Primary central nervous system lymphoma

Correlation between hematocrit and the risk of common human cancers: results of a 1999-2020 observational survey and Mendelian randomization analysis

BACKGROUND

Previous studies have underscored the significance of hematocrit (HCT) in different tumors. However, further research is needed to explore its causal relationship with various tumors.

RESEARCH DESIGN AND METHODS

A retrospective analysis and a Mendelian randomization analysis were conducted on a sample of 3,580,275 samples to investigate the causal relationships between high HCT levels and the risks of developing the 15 prevalent malignant tumors. Additionally, using an in-house cohort, Kaplan-Meier curves were utilized to examine the relationship between HCT levels and the prognosis of patients with prostate cancer (PCa).

RESULTS

An elevated HCT level was identified as a protective factor against six types of cancers, including PCa (odds ratio [OR] < 1.000, p < 0.05), and a risk factor for cervical cancer, melanoma, and non-melanoma skin cancer (OR > 1.000, p < 0.05). A potential causal association was found between high HCT levels and decreased risks of developing PCa (OR = 0.887, p < 0.05) and breast cancer (OR = 0.893, p < 0.05). HCT was identified as a protective factor against PCa (p < 0.05).

CONCLUSIONS

This study identified significant associations between HCT and nine tumors. HCT levels may serve as a protective factor against PCa.

Prognostic Value of 18 F-FDG PET in Primary Central Nervous System Lymphoma : Assessing Interim Metabolic Response for Improving Patient Stratification

PURPOSE OF THE REPORT

The usefulness of brain 18 F-FDG PET/CT in primary central nervous system lymphoma (PCNSL) remains underexplored. This study investigated whether early metabolic responses in interim brain FDG PET/CT serve as a prognostic indicator of PCNSL treatment outcomes.

PATIENTS AND METHODS

This prospective study included 53 patients with PCNSL who underwent a high-dose methotrexate-based treatment. Brain FDG PET was performed at diagnosis (baseline PET) and after induction chemotherapy (interim PET), assessing interim PET parameters such as the highest maximum standardized uptake value (hSUV max ), sum of SUV max (sumSUV max ), highest tumor-to-normal ratio (hTNR max ), sum of TNR max (sumTNR max ), highest metabolic tumor volume (MTV) (hMTV), and sum of MTV (sumMTV) across all PET-positive lesions.

RESULTS

High interim hTNR max (hazards ratio: 9.76, 95% confidence interval: 1.90-50.11, P = 0.01) was an independently significant predictor of poor progression-free survival in multivariate analysis. Patients with low interim hTNR max (≤1.0) had a significantly longer median progression-free survival than those with high interim hTNR max (>1.0) (25.0 vs 3.6 months, P < 0.001). Incorporating interim MRI-based clinical response assessments and hTNR max allowed the classification of partial response subgroups with markedly different prognoses ( P < 0.001). High interim hTNR max (hazards ratio: 2.76, 95% confidence interval: 1.39-5.48, P = 0.004) was an independently significant predictor of poor overall survival in multivariate analysis.

CONCLUSIONS

The hTNR max measurement from interim brain FDG PET scans emerges as an important prognostic marker in PCNSL. These findings underscore the potential of interim FDG PET evaluations to refine response assessments and inform tailored therapeutic strategies.

Antiepileptic drugs failed to prevent initial seizures or improve survival outcomes in patients with primary CNS lymphoma

This study examined the prevalence, risk factors, and prognosis of epilepsy in patients with primary central nervous system lymphoma (PCNSL) and explored the necessity of prophylactic antiepileptic treatment in this population. In this retrospective, observational, single-center study, we analyzed clinical data from PCNSL patients who were diagnosed at our institution between January 2018 and April 2023. The cohort comprised 214 patients with PCNSL (with a median age of 62 years), of which 128 (47.6%) patients were male. Epilepsy was observed in 16.82% (36/214) of the patients, with 9.35% (20/214) presenting with seizures as the initial symptom. Cortical involvement was significantly associated with seizures (OR = 9.512, 95% CI 3.870-23.381; p = 0.036). Other potential risk factors included an edema zone > 1 cm around the lesion and PIM1 wild-type status. Antiepileptic drugs (AEDs) neither reduced seizure incidence (8.11% with AEDs vs. 8.43% with no AEDs, p = 0.970) nor improved PFS (HR = 0.613, 95% CI 0.338-1.109; p = 0.106). Therefore, AEDs should not be used as preventive measures in this population.

Establishment and molecular characterisation of patient-derived organoids for primary central nervous system lymphoma

Primary central nervous system lymphoma (PCNSL) exhibits substantial intratumoural and intertumoural heterogeneity, complicating the development of effective treatment methods. Existing in vitro models fail to simulate the cellular and mutational diversity of native tumours and require prolonged generation times. Therefore, we developed a culture method for patient-derived PCNSL organoids (CLOs) and evaluated the organoids through extensive molecular characterisation, histopathological analysis, single-nucleus RNA sequencing, bulk RNA sequencing and whole-exome sequencing. These CLOs accurately mimicked the histological attributes, gene expression landscapes and mutational profiles of their original tumours. Single-nucleus RNA sequencing also revealed that CLOs maintained cell-type heterogeneity and the molecular signatures of their original tumours. CLOs were generated within 2 weeks, demonstrating rapid development and reliability. Therapeutic profiling was performed on three selected CLOs treated with four standard drugs. The CLOs exhibited specific sensitivity to methotrexate, and resistance to dexamethasone, ibrutinib and rituximab, suggesting that CLOs may be valuable tools for reflecting drug sensitivities. Taken together, these results emphasise that CLOs effectively emulate the key characteristics of PCNSL, increasing the understanding of the genetic landscape of this complex disease. CLOs provide a rapid and reliable platform for exploring individualised treatment strategies, potentially accelerating the transition of research findings to clinical practice.

Overcoming missed diagnoses of primary central nervous system Lymphoma-The key role of cerebrospinal fluid cytology: a case report

BACKGROUND

Central nervous system (CNS) involvement in diffuse large B-cell lymphoma (DLBCL) is relatively rare, occurring at a rate of approximately 5%. Primary CNS lymphoma (CNS-DLBCL), a subtype of DLBCL, is rare clinically but highly malignant and invasive. Its atypical clinical symptoms and imaging features contribute to a high rate of misdiagnosis and a poor prognosis. Thus, early and accurate diagnosis is imperative for improving the patient's prognosis. Cerebrospinal fluid (CSF) cytology, a rapid and convenient diagnostic method, plays a crucial role in diagnosing intracranial tumors.

CASE PRESENTATION

In this instance, the patient presented with nonspecific early symptoms and exhibited atypical imaging findings. A lumbar puncture performed at another hospital yielded a low cell count in the CSF, leading to an incorrect diagnosis. Upon admission to our hospital, CSF cytology identified abnormal cells. A definitive diagnosis of CNS-DLBCL was established utilizing additional diagnostic methods, facilitating targeted treatment.

CONCLUSIONS

This case underscores the pivotal role of CSF cytology in rapidly guiding the differential diagnosis of intracranial tumors and underscores the necessity of training laboratory personnel in morphological examination.

