Primary brain lymphoma and glioblastoma: evaluation of DCE T1 and DSC T2 MRI perfusion findings

BACKGROUND

The accurate differentiation of primary central nervous system lymphoma (PCNSL) from glioblastoma multiforme (GBM) is clinically crucial due to the different treatment strategies between them.

PURPOSE

To define magnetic resonance imaging (MRI) perfusion findings in PCNSL to make a safe distinction from GBM with dynamic contrast-enhanced (DCE) T1 and DSC T2 MRI perfusion findings.

MATERIAL AND METHODS

This retrospective analysis included 19 patients with histopathologically diagnosed PCNSL and 21 individuals with GBM. DCE T1 vascular permeability perfusion values including K-trans, Ve, Kep, IAUGC, and DSC T2 perfusion values including cerebral blood volume (CBV) and cerebral blood flow (CBF) in axial sections from the pathological lesion and contralateral normal brain parenchyma were measured quantitatively using region of interest analysis.

RESULTS

The study observed no statistically significant difference between patients with PCNSL (T/B cell) and GBM in the median values of DCE T1 perfusion ratios (P > 0.05). Nevertheless, the DSC T2 perfusion ratios showed a substantial distinction between the two groups. In contrast to patients with PCNSL (1.185 vs. 1.224, respectively), those with GBM had higher median levels of r-CBV and r-CBF (2.898 vs. 2.467, respectively; P 0.01). A cutoff value of ≤1.473 for r-CBV (Lesion/N) and ≤1.6005 for r-CBF (Lesion/N) was found to estimate the positivity of PCNSL.

CONCLUSION

DSC T2 MRI perfusion values showed lower r-CBV and r-CBF values in PCNSL patients compared to GBM patients. According to the findings, r-CBV and r-CBF are the most accurate MRI perfusion parameters for distinguishing between PCSNL and GBM.

Central nervous system lymphomas-Assessment and treatment and prevention of central nervous system relapse

In this review focused on lymphoma and the central nervous system (CNS), we summarize recent developments in the management of primary (PCNSL) and secondary CNS lymphoma (SCNSL), treatment of CNS lymphoma in the older population, the neuroradiological assessment of CNS lymphoma and finally highlight the ongoing debate on optimal CNS prophylaxis. The section on PCNSL focuses on the different approaches available for frontline treatment in Europe and the United States and discusses consolidation strategies. We then highlight available strategies to treat PCNSL in the elderly population, an area of unmet need. New therapies aiming at minimizing toxicity and prioritizing quality of life are emerging for these patients. Secondary CNS lymphoma, especially in the relapsed/refractory setting is another area of unmet need, and the efficacy of CAR-T cell therapy is being explored. We provide an overview of the imaging challenges in the neuroradiological assessment of CNS lymphoma. Finally, the section on CNS prophylaxis summarizes recent findings from large retrospective studies challenging the efficacy of present approaches to prophylaxis in higher-risk patients with lymphoma.

Radiomic features define risk and are linked to DNA methylation attributes in primary CNS lymphoma

Background

The prognostic roles of clinical and laboratory markers have been exploited to model risk in patients with primary CNS lymphoma, but these approaches do not fully explain the observed variation in outcome. To date, neuroimaging or molecular information is not used. The aim of this study was to determine the utility of radiomic features to capture clinically relevant phenotypes, and to link those to molecular profiles for enhanced risk stratification.

Methods

In this retrospective study, we investigated 133 patients across 9 sites in Austria (2005-2018) and an external validation site in South Korea (44 patients, 2013-2016). We used T1-weighted contrast-enhanced MRI and an L1-norm regularized Cox proportional hazard model to derive a radiomic risk score. We integrated radiomic features with DNA methylation profiles using machine learning-based prediction, and validated the most relevant biological associations in tissues and cell lines.

Results

The radiomic risk score, consisting of 20 mostly textural features, was a strong and independent predictor of survival (multivariate hazard ratio = 6.56 [3.64-11.81]) that remained valid in the external validation cohort. Radiomic features captured gene regulatory differences such as in BCL6 binding activity, which was put forth as testable treatment target for a subset of patients.

