [PMID: 11908865 DOI: 10.1007/bf02479422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We performed clinicopathologic examinations of 27 cases of primary lymphoma of the central nervous system not related to acquired immune deficiency syndrome. We considered age and change of performance status (PS) to be especially important in clinical examination. We also conducted pathological studies of these tumors and the characteristics of their cells, in order to characterize pathological subtypes, cell kinetics, and involvement of viruses. PS of patients more than 70 years old decreased markedly before treatment and did not show the improvement after treatment that was exhibited by those under 70 years of age. Low PS (60% or less) after initial treatment, high MIB-1 positivity (over 44.0%), and high counts of AgNOR (over 4.56/cell) were significantly associated with lower survival rates. Patients with immunoblastic lymphoma and high MIB-1 positivity are likely to die from general debilitation, without evidence of recurrence from imaging. Preoperative steroid therapy was significantly associated with higher apoptotic positivity.
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Affiliation(s)
- E Taniguchi
- Department of Neurosurgery, National Hospital Kure Medical Center, Hiroshima, Japan.
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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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