Blood-brain barrier crossing biopolymer targeting c-Myc and anti-PD-1 activate primary brain lymphoma immunity: Artificial intelligence analysis

Primary Central Nervous System Lymphoma is an aggressive central nervous system neoplasm with poor response to pharmacological treatment, partially due to insufficient drug delivery across blood-brain barrier. In this study, we developed a novel therapy for this lymphoma by combining a targeted nanopolymer treatment with an immune checkpoint inhibitor antibody (anti-PD-1). A N-(2-hydroxypropyl)methacrylamide copolymer-based nanoconjugate was designed to block tumor cell c-Myc oncogene expression by antisense oligonucleotide. Angiopep-2 peptide was conjugated to the copolymer to facilitate nanodrug crossing of the blood-brain barrier. Systemically administered polymeric nanodrug, alone or in combination with immune checkpoint inhibitor antibody anti-PD-1, was tested in syngeneic mouse model of A20 intracranial brain lymphoma. There was no significant survival difference between saline- and free anti-PD-1-treated groups. However, significant survival advantage vs. saline was observed upon treatment with nanodrug bearing Angiopep-2, H6 (6 histidines for endosome escape), and c-Myc antisense alone and especially when it was combined with anti-PD-1 antibody. Animal survival after combined treatment was also significantly increased vs. free anti-PD-1. Artificial Intelligence-assisted analysis of gene expression database after RNA-seq of tumors was used to find novel immune pathways, molecular targets and the most effective multifunctional drugs together with future drug prediction for brain lymphoma in vivo model. Spectral flow cytometry and RNA-seq analysis revealed a robust activation of tumor infiltrating T lymphocytes with enhanced interferon γ signaling and polarization to M1-type macrophages in treated tumors, which was confirmed by immunofluorescence staining. In summary, a new effective blood-brain barrier crossing nano immuno therapeutic system was developed that effectively blocked tumor c-Myc acting in combination with immune checkpoint inhibitor anti-PD-1 to treat primary brain lymphoma. The treatment improved survival of tumor-bearing animals through activation of both the adaptive and innate immune responses.

Single-cell RNA-seq reveals diverse molecular signatures associated with Methotrexate resistance in primary central nervous system lymphoma cells

PURPOSE

Methotrexate is one of the most essential single agents in patients with primary central nervous system lymphoma (PCNSL). However, 25-50% result in relapse with a poor prognosis. Therefore, studies on methotrexate resistance are warranted to explore salvage chemotherapy for recurrent PCNSL. Single-cell sequence analysis enables the characterization of novel cell types and provides a precise understanding of cancer biology.

METHODS

Single-cell sequence analysis of parental and methotrexate-resistant PCNSL cells was performed. We used a Weighted Gene Co-expression Network Analysis to identify groups of significantly connected genes.

RESULTS

We identified consensus modules in both the HKBML and TK datasets. HLA-DRβ1, HLA-DQβ1,and SNRPG were hub genes those detected in both datasets revealed by network analysis. Cyclosporine A was selected as the candidate drug for treating methotrexate-resistant cells.

CONCLUSION

The results of the present study characterized the methotrexate resistance-related signaling pathways in cultured PCNSL cells. Overall, these results may account for variations in treatment responses and lead potential novel therapeutic strategies for patients with PCNSL.

Both consolidation and maintenance treatment improve outcomes in primary central nervous system lymphoma: real-world evidence from a tertiary medical center

Background: Intensive consolidation treatment following high-dose methotrexate (HDMTX)-based chemotherapy is recommended for fit patients with primary central nervous system lymphoma (PCNSL). Otherwise, HDMTX maintenance might be a useful alternative to consolidation approach in certain circumstances. However, the real-world evidence supporting the beneficial role of consolidation treatment or HDMTX maintenance in PCNSL is limited. Methods: We retrospectively analyzed the clinical efficacy and survival impact of consolidation treatment or HDMTX maintenance on patients with PCNSL treated with HDMTX-based induction chemotherapy. Results: A total of 109 patients were evaluated, with a median age at diagnosis being 63 years. Among them, 69 received induction therapy with HDMTX monotherapy and 40 with HDMTX-based polychemotherapies. In total, 67 (61.5%) patients responded to treatment, of whom 56 (51.4%) had complete response. After a 58.9-month median follow-up, overall survival (OS) at 2 and 5 years was 69% and 45%, respectively. The types of induction regimen or frontline rituximab had no survival impact (P = 0.364 and 0.328, respectively). Among the 67 responding patients, 51 received the consolidation/maintenance therapy. Compared to the patients without consolidation/maintenance, those being treated had lower relapse/PD rates (2-year cumulative incidence of relapse/PD, 39.5% vs. 63.6%, P <0.001) and a significantly better OS (5-year survival rate, 63.8% vs. 27.2%, P = 0.016). Multivariate analysis revealed consolidation/maintenance treatment strikingly reduced mortality risk. Notably, HDMTX maintenance had similar efficacy comparable to consolidative whole-brain radiotherapy. Moreover, consolidation treatment was conducive to prolonging remission duration in the later-line settings of patients who responded to subsequent salvage therapies. Conclusion: This real-world evidence provides clear insight that consolidation/maintenance treatment could prolong OS in PCNSL, emphasizing its critical and indispensable role in treating PCNSL.

Advances in primary large B-cell lymphoma of immune-privileged sites

Primary large B-cell lymphoma of immune-privileged sites (IP-LBCL) encompasses a spectrum of relatively rare aggressive B-cell lymphomas, such as primary central nervous system lymphoma (PCNSL), primary testicular large B-cell lymphoma (PTL), and primary vitreoretinal large B-cell lymphoma (PVRL). Macroscopically, the development of IPI-LBCL may be associated with the dysfunction of meningeal lymphatic vessels (mLVs) and the perivascular channel system formed by astrocytes. Microscopically, mutation in MYD88 and CD79B genes plays a pivotal role in the pathogenesis of IP-LBCL. Pathological examination remains the cornerstone for establishing a diagnosis of IP-LBCL. Moreover, traditional imaging is now supplemented by a suite of advanced diagnostic methods, including cytological, genetic, immunological, multiple omics, and molecular biological, which collectively enhance the diagnostic accuracy of IP-LBCL. Despite these advancements, the high recurrence rates and attendant high mortality rates pose significant challenges to achieving long-term survival in IP-LBCL patients. However, the emergence of novel therapeutic agents, such as Bruton's tyrosine kinase inhibitors (BTKi), immune checkpoint inhibitors, immunomodulators, and anti-CD19 chimeric antigen receptor T (CAR-T) cell therapy, has offered promising new avenues for the treatment of IP-LBCL, demonstrating remarkable anti-tumor efficacy in recent years. This review delves into the epidemiology, pathogenesis mechanisms, diagnosis approaches, therapeutic strategies, and prognosis factors associated with IP-LBCL. It meticulously examines the parallels and divergences between the National Comprehensive Cancer Network (NCCN) and European Society for Medical Oncology (ESMO) guidelines, enhancing the professional comprehension of the complexities inherent to IP-LBCL.

Next-generation sequencing of circulating tumor DNA in cerebrospinal fluid for detecting gene mutations in central nervous system lymphoma patients

Background

To evaluate the potential clinical value of cerebrospinal fluid (CSF) circulating tumor DNA (ctDNA) in the diagnosis and monitors the central nervous system (CNS) lymphomas.

Methods

This was a prospective study of 17 consecutive patients with B-cell lymphoma: 10 patients with CNS lymphomas and 7 patients with B-cell lymphomas at high clinical risk of CNS relapse. Genomic profiles were performed on the CSF and plasma samples of patients by next-generation sequencing.

Results

In patients with CNS lymphomas, ctDNA was detected in 70.0% of CSF and 60.0% of plasma. The detection rate and gene mutation abundance of CSF were higher than plasma (p = 0.016). CSF had a unique genetic profile. Furthermore, we newly found that gene mutations consistent with plasma or lymphoma-related were also detected in the CSF of the high-risk group without CNS involvement. Analysis of paired plasma and CSF samples from three patients at different time points, changes of CSF ctDNA abundance occurred at the same time or earlier than clinical disease changes, which could timely monitor the therapeutic response and relapse trend.

Conclusion

The detection rate of ctDNA in CSF is higher than that in plasma. The dynamic monitoring of ctDNA in CSF has hint significance for therapeutic response of CNS lymphoma patients.