Conclusions

The radiomic risk score was a robust and complementary predictor of survival and reflected characteristics in underlying DNA methylation patterns. Leveraging imaging phenotypes to assess risk and inform epigenetic treatment targets provides a concept on which to advance prognostic modeling and precision therapy for this aggressive cancer.

Diffuse Large B-Cell Epstein-Barr Virus-Positive Primary CNS Lymphoma in Non-AIDS Patients: High Diagnostic Accuracy of DSC Perfusion Metrics

BACKGROUND AND PURPOSE

Immunodeficiency-associated CNS lymphoma may occur in different clinical scenarios beyond AIDS. This subtype of CNS lymphoma is diffuse large B-cell and Epstein-Barr virus-positive. Its accurate presurgical diagnosis is often unfeasible because it appears as ring-enhancing lesions mimicking glioblastoma or metastasis. In this article, we describe clinicoradiologic features and test the performance of DSC-PWI metrics for presurgical identification.

MATERIALS AND METHODS

Patients without AIDS with histologically confirmed diffuse large B-cell Epstein-Barr virus-positive primary CNS lymphoma (December 2010 to January 2022) and diagnostic MR imaging without onco-specific treatment were retrospectively studied. Clinical, demographic, and conventional imaging data were reviewed. Previously published DSC-PWI time-intensity curve analysis methodology, to presurgically identify primary CNS lymphoma, was used in this particular lymphoma subtype and compared with a prior cohort of 33 patients with Epstein-Barr virus-negative CNS lymphoma, 35 with glioblastoma, and 36 with metastasis data. Normalized curves were analyzed and compared on a point-by-point basis, and previously published classifiers were tested. The standard percentage of signal recovery and CBV values were also evaluated.

RESULTS

Seven patients with Epstein-Barr virus-positive primary CNS lymphoma were included in the study. DSC-PWI normalized time-intensity curve analysis performed the best for presurgical identification of Epstein-Barr virus-positive CNS lymphoma (area under the receiver operating characteristic curve of 0.984 for glioblastoma and 0.898 for metastasis), followed by the percentage of signal recovery (0.833 and 0.873) and CBV (0.855 and 0.687).

CONCLUSIONS

When a necrotic tumor is found in a potentially immunocompromised host, neuroradiologists should consider Epstein-Barr virus-positive CNS lymphoma. DSC-PWI could be very useful for presurgical characterization, with especially strong performance of normalized time-intensity curves.

Longitudinally extensive transverse myelitis preceding primary central nervous system lymphoma: Spinal sentinel neuroinflammation

65-year-old female diagnosed with longitudinally extensive transverse myelitis. She had excellent response to immunotherapy despite her atypical features, and her spinal lesion was fully recovered in the second month of the treatment. Nine months after, she was diagnosed with primary cerebral central nervous system lymphoma while there was no recurrence of the spinal cord lesion as her most recent follow-up visit being 2 years after the LETM. Spinal sentinel neuroinflammation preceding primary central nervous system lymphoma might represent a valuable etiology in the differentials of LETM, as illustrated here.

Differentiation between primary CNS lymphoma and atypical glioblastoma according to major genomic alterations using diffusion and susceptibility-weighted MR imaging

PURPOSE

We aimed to differentiate primary central nervous system lymphoma (PCNSL) from atypical glioblastoma (GB) and distinguish major genomic subtypes between these tumors using susceptibility-weighted imaging (SWI) along with diffusion-weighted imaging (DWI).

METHODS

Thirty-one immuno-competent patients with PCNSL stratified by BCL2 and MYC rearrangement, and 57 patients with atypical GB (no visible necrosis) grouped according to isocitrate dehydrogenase-1 (IDH1) mutation status underwent 3.0-Tesla MRI before treatment in this retrospective study. Region of interest analysis with apparent diffusion coefficient (ADC) and SWI signal intensity values of the tumors were normalized by dividing those of contralateral white matter. The independent-samples t-test and Kruskal-Wallis test were utilized to compare parameters. The diagnostic ability of each parameter and their optimal combination was evaluated by logistic regression analysis and receiver operating characteristic.

