Primary central nervous system lymphoma in immunocompetent adults: poor results mainly associated with high treatment related toxicities

Thrombosis in hematologic malignancies: risks and consequences

SUMMARY Thrombotic complications in hematologic malignancies have been found to be high among the various forms of cancer. Thrombosis not only increases the morbidity, but also has an adverse impact on survival. The pathogenesis among the different forms of hematologic malignancies is reviewed in this article. The thrombogenicity of the individual malignant cells, the tumor burden, treatment modalities and presence of comorbidities are among the major risk factors. These factors vary with the acute leukemias, lymphomas, multiple myeloma and myeloproliferative neoplasms. The thrombogenetic factors in the more common hematologic malignancies are discussed. Results of recent randomized controlled clinical trials are beginning to provide data for meaningful therapeutic guidelines on thromboprophylaxis. They also enable the clinician to assess the risk factors in each individual patient. More clinical trials are needed to provide better risk stratification and to devise risk-adapted treatment regimens.

Primary central nervous system lymphoma treated with high-dose methotrexate, high-dose busulfan/thiotepa, autologous stem-cell transplantation and response-adapted whole-brain radiotherapy: results of the multicenter Ostdeutsche Studiengruppe Hamato-Onkologie OSHO-53 phase II study

BACKGROUND

We investigated the efficacy and safety of tandem high-dose methotrexate (HD-MTX) induction followed by high-dose busulfan/thiotepa (HD-BuTT) with autologous peripheral blood stem-cell transplantation (aPBSCT) and response-adapted whole-brain radiation therapy (WBRT) in patients with newly diagnosed primary central nervous system lymphoma.

PATIENTS AND METHODS

Twenty-three patients were treated with HD-MTX on days 1 and 10. In case of at least a partial remission (PR), HD-BuTT followed by aPBSCT was given. Patients without response to induction or without complete remission (CR) after HD-BuTT received WBRT.

RESULTS

Sixteen patients received HD-MTX and HD-BuTT achieving a CR/PR rate of 69%/13%. CR/PR rates for all patients (n = 23) were 70%/13%. There were three deaths during therapy. With longer follow-up three neurotoxic deaths occurred in irradiated patients (n = 9), while no persistent neurotoxicity was seen after HD-BuTT without subsequent WBRT. At a median follow-up of 15 months (range 1-69) median event-free survival (EFS) and overall survival (OS) for all patients were 17 and 20 months (Kaplan-Meier), after HD-BuTT 27 months and "not reached", respectively. Estimated 2-year EFS and OS were 45% and 48% for all patients versus 56% and 61% for the HD-BuTT group, respectively.

CONCLUSION

MTX induction followed by HD-BuTT is an effective and very short time-on-treatment regimen. Median survival for patients treated with high-dose chemotherapy is not reached yet. The induction regimen needs optimisation. In this study WBRT was associated with a high incidence of severe neurotoxicity.

Initial response to glucocorticoids

BACKGROUND

Known prognostic variables in patients with primary central nervous system lymphomas (PCNSL) include age, Karnofsky performance status, involvement of deep regions of the brain, intensity of blood-brain barrier disruption, and treatment with radiation and chemotherapy. PCNSL often responds transiently to glucocorticoids administered to control neurologic symptoms before radiation or chemotherapy. This retrospective chart review was designed to estimate the prognostic significance of a clinical or radiologic response to initial glucocorticoid therapy.

METHODS

By using data from The Johns Hopkins Cancer Registry from January 1980 to June 2001, a total of 76 human immunodeficiency virus (HIV)-negative adults with newly diagnosed PCNSL were identified. Nineteen patients with uninformative medical records were excluded from the study.

RESULTS

The median survival of the remaining 57 patients was 11.8 months. The median survival for the 48 patients who had clinical response to initial steroid therapy was 17.9 months, and for nonresponders, it was 5.5 months (P = 0.05). The 16 patients with documented radiologic response had a median survival of 117.0 months compared with 5.5 months for nonresponders (P = 0.001). After adjusting for known prognostic factors (age and treatment), significant reduction in risk of death was noted in patients who had either clinical (hazard ratio [HR] = 0.40; 95% confidence interval [CI], 0.16-0.99}) or radiologic response (HR = 0.14; 95% CI, 0.04-0.46) to glucocorticoids given before radiation or chemotherapy.

CONCLUSION

This analysis suggests that initial response to treatment with glucocorticoids may be an important prognostic factor in patients with PCNSL.

Combined-modality therapy for primary central nervous system lymphoma: long-term data from a Phase II multicenter study (Trans-Tasman Radiation Oncology Group)

PURPOSE

To assess, in a multicenter setting, the long-term outcomes of a brief course of high-dose methotrexate followed by radiotherapy for patients with primary central nervous system lymphoma (PCNSL).

METHODS AND MATERIALS

Forty-six patients were entered in a Phase II protocol consisting of methotrexate (1 g/m(2) on Days 1 and 8), followed by whole-brain irradiation (45-50.4 Gy). The median follow-up time was 7 years, with a minimum follow-up of 5 years.

RESULTS

The 5-year survival estimate was 37% (+/-14%, 95% confidence interval [CI]), with progression-free survival being 36% (+/-15%, 95% CI), and median survival 36 months. Of the original 46 patients, 10 were alive, all without evidence of disease recurrence. A total of 11 patients have developed neurotoxicity, with the actuarial risk being 30% (+/-18%, 95% CI) at 5 years but continuing to increase. For patients aged>60 years the risk of neurotoxicity at 7 years was 58% (+/-30%, 95% CI).

CONCLUSION

Combined-modality therapy, based on high-dose methotrexate, results in improved survival outcomes in PCNSL. The risk of neurotoxicity for patients aged>60 years is unacceptable with this regimen, although survival outcomes for patients aged>60 years were higher than in many other series.