Detection of human brain cancers using genomic and immune cell characterization of cerebrospinal fluid through CSF-BAM

Patients who have radiographically detectable lesions in their brain or other symptoms compatible with brain tumors pose challenges for diagnosis. The only definitive way to diagnose such patients is through brain biopsy, an obviously invasive and dangerous procedure. Here we present a new workflow termed "CSF-BAM" that simultaneously identifies B cell or T cell receptor rearrangements, A neuploidy, and M utations using PCR-mediated amplification of both strands of the DNA from CSF samples. We first describe the details of the molecular genetic assessments and then establish thresholds for positivity using training sets of libraries from patients with or without cancer. We then applied CSF-BAM to an independent set of 206 DNA samples from patients with common, aggressive cancer types as well as other forms of brain cancers. Among the 126 samples from patients with the most common aggressive cancer types (high grade gliomas, medulloblastomas, or metastatic cancers to the brain), the sensitivity of detection was >81%. None of 33 CSF-BAM assays (100% specificity, 90% to 100% credible interval) were positive in CSF samples from patients without brain cancers. The sensitivity of CSF-BAM was considerably higher than that achieved with cytology. CSF-BAM provides an integrated multi-analyte approach to identify neoplasia in the central nervous system, provides information about the immune environment in patients with or without cancer, and has the potential to inform the subsequent management of such patients.

Statement of significance

There is a paucity of technologies beyond surgical biopsy that can accurately diagnose central nervous system neoplasms. We developed a novel, sensitive and highly specific assay that can detect brain cancers by comprehensively identifying somatic mutations, chromosomal copy number changes, and adaptive immunoreceptor repertoires from samples of cerebrospinal fluid.

Salivary duct carcinoma presenting with unilateral multiple cranial nerve lesions and concurrent intracranial metastasis: A case report

RATIONALE

Salivary gland ductal carcinoma (SDC) is a rare malignant tumor of the head and neck, accounting for 1% to 3% of salivary gland malignancy. SDC usually occurs in parotid gland, has a high malignancy degree, poor prognosis, and is prone to distant metastasis. In particular, intracranial metastasis accompanied by multiple cranial nerve lesions is very rare, and early diagnosis is difficult, which easily leads to missed diagnosis and misdiagnosis. Therefore, the diagnosis and treatment of SDC face major challenges. We report a unique case of SDC, which initially presented with progressive facial paralysis followed by progressive intracranial metastases and multiple cranial nerve lesions. After surgery and pathological examination, SDC was finally diagnosed.

PATIENT CONCERNS

A previously healthy 53-year-old male with persistent facial paralysis gradually developed symptoms of ipsilateral multiple cranial nerve lesions, and was hospitalized 8 months after onset.

DIAGNOSES

Brain magnetic resonance imaging enhancement showed multiple irregular intracranial T1 and T2 with uneven signal intensity. Brain computed tomography showed intracranial space-occupying lesions, the largest of which was about 55 × 42 × 38 mm, with extensive bone destruction. Pathological findings showed malignant cell mass in the left temporal lobe tumor. Immunohistochemical: (++), CK7(+++), AR(++), Brg-1(+), Her-2(2+), Ki67(+, approximately 80%), consistent with high-grade ductal carcinoma, considering salivary gland origin. The final diagnosis was SDC.

INTERVENTIONS

The space-occupying lesions in the left cavernous sinus region and temporal lobe were partially resected. Local radiotherapy was recommended, but the patient refused.

OUTCOMES

Postoperative symptoms did not improve significantly. Follow-up after 4 months showed no improvement in the extensive cranial nerve lesions on the left side.

LESSONS

In clinical practice, in the face of persistent facial palsy symptoms that gradually spread to other cranial nerves, the possibility of secondary facial nerve injury and malignant salivary gland tumors, especially SDC, cannot be easily ruled out even if imaging studies do not reveal any space-occupying intracranial lesions. Through the comprehensive use of imaging, pathology and immunohistochemistry and other diagnostic methods, the early detection and accurate diagnosis of SDC can be achieved, so as to provide the best treatment strategy for patients and improve the prognosis.

Building a Bridge Between the Mechanism of EBV Reactivation and the Treatment of EBV-Associated Cancers

Epstein-Barr virus (EBV) infection is closely associated with the development of various tumors such as lymphomas and epithelial cancers. EBV has a discrete life cycle with latency and lytic phases. In recent years, significant progress has been made in the understanding of the mechanism underlying the transition of EBV from latency to lytic replication. Multiple new lytic activation factors have been emerged and promoted our understanding of this field. In addition, we have comprehensively presented the existing therapeutic strategies and their relationship to the mechanism underlying the transition of EBV from latency to lytic replication in this review, such as lytic induction therapy and drugs to prevent EBV from entering the lytic phase fully utilize the EBV reactivation mechanisms. This year marks the 60th anniversary of the discovery of EBV, and building a bridge between the mechanism of EBV reactivation and the treatment may help us to design new approaches for treating EBV-associated diseases.

Advances in the Classification of Aggressive B-cell Lymphomas

Aggressive B-cell lymphomas are a biologically and clinically very heterogeneous group of tumors that may be related to different stages of B-cell differentiation development. This review aims to summarize recent advances in the understanding of these tumors with a focus on the practical approach to the diagnosis of these entities. We analyze the defining characteristics of the different subtypes of aggressive B-cell lymphomas, including nodal and extranodal diffuse large B-cell lymphoma, virus-associated lymphomas, terminally differentiated B-cell lymphomas, high-grade B-cell lymphomas, and Burkitt lymphoma. This review particularly explores the integration of morphologic, immunophenotypic, and genetic data that refine diagnostic accuracy and prognostic stratification, underscoring the necessity for a standardized approach in clinical practice. By synthesizing current knowledge, this review aims to enhance the understanding of aggressive B-cell lymphomas within the context of the evolving classification system, paving the way for future research and clinical advancements.

MRI-based radiomics virtual biopsy for BCL6 in primary central nervous system lymphoma

AIM

To establish a machine learning model based on a radiomic signature for predicting B-cell lymphoma 6 (BCL-6) rearrangement in primary central nervous system lymphoma (PCNSL).

MATERIALS AND METHODS

Retrospective study on 102 PCNSL patients (31 with BCL-6 rearrangement positive, 71 with BCL-6 rearrangement negative) were randomly divided into the training and validation sets at a ratio of 7:3. Radiomics models based on contrast-enhanced T1-weighted imaging (CE-T1WI) and fluid-attenuated inversion recovery (FLAIR) in different regions, including VOItumour core and VOIperitumoural oedema. Radiomics features were extracted and selected using LASSO regression, and radiomics score (rad-score) were calculated using the weighted coefficients. Four machine learning models (logistic regression, random forest, support vector machine, K-nearest neighbours) were developed and evaluated based on rad-score. The optimal radiomics model was integrated into the clinical or radiological factors to construct a predictive model through logistic regression analysis. A nomogram was constructed based on independent significant features for individualised prediction.

RESULTS

All rad-scores based on CE-T1WI and FLAIR sequences were significantly associated with BCL6 rearrangement (p < 0.05) in univariate regression analysis. The logistic regression machine learning model performed best with AUCs of 0.935 (training) and 0.923 (validation). Rad-scores from CE-T1WI tumour core and peritumoural oedema were independent significant predictors.

CONCLUSION

Radiomics signatures based on CE-T1WI and FLAIR sequences have significant value in distinguishing BCL6 rearrangement. The CE-T1WI radiomics model based on VOItumour core and VOIperitumoural oedema are robust markers for identifying BCL6 rearrangement.

Defining MRI-based follow-up protocol for primary central nervous system lymphoma

BACKGROUND

The optimal follow-up protocol for primary central nervous system lymphoma (PCNSL) is unclear. This is the first study to evaluate the benefit of structured follow-up imaging of PCNSL with respect to the timing of relapse.

METHODS

A total of 198 PCNSL patients (57.1% males) diagnosed between 2003 and 2020 were included. The data were collected retrospectively from 8 hospitals in Finland. Relapse detection details included structured follow-up imaging (sMRI) studies, additional imaging (aMRI) studies based on patients' new symptoms, and all outpatient and emergency visits. Overall survival (OS) with respect to the relapse detection method, sMRI versus aMRI, was also evaluated.