RESULTS

PCNSL with rearrangement of both MYC and BCL2 (n = 7) [mean relative (r) ADCmean:0.87 ± 0.06, rADCmin:0.72 ± 0.08] demonstrated significantly lower rADCmean, and rADCmin compared to other PCNSLs (n = 24) (rADCmean:1.19 ± 0.18, rADCmin:1.03 ± 0.17;p < 0.001) and GBs (p < 0.001). GB without IDH1 mutation (n = 44) (mean rSWI value:0.95 ± 0.15) demonstrated significantly lower rSWI value compared to GB with IDH1 mutation (n = 13) (rSWI value:1.13 ± 0.09;p < 0.001) and PCNSL (p < 0.001). The incorporation of rADCmean and rSWI parameters distinguished GB with IDH1 mutation [Area under the curve (AUC):0.985] with sensitivity and specificity of 94.3 and 100 % respectively; and PCNSL with rearrangement of both MYC and BCL2 (AUC:0.982) with sensitivity and specificity of 100 % and 95.4 %, respectively. CONCLUSıONS: Combined analysis of SWI and DWI could differentiate atypical GB from PCNSL and distinguish major genomic subtypes between these tumors.

CXCL13 and CXCL9 CSF Levels in Central Nervous System Lymphoma-Diagnostic, Therapeutic, and Prognostic Relevance

Background: Diagnostic delay and neurologic deterioration are still a problem for the treatment of rapidly progressing CNS lymphoma (CNSL); there is an unmet need for a diagnostic test with a high diagnostic yield and limited risk, minimizing the time to the initiation of effective treatment.

Methods: In this prospective monocentric study, we analyzed the utility of CXCL13 and CXCL9 as diagnostic, therapeutic and prognostic biomarkers for CNSL. Cerebrospinal fluid (CSF) from 155 consecutive patients admitted with brain lesions of various origins was collected. Levels of CXCL13 and CXCL9 were analyzed by ELISA. Additionally, CSF was analyzed during CNSL disease course (relapse, remission, progress) in 17 patients.

Results: CXCL13 and CXCL9 CSF levels were significantly increased in patients with CNSL compared to control patients with lesions of other origin. Using logistic regression and a minimal-p-value approach, a cut-off value of 80 pg/ml for CXCL13 shows high sensitivity (90.7%) and specificity (90.1%) for the diagnosis of active CNSL. CXCL9 at a cut-off value of 84 pg/ml is less sensitive (61.5%) and specific (87.1%). Both cytokines correlate with the clinical course and response to therapy.

Conclusions: Our results confirm the excellent diagnostic potential of CXCL13 and introduce CXCL9 as a novel albeit less powerful marker for PCNSL.

Traditional and Advanced Neuroimaging Contributions to the Diagnosis and Differential Diagnosis of Central Nervous System Lymphoma Patients Visiting a Comprehensive Medical Center

Introduction:

The diagnosis of Central Nervous System Lymphoma, especially the Primary Central Nervous System Lymphoma is carried out based on brain imaging, thus avoiding an unnecessary extend of surgery. But the traditional imaging techniques, such as Computed Tomography and Magnetic Resonance Imaging, were not satisfactory.

Aims:

This study was conducted to characterize the spectrum of advanced Neuroimaging, such as the advanced Magnetic Resonance Imaging features in the Central Nervous System Lymphoma patients in a comprehensive medical center in Lebanon, and compare them to what has been described in the literature review.

Methods:

It is a retrospective exploratory study of the clinical data and imaging features for patients admitted to the emergency and radiology departments with ages above 10 years, and who were diagnosed histopathologically with intracranial lymphoma. This study may be the first to make a Radiological evaluation of Central Nervous System Lymphoma on the local population of patients over 9 years .

