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Alderuccio JP, Nayak L, Cwynarski K. How I treat secondary CNS involvement by aggressive lymphomas. Blood 2023; 142:1771-1783. [PMID: 37702537 PMCID: PMC10862244 DOI: 10.1182/blood.2023020168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/14/2023] [Accepted: 08/17/2023] [Indexed: 09/14/2023] Open
Abstract
Secondary central nervous system (CNS) lymphoma (SCNSL) is a rare but clinically challenging scenario with historically disappointing outcomes. SCNSL refers to lymphoma that has spread into the CNS concurrently with systemic disease or CNS relapse during or after frontline immunochemotherapy, presenting with or without systemic lymphoma. Diffuse large B-cell lymphoma (DLBCL) denotes the most common entity, but an increased incidence is observed in other histologies, such as Burkitt lymphoma and mantle-cell lymphoma. The incidence, timing in disease course, location, evidence supporting the use of CNS prophylaxis, and treatment pathways vary according to histology. No randomized data exist to delineate the best treatment approaches with current recommendations based on retrospective and single-arm studies. However, a regimen comprising immunochemotherapy, incorporating agents that cross the blood-brain barrier, followed by thiotepa-containing conditioning and autologous stem-cell transplant outlined in the international MARIETTA study demonstrated improvement in outcomes, representing a major accomplishment in the care of patients with DLBCL with SCNSL. Anti-CD19 chimeric antigen receptor T cell denotes a paradigm shift in the treatment of patients with systemic aggressive lymphomas, with emerging data also demonstrating efficacy without higher neurotoxicity in those with SCNSL. In this manuscript we discuss 5 clinical scenarios and review the evidence supporting our recommendations.
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Affiliation(s)
- Juan Pablo Alderuccio
- Division of Hematology, Department of Medicine, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL
| | - Lakshmi Nayak
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Kate Cwynarski
- Department of Haematology, University College London Hospital, London, United Kingdom
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2
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Simard J, Roschewski M. SOHO State of the Art Updates and Next Questions: Prophylaxis and Management of Secondary CNS Lymphoma. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:709-717. [PMID: 35787364 PMCID: PMC9529879 DOI: 10.1016/j.clml.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/01/2022] [Accepted: 06/04/2022] [Indexed: 06/15/2023]
Abstract
Secondary CNS lymphoma (SCNSL) is a rare but frequently fatal complication of systemic lymphoma. There is no standard treatment for SCNSL, and patients who develop SCNSL at diagnosis or after frontline therapy often receive highly intensive chemotherapy regimens that are inactive against primary chemorefractory disease and too toxic for older, frail patients to tolerate. Because the prognosis of SCNSL is so poor, management has historically emphasized prevention, but the current methods of CNS prophylaxis are not universally effective. To improve both the prevention and management of SCNSL, better characterization of the molecular determinants of CNS invasion is needed. Novel treatments that are currently being studied in SCNSL include targeted pathway inhibitors and cellular therapy, but SCNSL patients are often excluded from clinical trials of promising new therapies.
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Affiliation(s)
- Jillian Simard
- Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD
| | - Mark Roschewski
- Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD.
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3
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Fleming M, Huang Y, Dotson E, Bond DA, Reneau J, Epperla N, Alinari L, Brammer J, Christian B, Baiocchi RA, Maddocks K, Sawalha Y. Outcomes of patients with diffuse large B-cell and high-grade B-cell lymphomas with synchronous CNS and systemic involvement at diagnosis treated with high-dose methotrexate and R-CHOP: a single-center retrospective study. Ther Adv Hematol 2022; 13:20406207221112900. [PMID: 35898434 PMCID: PMC9310204 DOI: 10.1177/20406207221112900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/01/2022] [Indexed: 12/12/2022] Open
Abstract
Background: The optimal treatment of patients with systemic diffuse large B-cell (DLBCL) or high-grade B-cell (HGBL) lymphomas with synchronous central nervous system (CNS) involvement at diagnosis is not well defined. High-dose methotrexate administered concurrently with R-CHOP (RM-CHOP) is a commonly used regimen, but data on outcomes achieved with this regimen are limited. Objective: To report our experience with RM-CHOP in patients with systemic DLBCL or HGBL with synchronous CNS involvement at diagnosis. Design: A single-center retrospective analysis. Methods: We identified consecutive patients with systemic DLBCL or HGBL with synchronous CNS involvement at diagnosis who were treated with RM-CHOP from January 2012 to January 2021. Results: Fifty patients were included with a median age of 62 years; 82% had DLBCL (n = 41) and 18% had HGBL (n = 9). Treatment with RM-CHOP was followed by consolidative autologous hematopoietic cell transplantation in 14 patients (28%). The complete response (CR) rate following RM-CHOP was 62%. With a median follow-up of 40 months, the median progression-free (PFS) and overall (OS) survivals were 16 and 58 months, and the 2-year PFS and OS were 41% and 57%, respectively. The 2-year cumulative incidence of CNS progression/relapse was 29%. Outcomes were particularly poor in HGBL, with median PFS and OS of 6 and 7 months, compared with median PFS and OS of 22 months and not reached in DLBCL, respectively. The outcomes of patients with relapsed/progressive disease were poor, with only 63% of patients receiving subsequent treatments and only 21% achieving CR to next subsequent treatment. Most patients (58%) with disease relapse/progression had CNS involvement which was associated with very poor outcomes (median OS of 2 months). Conclusion: CNS involvement in aggressive B-cell non-Hodgkin lymphoma at diagnosis dictates clinical outcomes and requires more effective treatment options.