RESULTS

Relapse was diagnosed in 71 patients (35.9%), 66.1% of whom experienced relapse during the first 2 years after diagnosis. During the first year, 48.3% (14/29) of the relapses were detected via sMRI, and 51.7% (15/29) via aMRI. During the second year, the percentages were 33.3% and 66.7%, respectively. More than 5 years after the diagnosis, all the relapses were detected via aMRI. To observe one relapse during the first year, 9.4 sMRI studies were needed. Overall survival after relapse (OS2) was 4.0 months for the patients whose first relapse was detected via sMRI and 3.0 months for those whose first relapse was detected via aMRI (P = 0.203).

CONCLUSIONS

We found that structured imaging was beneficial for relapse detection during the first year after PCNSL diagnosis. A minor trend towards better survival after relapse was observed for patients who experienced relapse according to structured imaging.

Primary large B-cell lymphomas of immune-privileged sites

ABSTRACT

Diffuse large B-cell lymphoma (DLBCL) encompasses a diverse spectrum of aggressive B-cell lymphomas with remarkable genetic heterogeneity and myriad clinical presentations. Multiplatform genomic analyses of DLBCL have identified oncogenic drivers within genetic subtypes that allow for pathologic subclassification of tumors into discrete entities with shared immunophenotypic, genetic, and clinical features. Robust classification of lymphoid tumors establishes a foundation for precision medicine and enables the identification of novel therapeutic vulnerabilities within biologically homogeneous entities. Most cases of DLBCL involving the central nervous system (CNS), vitreous, and testis exhibit immunophenotypic features suggesting an activated B-cell (ABC) origin. Shared molecular features include frequent comutations of MYD88 (L265P) and CD79B and frequent genetic alterations promoting immune evasion, which are hallmarks of the MCD/C5/MYD88 genetic subtype of DLBCL. Clinically, these lymphomas primarily arise within anatomic sanctuary sites and have a predilection for remaining confined to extranodal sites and strong CNS tropism. Given the shared clinical and molecular features, the umbrella term primary large B-cell lymphoma of immune-privileged sites (IP-LBCL) was proposed. Other extranodal DLBCL involving the breast, adrenal glands, and skin are often ABC DLBCL but are more heterogeneous in their genomic profile and involve anatomic sites that are not considered immune privileged. In this review, we describe the overlapping clinical, pathologic, and molecular features of IP-LBCL and highlight important considerations for diagnosis, staging, and treatment. We also discuss potential therapeutic vulnerabilities of IP-LBCL including sensitivity to inhibitors of Bruton tyrosine kinase, immunomodulatory agents, and immunotherapy.

Clinical characteristics and survival outcomes of patients with primary central nervous system lymphoma treated with high-dose methotrexate-based polychemotherapy and consolidation therapies

Given the rarity of primary central nervous system lymphoma (PCNSL), evaluations of different high-dose methotrexate-(HD-MTX)-based treatment regimens is sparse. This retrospective, multicenter study evaluates clinical characteristics and outcomes (progression-free, overall and disease-specific survival) after five HD-MTX-based polychemotherapeutic regimens and two consolidation therapies. 346 patients with histologically confirmed PCNSL, treated with ≥ 1 cycle HD-MTX-based strategies (≥3g/m2/cycle) were included. The regimens included MATRIX (HD-MTX, HD-AraC, thiotepa, and rituximab), (R)MBVP±HD-AraC (HD-MTX, teniposide/etoposide, carmustine, prednisolone, ± HD-AraC, ± rituximab), (R)MP (HD-MTX, procarbazine, ± rituximab), and a combination of HD-MTX and HD-AraC. The overall response rate after induction was 69 %, 28 % complete remission and progressive disease was observed in 100 (29 %) patients. 126 (36 %) patients received consolidation, including high-dose-BCNU-thiotepa with autologous stem cell transplantation (HD-BCNU-TT/ASCT, n = 59 (17 %)) or whole brain radiotherapy (WBRT, n = 67 (19 %)). Clinical characteristics associated with adverse mortality risk by multivariable prognostication contained age > 60 years (HR 1.61, p = 0.011), elevated LDH (HR 1.75, p = 0.004) and WHO status ≥ 2 (HR 1.56, p = 0.010). Independently, induction regimens containing HD-AraC demonstrated survival benefit compared to induction regimens without HD-AraC (HR 0.59, p = 0.002). Without preference for HD-BCNU-TT/ASCT or WBRT, a favorable effect of consolidation (HR 0.44 and HR 0.42, p < 0.001) was confirmed, also with consolidation as time-dependent variable. Competing risk analysis showed similar low incidence of lymphoma-unrelated deaths in consolidated and unconsolidated patients. This study confirms that age, elevated LDH and WHO status increase the mortality risk. HD-AraC containing treatment regimens and consolidation with HD-BCU-TT/ASCT or WBRT were associated with superior survival, including a favorable low incidence of lymphoma-unrelated deaths.

Primary Cerebral Lymphoma With Isolated Vitreoretinal and Cerebral Recurrences Without Meningeosis: A Case Report

Primary central nervous system lymphoma (PCNSL) is a diffuse, large B-cell lymphoma affecting the brain, spinal cord, leptomeninges, or eyes. A patient with a recurrence of a previous PCNSL manifesting as an isolated vitreoretinal disease without central nervous system (CNS) involvement and a second cerebral recurrence without vitreoretinal involvement has not yet been reported. The patient is an 86-year-old man with PCNSL of the left cerebellum diagnosed at the age of 82 years and treated with suboccipital trepanation and resection of the lesion followed by chemotherapy. At the age of 84, he suffered a first recurrence, which manifested as vitreoretinal lymphoma on the right and later also on the left eye, without CNS involvement. The recurrence was treated by vitrectomy on both sides. At the age of 86, the patient suffered a second recurrence, which manifested as infratentorial lesions treated by radiotherapy. He was discharged with dexamethasone, entecavir, valacyclovir, amphotericin-B, candesartan, tramadol, trazodone, and pantoprazole. This case demonstrates that PCNSL can recur with isolated secondary ophthalmologic lymphoma and a second time with isolated cerebral lymphoma. Although glucocorticoids, chemotherapy, and radiotherapy can be highly effective, the long-term outcomes of patients with PCNSL are not as favorable.

A comprehensive neuroimaging review of the primary and metastatic brain tumors treated with immunotherapy: current status, and the application of advanced imaging approaches and artificial intelligence

Cancer immunotherapy has emerged as a novel clinical therapeutic option for a variety of solid tumors over the past decades. The application of immunotherapy in primary and metastatic brain tumors continues to grow despite limitations due to the physiological characteristics of the immune system within the central nervous system (CNS) and distinct pathological barriers of malignant brain tumors. The post-immunotherapy treatment imaging is more complex. In this review, we summarize the clinical application of immunotherapies in solid tumors beyond the CNS. We provide an overview of current immunotherapies used in brain tumors, including immune checkpoint inhibitors (ICIs), oncolytic viruses, vaccines, and CAR T-cell therapies. We focus on the imaging criteria for the assessment of treatment response to immunotherapy, and post-immunotherapy treatment imaging patterns. We discuss advanced imaging techniques in the evaluation of treatment response to immunotherapy in brain tumors. The imaging characteristics of immunotherapy treatment-related complications in CNS are described. Lastly, future imaging challenges in this field are explored.

Liquid biopsy in brain tumors: moving on, slowly

PURPOSE OF REVIEW

Due to limited access to the tumor, there is an obvious clinical potential for liquid biopsy in patients with primary brain tumors. Here, we review current approaches, present limitations to be dealt with, and new promising data that may impact the field.

RECENT FINDINGS

The value of circulating tumor cell-free DNA (ctDNA) in the cerebrospinal fluid (CSF) for the noninvasive diagnosis of primary brain tumors has been confirmed in several reports. The detection of ctDNA in the peripheral blood is desirable for patient follow-up but requires ultrasensitive methods to identify low mutant allelic frequencies. Digital PCR approaches and targeted gene panels have been used to identify recurrent hotspot mutations and copy number variations (CNVs) from CSF or plasma. Tumor classification from circulating methylomes in plasma has been actively pursued, although the need of advanced bioinformatics currently hampers clinical application. The use of focused ultrasounds to open the blood-brain barrier may represent a way to enrich of ctDNA the peripheral blood and enhance plasma-based liquid biopsy.