Results:

Results showed that the study of the Computed Tomography and Magnetic Resonance Imaging data of 10 immunocompetent patients with Central Nervous System Lymphoma concurs with the previously described patient populations, except for the gender parameter. Tumors were mostly presented in the fifth or Sixth decade and they could be solitary or multi-focal. Lesions were typically located Preprint submitted to The Open Neuroimaging Journal May 14, 2020 in the supratentorial compartment. On the brain Computed Tomography, the lesions were hyperdense, and in pre-contrast Magnetic Resonance images, the lesions appeared hypointense on T1 and hyperintense on T2-Weighted images, but hypointense with respect to the grey matter. The lesions were also surrounded with a mild to moderate edema as compared to other intracranial neoplasms, such as glioblastomas. Evaluation results showed that on post-contrast Magnetic Resonance images, the majority of lesions exhibited a homogeneous enhancement of 50%. Majority of the lesions also showed a less common heterogeneous ring-like enhancement of 40%, and revealed the uncommon absence of enhancement of 10%. Calcifications, hemorrhage, and necrosis were rare findings and were present in only one patient.

Conclusion:

As a future prospect, studying whether the advanced imaging techniques may provide not only non-invasive and morphological characteristics but also non-invasive biological characteristics and thus accurate diagnosis could be considered.

A Multiplex Assay for the Stratification of Patients with Primary Central Nervous System Lymphoma Using Targeted Mass Spectrometry

Primary central nervous system lymphomas (PCNSL) account for approximately 2% to 3% of all primary brain tumors. Until now, neuropathological tumor tissue analysis, most frequently gained by stereotactic biopsy, is still the diagnostic gold standard. Here, we rigorously analyzed two independent patient cohorts comprising the clinical entities PCNSL (n = 47), secondary central nervous system lymphomas (SCNSL; n = 13), multiple sclerosis (MS, n = 23), glioma (n = 10), other tumors (n = 17) and tumor-free controls (n = 21) by proteomic approaches. In total, we identified more than 1220 proteins in the cerebrospinal fluid (CSF) and validated eight candidate biomarkers by a peptide-centric approach in an independent patient cohort (n = 63). Thus, we obtained excellent diagnostic accuracy for the stratification between PCNSL, MS and glioma patients as well as tumor-free controls for three peptides originating from the three proteins VSIG4, GPNMB4 and APOC2. The combination of all three biomarker candidates resulted in diagnostic accuracy with an area under the curve (AUC) of 0.901 (PCNSL vs. MS), AUC of 0.953 (PCNSL vs. glioma) and AUC 0.850 (PCNSL vs. tumor-free control). In summary, the determination of VSIG4, GPNMB4 and APOC2 in CSF as novel biomarkers for supporting the diagnosis of PCNSL is suggested.

Differentiation of Primary Central Nervous System Lymphoma From Glioblastoma: Quantitative Analysis Using Arterial Spin Labeling and Diffusion Tensor Imaging

OBJECTIVE

Differentiation of primary central nervous system lymphoma (PCNSL) from glioblastoma using arterial spin labeling perfusion and diffusion tensor imaging (DTI).

METHODS

We performed a prospective study of 31 patients with a provisional diagnosis of PCNSL and glioblastoma who underwent conventional magnetic resonance imaging, DTI, and arterial spin labeling of the brain. The tumor blood flow (TBF), mean diffusivity (MD) plus fractional anisotropy (FA) of the mass were measured. The final diagnosis was confirmed by pathological examination.

RESULTS

The TBF of PCNSL (26.41 ± 4.03 mL/100 g/minute) was significantly lower than that of glioblastoma (51.08 ± 3.9 mL/100 g/minute; P = 0.001). The TBF cutoff (35.73 mL/100 g/minute) used for differentiation showed area under the curve (AUC) of 0.93, accuracy of 95.2%, sensitivity of 91.7%, and specificity of 100%. The MD of PCNSL (0.87 ± 0.2X 10^-3 mm²/second) was significantly lower than that of glioblastoma (0.87 ± 0.2 × 10^-3 mm²/second; P = 0.01). The MD cutoff (0.935 × 10^-3 mm²/second) used for differentiation showed an AUC of 0.73 and accuracy of 66.7% and a sensitivity of 75% and specificity of 55.6%. The FA of PCNSL (0.253 ± 0.05) was significantly greater than that of glioblastoma (0.135 ± 0.06; P = 0.001). The FA cutoff (0.185) used for differentiation revealed an AUC of 0.944 and accuracy of 85.7% and a sensitivity of 83.3% and specificity of 88.9%. The combined TBF, MD, and FA cutoffs revealed an AUC of 0.96 and accuracy of 95.5% and a sensitivity of 83.3% and specificity of 100%.