SUMMARY

Monitoring CNVs and hotspot mutations by liquid biopsy is a promising tool to detect minimal residual disease and strengthen response assessment in patients with primary brain tumors. Novel methods to increase the relative and/or absolute amount of ctDNA can improve the clinical potential of plasma-based liquid biopsies.

Clinical characteristics and prognosis of patients with newly diagnosed primary central nervous system lymphoma: a multicentre retrospective analysis

Bruton's tyrosine kinase inhibitors (BTKi) exhibit superior efficacy in relapsed/refractory primary central nervous system lymphoma (PCNSL), but few studies have evaluated patients with newly diagnosed PCNSL, and even fewer studies have evaluated differences in efficacy between treatment with BTKi and traditional chemotherapy. This study retrospectively analyzed the clinical characteristics of 86 patients with PCNSL and identified predictors of poor prognosis for overall survival (OS). After excluding patients who only received palliative care, 82 patients were evaluated for efficacy and survival. According to the induction regimen, patients were divided into the traditional chemotherapy, BTKi combination therapy, and radiotherapy groups; the objective response rates (ORR) of the three groups were 71.4%, 96.2%, and 71.4% (P = 0.037), respectively. Both median progression-free survival and median duration of remission showed statistically significant differences (P = 0.019 and P = 0.030, respectively). The median OS of the BTKi-containing therapy group was also longer than that of the traditional chemotherapy group (not reached versus 47.8 (32.5-63.1) months, P = 0.038).Seventy-one patients who achieved an ORR were further analyzed, and achieved an ORR after four cycles of treatment and maintenance therapy had prolonged OS (P = 0.003 and P = 0.043, respectively). In conclusion, survival, and prognosis of patients with newly diagnosed PCNSL are influenced by the treatment regimen, with the BTKi-containing regimen showing great potential.

Not everything is ischemic optic neuropathy

A 71-year-old woman developed sudden, painful, decreased vision in the left eye accompanied by progressive instability. Initial examination revealed left optic disc edema, and macular optical coherence tomography confirmed the presence of intraretinal and subretinal fluid, as well as hyperreflective material under the retinal pigment epithelium. Subsequent investigations, including brain magnetic resonance imaging and a comprehensive serological analysis, ruled out infectious and autoimmune causes, further complicating the diagnostic picture. The patient's vision in both eyes continued to deteriorate, prompting empirical corticosteroid treatment. While the vision improved, the case took an unexpected turn with worsening neurological symptoms. Ultimately a brain biopsy was consistent with diffuse large B-cell lymphoma.

Distinguishing clinical and imaging characteristics of primary central nervous system lymphoma from high-grade glioma and metastatic brain tumors

OBJECTIVE

The purpose of this retrospective analysis was to evaluate the clinical presentations, radiological characteristics, patient outcomes, and therapeutic approaches among individuals diagnosed with primary central nervous system lymphoma (PCNSL), high-grade glioma (HGG), and metastatic brain tumors (METS).

METHODS

We assembled a cohort of brain tumor patients from two medical centers, with two oncologists independently reviewing their clinical profiles. A retrospective examination of 87 PCNSL, 87 HGG, and 71 METS cases was performed to assess the aforementioned parameters.

RESULTS

Notable variations were identified in the incidence of epileptic seizures and cognitive impairments between PCNSL and METS patients. Cerebral hemisphere involvement was predominantly observed in HGG and METS cases. PCNSL cases exhibited a higher likelihood of multiple lesions, whereas HGG showed a greater tendency for recurrence. The median survival times were established at 24.3 months for PCNSL, 44.5 months for HGG, and 27.1 months for METS patients. In PCNSL cases, the number of lesions was identified as a significant predictor of mortality (P = 0.008).

CONCLUSIONS

Our findings highlight the importance of clinical and imaging features in diagnosing PCNSL, which may present distinct features compared to HGG and METS.

Comparative analyses of immune cells and alpha-smooth muscle actin-positive cells under the immunological microenvironment between with and without dense fibrosis in primary central nervous system lymphoma

Histopathologic examinations of primary central nervous system lymphoma (PCNSL) reveal concentric accumulation of lymphocytes in the perivascular area with fibrosis. However, the nature of this fibrosis in "stiff" PCNSL remains unclear. We have encountered some PCNSLs with hard masses as surgical findings. This study investigated the dense fibrous status and tumor microenvironment of PCNSLs with or without stiffness. We evaluated by silver-impregnation nine PCNSLs with stiffness and 26 PCNSLs without stiffness. Six of the nine stiff PCNSLs showed pathological features of prominent fibrosis characterized by aggregation of reticulin fibers, and collagen accumulations. Alpha-smooth muscle actin (αSMA)-positive spindle cells as a cancer-associated fibroblast, the populations of T lymphocytes, and macrophages were compared between fibrous and control PCNSLs. Fibrous PCNSLs included abundant αSMA-positive cells in both intra- and extra-tumor environments (5/6, 87% and 3/6, 50%, respectively). Conversely, only one out of the seven control PCNSL contained αSMA-positive cells in the intra-tumoral area. Furthermore, the presence of extra-tumoral αSMA-positive cells was associated with infiltration of T lymphocytes and macrophages. In conclusion, recognizing the presence of dense fibrosis in PCNSL can provide insights into the tumor microenvironment. These results may help stratify patients with PCNSL and improve immunotherapies for these patients.

Totally Implantable Central Venous Access Port-Associated Bloodstream Infection Caused by Corynebacterium provencense: The First Case Report

Corynebacterium species are associated with healthcare-associated infections, specifically in device implantation. Here, we report a rare case of a 44-year-old man with a totally implantable central venous access port-related Corynebacterium infection. When he developed a fever on day four of admission, vancomycin treatment was initiated. On the 11th day, the totally implantable central venous access port was removed. Corynebacterium provencense was identified from two sets of blood cultures. Vancomycin treatment was continued for 14 days after port removal, and the patient was discharged home on the 47th day. Although C. provencense infection had not been previously reported in humans, it could be treated by port removal and vancomycin administration, as demonstrated in other reports on Corynebacterium infections.

Impact of Postoperative Chemotherapy on Survival in Patients with Primary Central Nervous System Lymphoma: A Study Based on the SEER Database

Aims/Background We aimed to investigate the impact of postoperative chemotherapy (POCT) on survival in patients with primary central nervous system lymphoma (PCNSL) using data from the Surveillance, Epidemiology, and End Results (SEER) database. Methods This study included 786 PCNSL patients, of which 605 received chemotherapy after surgery, and 181 did not. Data from the SEER registry database (2007-2020) were used to analyze PCNSL. Baseline information, including age, sex, race, marital status, primary tumour site, histological type, summary stage, surgical procedures, chemotherapy, and radiotherapy, was analyzed. Propensity Score Matching (PSM) (1:1) was employed to balance the effects of confounding variables between the two groups. Subsequently, Cox regression and bidirectional stepwise regression were used to identify independent prognostic factors. Kaplan-Meier (K-M) survival curves were constructed to assess the impact of POCT on patient prognosis. Additionally, two cases of PCNSL with typical magnetic resonance imaging appearances were presented. Results Multivariate Cox regression results revealed that age older than 60 years (hazard ratio [HR] = 1.786; 95% confidence interval [CI]: 1.272-2.509; p = 0.001) and absence of POCT (HR = 2.841; 95% CI: 2.159-3.738; p < 0.001) were independent prognostic risk factors, while primary tumour locations in the meninges (HR = 0.136; 95% CI: 0.032-0.569; p = 0.006) and other nervous system regions (HR = 0.552; 95% CI: 0.326-0.936; p = 0.027), as well as histological morphologies such as diffuse large B-cell lymphoma (HR = 0.233; 95% CI: 0.128-0.425; p < 0.001) and non-Hodgkin lymphoma (HR = 0.559; 95% CI: 0.356-0.876; p = 0.011), were associated with favourable patient outcomes. K-M curves demonstrated that the group undergoing POCT had a significantly more favourable prognosis compared to the non-POCT group, before (HR = 0.454; 95% CI: 0.343-0.600; p < 0.0001) or after PSM (HR = 0.580; 95% CI: 0.431-0.780; p < 0.0001). For patients with PCNSL, those with tumours located in the infratentorial region (HR = 0.231; 95% CI: 0.078-0.682; p = 0.046), supratentorial region (HR = 0.250; 95% CI: 0.163-0.383; p < 0.0001), overlapping brain regions (HR = 0.201; 95% CI: 0.056-0.727; p = 0.0058), and those who underwent biopsy (HR = 0.740; 95% CI: 0.463-1.182; p = 0.003), subtotal resection (STR) (HR = 0.490; 95% CI: 0.265-0.906; p = 0.0064), or gross total resection (GTR) (HR = 0.613; 95% CI: 0.292-1.287; p = 0.0003) had better prognoses in the postoperative chemotherapy group compared to the non-chemotherapy group. Conclusion POCT significantly improves the prognosis of PCNSL patients and identifies the characteristics of the benefiting population. This information aids clinical practitioners in designing personalized treatment plans for individuals and advancing precise treatment.

Radiomic prediction for durable response to high-dose methotrexate-based chemotherapy in primary central nervous system lymphoma

BACKGROUND

The rarity of primary central nervous system lymphoma (PCNSL) and treatment heterogeneity contributes to a lack of prognostic models for evaluating posttreatment remission. This study aimed to develop and validate radiomic-based models to predict the durable response (DR) to high-dose methotrexate (HD-MTX)-based chemotherapy in PCNSL patients.

METHODS

A total of 159 patients pathologically diagnosed with PCNSL between 2011 and 2021 across two institutions were enrolled. According to the NCCN guidelines, the DR was defined as the remission lasting ≥1 year after receiving HD-MTX-based chemotherapy. For each patient, a total of 1218 radiomic features were extracted from prebiopsy T1 contrast-enhanced MR images. Multiple machine-learning algorithms were utilized for feature selection and classification to build a radiomic signature. The radiomic-clinical integrated models were developed using the random forest method. Model performance was externally validated to verify its clinical utility.

RESULTS

A total of 105 PCNSL patients were enrolled after excluding 54 cases with ineligibility. The training and validation cohorts comprised 76 and 29 individuals, respectively. Among them, 65 patients achieved DR. The radiomic signature, consisting of 8 selected features, demonstrated strong predictive performance, with area under the curves of 0.994 in training cohort and 0.913 in validation cohort. This signature was independently associated with the DR in both cohorts. Both the radiomic signature and integrated models significantly outperformed the clinical models in two cohorts. Decision curve analysis underscored the clinical utility of the established models.

CONCLUSIONS

This radiomic signature and integrated models have the potential to accurately predict the DR to HD-MTX-based chemotherapy in PCNSL patients, providing valuable therapeutic insights.

Logistic regression modeling of cytokines for cerebrospinal fluid evaluation in primary central nervous system lymphoma

BACKGROUND

The diagnostic utility of cerebrospinal fluid (CSF) cytology encounters impediments stemming from variability in cell collection techniques and pathologists' morphological acumen, resulting in wide-ranging CSF positivity rates for primary central nervous system lymphomas (PCNSL). Such disparity impacts patient evaluation, treatment stratagem, and prognostication. Thus, this study endeavors to explore liquid biomarkers complementary to CSF cytology or immunophenotype analysis in the diagnosis of CSF involvement.

METHODS

398 newly diagnosed PCNSL patients were categorized into CSF involvement and non-involvement groups based on CSF cytology and immunophenotype analysis. Binary logistic regression analysis was performed on 338 patients to investigate factors predicting CSF involvement and to develop a joint prediction model. An additional cohort of 60 PCNSL patients was recruited for model validation. Statistical analyses included the Mann-Whitney U test for comparing various CSF parameters between two groups. ROC curve analyses were performed for each biomarker to identify PCNSL CSF involvement.

RESULTS

The cytokine IL-10 level in CSF has emerged as the most promising biomarker for CSF evaluation, boasting an ROC AUC of 0.922. C-TNFα and soluble C-IL2R demonstrate efficacy in quantifying tumor burden within the CSF. Logistic regression identified C-IL10lg (OR = 30.103, P < 0.001), C-TNC (OR = 1.126, P < 0.001), C-IL2Rlg (OR = 3.743, P = 0.029) as independent predictors for CSF involvement, contributing to a joint predictive model with an AUC of 0.935, sensitivity of 74.1 %, and specificity of 93.0 %. Validation of the model in an independent cohort confirmed its effectiveness, achieving an AUC of 0.9713.

CONCLUSIONS

The identification of these feasible biomarkers and the development of an accurate prediction model may facilitate the precise evaluation of CSF status in PCNSL, offering significant advancements in patient management.

Prognostic Impacts of Age, Diagnosis Time, and Relapses in Primary CNS Lymphoma

Background: The incidence of lymphomatous involvement of the central nervous system (CNS) has been increasing in recent years. However, the rarity of the disease has resulted in a scarcity of available data regarding its clinical presentation, natural history, and prognosis. We aimed to investigate the neurological characteristics of uncommon lymphomatous involvements confined to the CNS and to identify key variables that could serve as predictive biomarkers for treatment outcomes. Methods: We identified patients presenting with neurological symptoms and diagnosed with CNS-restricted lymphomatous involvement between 2005 and 2023. Results: We identified 44 cases, 93% of which were diagnosed with primary central nervous system lymphoma (PCNSL) and 7% with intravascular lymphoma. The median time from symptom onset to diagnosis was 47 days (range: 6-573 days), with no statistically significant difference between patients older and younger than 60 years (p = 0.22). The median follow-up time was 1144 days (range: 27-3501 days). Cognitive deterioration was the most common presenting symptom, occurring in 19 out of 44 patients (43%). Brain MRI revealed that lobar lesions were the most frequent location of lesions, found in 24 out of 44 patients (55%). By the end of the study period, 30 patients (68%) had died, with a median survival of 666 days (range: 17-3291 days). Death was significantly more common in patients who experienced relapses (p = 0.04; 95% CI: 0.99-0.03), with these patients having a four times higher chance of death (HR = 4.1; 95% CI: 1.01-16.09). The time to diagnosis significantly correlated with survival (p = 0.02; 95% CI: 0.005-0.54), as did the Eastern Cooperative Oncology Group (ECOG) performance status at the last follow-up (p = 0.006; 95% CI: 0.0012-0.62). Patients aged over 60 years did not exhibit a higher likelihood of death (p = 0.19; HR = 2.3; 95% CI: 0.63-8.61); however, the threshold age at diagnosis for the maximally predicted mortality was 64 years (ROC = 0.73; p = 0.03). Conclusions: Patients had significant delays in diagnosis, affecting patient outcomes. Cognitive deterioration and lobar lesions were prominent clinical and radiological features. Mortality was notably higher in patients with relapses and those who had a longer time to diagnosis.

Targets and treatments in primary CNS lymphoma

Primary central nervous system lymphoma (PCNSL) is a rare and highly aggressive lymphoma entirely localized in the central nervous system or vitreoretinal space. PCNSL generally initially responds to methotrexate-containing chemotherapy regimens, but progressive or relapsing disease is common, and the prognosis is poor for relapsed or refractory (R/R) patients. PCNSL is often characterized by activation of nuclear factor kappa B (NF-κB) due to mutations in the B-cell receptor (BCR) or toll-like receptor (TLR) pathways, as well as immune evasion. Targeted treatments that inhibit key PCNSL mechanisms and pathways are being evaluated; inhibition of Bruton's tyrosine kinase (BTK) downstream of BCR activation has demonstrated promising results in treating R/R disease. This review will summarize the evidence and potential for targeted therapeutic agents to improve treatment outcomes in PCNSL. This includes immunotherapeutic and immunomodulatory approaches and inhibitors of the key pathways driving PCNSL, such as aberrant BCR and TLR signaling.