CONCLUSION

The noninvasive imaging parameters using TBF and DTI might help in differentiating PCNSL from glioblastoma.

Soluble TACI and soluble BCMA as biomarkers in primary central nervous system lymphoma

Background

B-cell survival is regulated through interactions of B-cell-activating factor and a proliferation-inducing ligand with their receptors transmembrane activator and CAML interactor (TACI) and B-cell maturation antigen (BCMA). We evaluated the diagnostic potential of soluble TACI (sTACI) and soluble BCMA (sBCMA) in CSF and serum as biomarkers in primary CNS lymphoma (PCNSL).

Methods

CSF (n = 176) and serum samples (n = 105) from patients with clinically or radiologically suspected PCNSL as well as from control patients were collected prospectively. Levels of sTACI and sBCMA were analyzed by enzyme-linked immunosorbent assay. Additionally, in patients with PCNSL, CSF was analyzed during disease course (time of diagnosis, n = 26; relapse, n = 10; remission, n = 14), and in 2 patients long-term longitudinal analysis was performed.

Results

Soluble TACI and sBCMA are significantly increased in patients with PCNSL (sTACI, median: 445 pg/mL; sBCMA, median: 760 pg/mL) compared with control patients (sTACI, median: 0 pg/mL; sBCMA, median: 290 pg/mL). At a cutoff value of 68.4 pg/mL, sTACI shows high sensitivity (87.9%) and specificity (88.3%) for the diagnosis of active PCNSL. Soluble BCMA is less sensitive (72.7%) and specific (71.8%) (cutoff: 460 pg/mL). When both markers are combined, specificity increases, however, at the cost of a lower sensitivity. In serum, both sTACI and sBCMA are not increased in PCNSL patients. Both soluble receptors correlate with clinical course and therapy response.

Conclusions

Our results suggest that sTACI and sBCMA in the CSF are promising new biomarkers for diagnosis and therapy monitoring in PCNSL. However, our findings need to be validated in an independent cohort.

Primary CNS Lymphomas: Challenges in Diagnosis and Monitoring

Primary Central Nervous System Lymphoma (PCNSL) is a rare neoplasm that can involve brain, eye, leptomeninges, and rarely spinal cord. PCNSL lesions most typically enhance homogeneously on T1-weighted magnetic resonance imaging (MRI) and appear T2-hypointense, but high variability in MRI features is commonly encountered. Neurological symptoms and MRI findings may mimic high grade gliomas (HGGs), tumefactive demyelinating lesions (TDLs), or infectious and granulomatous diseases. Advanced MRI techniques (MR diffusion, spectroscopy, and perfusion) and metabolic imaging, such as Fluorodeoxyglucose Positron Emission Tomography (FDG-PET) or amino acid PET (usually employing methionine), may be useful in distinguishing these different entities and monitoring the disease course. Moreover, emerging data suggest a role for cerebrospinal fluid (CSF) markers in predicting prognosis and response to treatments. In this review, we will address the challenges in PCNSL diagnosis, assessment of response to treatments, and evaluation of potential neurotoxicity related to chemotherapy and radiotherapy.

Primary central nervous system lymphoma: essential points in diagnosis and management

Primary central nervous system lymphoma (PCNSL) is an extra-nodal non-Hodgkin lymphoma. PCNSL is defined as lymphoma involving the brain, leptomeninges, eyes, or spinal cord without evidence of lymphoma outside the CNS. Treatment includes induction with chemotherapy and consolidation with whole-brain radiotherapy or high-dose chemotherapy supported by autologous stem cell transplantation. High-dose methotrexate is the most important drug in cases with PCNSL, and this drug will be used in combination with small molecules, BTK inhibitors, new monoclonal antibodies, and checkpoint blockers.