"Vanishing" glioblastoma: A case report and review of the literature

Contrast enhancement resolution induced by corticosteroids is a phenomenon primarily associated with primary central nervous system lymphoma, while malignant brain gliomas usually maintain a consistent radiological appearance during systemic steroid treatment. Although rare, a few primary and metastatic intracranial lesions have shown similar radiographic changes following corticosteroid therapy. In the case of glioblastomas, corticosteroid therapy is commonly used to alleviate pressure effects from peritumoral edema, but its impact on contrast enhancement is not well-established. A few reported cases in the literature describe reduced contrast enhancement in glioblastomas after corticosteroid treatment. We present a case of corticosteroid-induced regression on imaging of glioblastoma evaluated at our institutionwith the intention to explore the pathogenesis of this response and discuss the therapeutic and prognostic implications of this discovery.

Role and application of chemokine CXCL13 in central nervous system lymphoma

Chemokine ligand 13 (CXCL13) and its chemokine receptor 5 (CXCR5) both play significant roles in the tumor microenvironment (TME). CXCL13 in cerebrospinal fluid (CSF) has recently been found to have significant diagnostic and prognostic value in primary and secondary central nervous system (CNS) diffuse large B-cell lymphoma (DLBCL), and the CXCL13-CXCR5 axis has been shown to play an important chemotactic role in the TME of CNS-DLBCL. In this review, we first describe the clinical value of CXCL13 in CSF as a prognostic and diagnostic biomarker for CNS-DLBCL. In addition, this review also discusses the specific mechanisms associated with the CXCL13-CXCR5 axis in tumor immunity of primary diffuse large B cell lymphoma of the central nervous system (PCNS-DLBCL) by reviewing the specific mechanisms of this axis in the immune microenvironment of DLBCL and CNS inflammation, as well as the prospects for the use of CXCL13-CXCR5 axis in immunotherapy in PCNS-DLBCL.

MRI radiomics-based interpretable model and nomogram for preoperative prediction of Ki-67 expression status in primary central nervous system lymphoma

Objectives

To investigate the value of interpretable machine learning model and nomogram based on clinical factors, MRI imaging features, and radiomic features to predict Ki-67 expression in primary central nervous system lymphomas (PCNSL).

Materials and methods

MRI images and clinical information of 92 PCNSL patients were retrospectively collected, which were divided into 53 cases in the training set and 39 cases in the external validation set according to different medical centers. A 3D brain tumor segmentation model was trained based on nnU-NetV2, and two prediction models, interpretable Random Forest (RF) incorporating the SHapley Additive exPlanations (SHAP) method and nomogram based on multivariate logistic regression, were proposed for the task of Ki-67 expression status prediction.

Results

The mean dice Similarity Coefficient (DSC) score of the 3D segmentation model on the validation set was 0.85. On the Ki-67 expression prediction task, the AUC of the interpretable RF model on the validation set was 0.84 (95% CI:0.81, 0.86; p < 0.001), which was a 3% improvement compared to the AUC of the nomogram. The Delong test showed that the z statistic for the difference between the two models was 1.901, corresponding to a p value of 0.057. In addition, SHAP analysis showed that the Rad-Score made a significant contribution to the model decision.

Conclusion

In this study, we developed a 3D brain tumor segmentation model and used an interpretable machine learning model and nomogram for preoperative prediction of Ki-67 expression status in PCNSL patients, which improved the prediction of this medical task.

Clinical relevance statement

Ki-67 represents the degree of active cell proliferation and is an important prognostic parameter associated with clinical outcomes. Non-invasive and accurate prediction of Ki-67 expression level preoperatively plays an important role in targeting treatment selection and patient stratification management for PCNSL thereby improving prognosis.

Correlation between hemoglobin and the risk of common malignant tumors: a 1999-2020 retrospective analysis and causal association analysis

BACKGROUND

The role of hemoglobin (HGB) in common malignant tumors remains unclear.

METHODS

A retrospective analysis was conducted to identify the correlation between HGB levels and risk of 15 malignant tumors using 50,085 samples from the National Health and Nutrition Examination Survey. Mendelian Randomization analyses (MRAs) were performed based on genome-wide association study data to assess the causal relationship between HGB levels and these malignant tumors using more than 700,000 samples. The robustness of the MRA results was confirmed through various analytical methods. Fifty-six in-house samples were used to investigate the correlation between HGB levels and the prognosis in prostate cancer (PRCA) using the Kaplan-Meier curve.

RESULTS

High HGB levels were associated with a higher risk for patients with cervix cancer, melanoma, and non-melanoma skin cancer (OR > 1.000, p < 0.05). It served as a protective factor for colon cancer, esophagus cancer, stomach cancer, bone cancer, lung cancer, renal cancer, and PRCA (OR < 1.000, p < 0.05). Furthermore, MRAs suggested that elevated HGB levels were correlated with a reduced risk of PRCA (OR = 0.869, p < 0.05), with no significant association observed between this marker and the remaining 14 malignant tumors. No pleiotropy or heterogeneity was found in the ultimate results for MRAs (p-values > 0.05), suggesting the robustness of the results. The results derived from the in-house data revealed a relationship between higher HGB values and a more favorable prognosis in PRCA (p < 0.05).

CONCLUSION

High circulating HGB levels may play a protective prognostic role for PRCA and serve as a protective factor against the occurrence of PRCA.

Updates of primary central nervous system lymphoma

Lymphoma occurring in the central nervous system is considered primary central nervous system lymphoma (PCNSL), usually without systematic lesions. Over the last few decades, a deep understanding of PCNSL has been lacking due to the low incidence rate, and the overall survival and progression-free survival of patients with PCNSL are lower than those with other types of non-Hodgkin lymphoma. Recently, there have been several advancements in research on PCNSL. Advances in diagnosis of the disease are primarily reflected in the promising diagnostic efficiency of novel biomarkers. Pathogenesis mainly involves abnormal activation of nuclear factor kappa-B signaling pathways, copy number variations, and DNA methylation. Novel therapies such as Bruton's tyrosine kinase inhibitors, immunomodulatory drugs, immune checkpoint inhibitors, and phosphoinositide 3-kinase/mammalian target of rapamycin inhibitors are being evaluated as possible treatment options for PCNSL, especially for relapsed/refractory (R/R) cases. Several clinical trials also indicated the promising feasibility and efficacy of chimeric antigen receptor T-cell therapy for selected R/R PCNSL patients. This review focuses on discussing recent updates, including the diagnosis, pathogenesis, and novel therapy of PCNSL.

Intrathecal IgM synthesis as a diagnostic marker in patients with suspected CNS lymphoma

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.

Machine learning-based pathomics signature of histology slides as a novel prognostic indicator in primary central nervous system lymphoma

PURPOSE

To develop and validate a pathomics signature for predicting the outcomes of Primary Central Nervous System Lymphoma (PCNSL).

METHODS

In this study, 132 whole-slide images (WSIs) of 114 patients with PCNSL were enrolled. Quantitative features of hematoxylin and eosin (H&E) stained slides were extracted using CellProfiler. A pathomics signature was established and validated. Cox regression analysis, receiver operating characteristic (ROC) curves, Calibration, decision curve analysis (DCA), and net reclassification improvement (NRI) were performed to assess the significance and performance.

RESULTS

In total, 802 features were extracted using a fully automated pipeline. Six machine-learning classifiers demonstrated high accuracy in distinguishing malignant neoplasms. The pathomics signature remained a significant factor of overall survival (OS) and progression-free survival (PFS) in the training cohort (OS: HR 7.423, p < 0.001; PFS: HR 2.143, p = 0.022) and independent validation cohort (OS: HR 4.204, p = 0.017; PFS: HR 3.243, p = 0.005). A significantly lower response rate to initial treatment was found in high Path-score group (19/35, 54.29%) as compared to patients in the low Path-score group (16/70, 22.86%; p < 0.001). The DCA and NRI analyses confirmed that the nomogram showed incremental performance compared with existing models. The ROC curve demonstrated a relatively sensitive and specific profile for the nomogram (1-, 2-, and 3-year AUC = 0.862, 0.932, and 0.927, respectively).

CONCLUSION

As a novel, non-invasive, and convenient approach, the newly developed pathomics signature is a powerful predictor of OS and PFS in PCNSL and might be a potential predictive indicator for therapeutic response.

[Clinicopathologic characteristics and survival analysis of primary large B-cell lymphoma of the central nervous system]

Objective: To retrospectively analyze the clinical and pathologic characteristics, response to treatment, survival, and prognosis of patients with primary large B-cell lymphoma of the central nervous system (PCNSLBCL) . Methods: Clinical and pathologic data of 70 patients with PCNSLBCL admitted to Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from December 2010 to November 2022 were collected for retrospective analysis. Survival analysis was performed using the Kaplan-Meier method and log-rank test, and prognosis analysis was conducted using the Cox proportional hazards model. Results: Among 70 patients with PCNSLBCL, complete remission (CRs) were achieved in 49 (70.0% ) and partial remission in 4 (5.7% ) after the first-line induction therapy; the overall remission rate was 75.7%. The 2-year progression-free survival (PFS) rate was 55.8% and the median progression-free survival (mPFS) time was 35.9 months, whereas the 2-year overall survival (OS) rate was 79.1% with a median OS time not reached. After CR induced by first-line therapy, cumulative incidence of relapse (CIR) was lower in patients who had received auto-HSCT than in those who had not received consolidation therapy (P=0.032), whose 2-year PFS rate was 54.4% and mPFS time was 35.9 months; comparatively, the 2-year PFS rate in patients having received oral maintenance of small molecule drugs reached 84.4% with a mPFS time of 79.5 months (P=0.038). Multivariant analysis demonstrated that Class 3 in the Memorial Sloan-Kettering Cancer Center (MSKCC) prognostic model is an independent adverse prognostic factor of OS in patients with PCNSLBCL (HR=3.127, 95% CI 1.057-9.253, P=0.039) . Conclusions: In patients with PCNSLBCL achieving CR after the first-line induction therapy, auto-HSCT as consolidation therapy would lead to a decreased CIR, and PFS time could be prolonged by oral maintenance of small molecule drugs. Class 3 MSKCC prognostic model is independently associated with poorer OS.

Circulating Tumor DNA in Diffuse Large B-Cell Lymphoma: from Bench to Bedside?

OPINION STATEMENT

Diffuse large B-cell lymphoma (DLBCL) is a curable disease with variable outcomes due to underlying heterogeneous clinical and molecular features-features that are insufficiently characterized with our current tools. Due to these limitations, treatment largely remains a "one-size-fits-all" approach. Circulating tumor DNA (ctDNA) is a novel biomarker in cancers that is increasingly utilized for risk stratification and response assessment. ctDNA is readily detectable from the plasma of patients with DLBCL but has not yet been incorporated into clinical care to guide treatment. Here, we describe how ctDNA sequencing represents a promising technology in development to personalize the care of patients with DLBCL. We will review the different types of ctDNA assays being studied and the rapidly growing body of evidence supporting the utility of ctDNA in different treatment settings in DLBCL. Risk stratification by estimation of tumor burden and liquid genotyping, molecular response assessment during treatment, and monitoring for measurable residual disease (MRD) to identify therapy resistance and predict clinical relapse are all potential applications of ctDNA. It is time for clinical trials in DLBCL to utilize ctDNA as an integral biomarker for patient selection, response-adapted designs, and surrogate endpoints. As more ctDNA assays become commercially available for routine use, clinicians should consider liquid biopsy when treatment response is equivocal on imaging. Incorporating MRD may also guide decision-making if patients experience severe treatment toxicities. Though important barriers remain, we believe that ctDNA will soon be ready to transition from bench to bedside to individualize treatment for our patients with DLBCL.

Entirely noninvasive outcome prediction in central nervous system lymphomas using circulating tumor DNA

ABSTRACT

State-of-the-art response assessment of central nervous system lymphoma (CNSL) by magnetic resonance imaging is challenging and an insufficient predictor of treatment outcomes. Accordingly, the development of novel risk stratification strategies in CNSL is a high unmet medical need. We applied ultrasensitive circulating tumor DNA (ctDNA) sequencing to 146 plasma and cerebrospinal fluid (CSF) samples from 67 patients, aiming to develop an entirely noninvasive dynamic risk model considering clinical and molecular features of CNSL. Our ultrasensitive method allowed for the detection of CNSL-derived mutations in plasma ctDNA with high concordance to CSF and tumor tissue. Undetectable plasma ctDNA at baseline was associated with favorable outcomes. We tracked tumor-specific mutations in plasma-derived ctDNA over time and developed a novel CNSL biomarker based on this information: peripheral residual disease (PRD). Persistence of PRD after treatment was highly predictive of relapse. Integrating established baseline clinical risk factors with assessment of radiographic response and PRD during treatment resulted in the development and independent validation of a novel tool for risk stratification: molecular prognostic index for CNSL (MOP-C). MOP-C proved to be highly predictive of outcomes in patients with CNSL (failure-free survival hazard ratio per risk group of 6.60; 95% confidence interval, 3.12-13.97; P < .0001) and is publicly available at www.mop-c.com. Our results highlight the role of ctDNA sequencing in CNSL. MOP-C has the potential to improve the current standard of clinical risk stratification and radiographic response assessment in patients with CNSL, ultimately paving the way toward individualized treatment.

Utility of contrast-enhanced MRI radiomics features combined with clinical indicators for predicting induction chemotherapy response in primary central nervous system lymphoma

PURPOSE

To assess the utility of combining contrast-enhanced magnetic resonance imaging (CE-MRI) radiomics features with clinical variables in predicting the response to induction chemotherapy (IC) for primary central nervous system lymphoma (PCNSL).

METHODS

A total of 131 patients with PCNSL (101 in the training set and 30 in the testing set) who had undergone contrast-enhanced MRI scans were retrospectively analyzed. Pyradiomics was utilized to extract radiomics features, and the clinical variables of the patients were gathered. Radiomics prediction models were developed using different combinations of feature selection methods and machine learning models, and the best combination was ultimately chosen. We screened clinical variables associated with treatment outcomes and developed clinical prediction models. The predictive performance of radiomics model, clinical model, and combined model, which integrates the best radiomics model and clinical characteristics, was independently assessed and compared using Receiver Operating Characteristic (ROC) curves.

RESULTS

In total, we extracted 1598 features. The best radiomics model we selected as the best utilized T-test and Recursive Feature Elimination (RFE) for feature selection and logistic regression for model building. Serum Interleukin 2 Receptor (IL-2R) and Eastern Cooperative Oncology Group (ECOG) Score were utilized to develop a clinical predictive model for assessing the response to induction chemotherapy. The results of the testing set revealed that the combined prediction model (radiomics and IL-2R) achieved the highest area under the ROC curve at 0.868 (0.683, 0.967), followed by the radiomics model at 0.857 (0.681, 0.957), and the clinical prediction model (IL-2R and ECOG) at 0.618 (0.413, 0.797). The combined model was significantly more accurate than the clinical model, with an AUC of 0.868 compared to 0.618 (P < 0.05). While the radiomics model had slightly better predictive power than the clinical model, this difference was not statistically significant (AUC, 0.857 vs. 0.618, P > 0.05).

CONCLUSIONS

Our prediction model, which combines radiomics signatures from CE-MRI with serum IL-2R, can effectively stratify patients with PCNSL before high-dose methotrexate (HD-MTX) -based chemotherapy.