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Affiliation(s)
- Megan Fleming
- Department of Pharmacy, The Ohio State University, Columbus, OH, USA
| | - Ying Huang
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Emily Dotson
- Department of Pharmacy, The Ohio State University, Columbus, OH, USA
| | - David A Bond
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - John Reneau
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | | | - Lapo Alinari
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Jonathan Brammer
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Beth Christian
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Robert A Baiocchi
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Kami Maddocks
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Yazeed Sawalha
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, The Ohio State University, 1140B Lincoln Tower, 1800 Cannon Dr, Columbus, OH 43210, USA
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4
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Feasibility of High-dose Methotrexate Administered on Day 1 of (R)CHOP in aggressive non-Hodgkin Lymphomas. Blood Adv 2021; 6:460-472. [PMID: 34788387 PMCID: PMC8791577 DOI: 10.1182/bloodadvances.2021005999] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/27/2021] [Indexed: 11/20/2022] Open
Abstract
HDMTX administration on day 1 of (R)CHOP is feasible and compares favorably with reports of HDMTX administration midcycle. Delaying prophylactic HDMTX beyond cycle 1 of (R)CHOP might lower the risks of neutropenic fever and acute kidney injury.
The optimal timing for administering high-dose methotrexate (HDMTX) when combined with (R)CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone, with/without rituximab) is unclear. Recent data showed that the administration of prophylactic HDMTX before day 10 of R- CHOP may lead to fewer treatment delays. Herein, we report our experience with HDMTX administered on day 1 of (R)CHOP in patients with aggressive non-Hodgkin lymphoma (NHL). We identified 140 patients treated with ≥1 cycle of HDMTX combined with (R)CHOP for prophylaxis against (n = 84) or treatment of (n = 56) central nervous system (CNS) involvement. Overall, (R)CHOP treatment delays ≥7 days (4% of cycles, 13% of patients), doxorubicin, and/or cyclophosphamide dose reductions (1% of cycles, 6% of patients) or (R)CHOP discontinuations due to toxicity (4% of patients) were uncommon. Neutropenic fever (NF) occurred in 7% of cycles and 24% of patients and was more common during HDMTX-containing cycles. Acute kidney injury (AKI) occurred in 19% of cycles but was mostly grade ≤2. Grade ≥3 hepatotoxicity and mucositis were uncommon (each 2% of cycles). In the prophylaxis cohort, the rates of NF and grade ≥2 AKI were lower in patients who initiated HDMTX with cycle 2 or later (11% vs 30%, P = .03 and 16% vs 39%, P = .03, respectively). Our data show that HDMTX administration on day 1 of (R)CHOP may improve the deliverability of (R)CHOP and the overall safety of the regimen compared with historical data of HDMTX administration on day 10 or later of R-CHOP. Delaying prophylactic HDMTX beyond cycle 1 of (R)CHOP may reduce the risk of NF and AKI.
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5
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Thiele B, Binder M, Schliffke S, Frenzel C, Dierlamm J, Wass M, Weisel KC, Bokemeyer C, Janjetovic S. Outcome of a Real-World Patient Cohort with Secondary CNS Lymphoma Treated with High-Intensity Chemoimmunotherapy and Autologous Stem Cell Transplantation. Oncol Res Treat 2021; 44:375-381. [PMID: 34289466 DOI: 10.1159/000517531] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 06/01/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Aggressive non-Hodgkin lymphomas with secondary central nervous system (CNS) involvement bear a dismal prognosis. Optimal treatment remains so far unclear, and effective treatment options remain an unmet clinical need. Remission rates are in general low, resulting in rapid relapses and palliative care in the majority of patients. High-intensity treatment combining effective CNS-directed chemoimmunotherapy with autologous stem cell transplantation was shown in a recent phase 2 trial to induce durable remissions. Here, we report the outcome of the first real-world patient cohort treated according to the published protocol. METHODS We retrospectively identified 17 HIV-negative lymphoma patients with secondary CNS involvement, either at first diagnosis or at relapse of lymphoma, treated according to the study protocol published by Ferreri et al. [J Clin Oncol. 2015] at two university medical centers in Germany. Treatment consisted of four cycles of chemoimmunotherapy with a consolidating autologous stem cell transplantation. Adverse events and overall outcome were assessed. RESULTS Five patients had CNS involvement at first diagnosis and 12 patients at relapse of lymphoma. A complete response was achieved in 9 patients. Median survival was 11 months. Five patients died of septic complications and 4 patients succumbed to progression or relapse of disease. CONCLUSIONS The outcome of our real-world cohort emphasizes the possible toxic character of the treatment protocol by Ferreri et al. [J Clin Oncol. 2015]. Further improvement in treatment regimens is still an unmet need.
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Affiliation(s)
- Benjamin Thiele
- Department of Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,
| | - Mascha Binder
- Department of Internal Medicine IV, Oncology/Hematology, Martin-Luther-University, Halle-Wittenberg, Halle (Saale), Germany
| | - Simon Schliffke
- Department of Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Frenzel
- Department of Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Judith Dierlamm
- Department of Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maxi Wass
- Department of Internal Medicine IV, Oncology/Hematology, Martin-Luther-University, Halle-Wittenberg, Halle (Saale), Germany
| | - Katja C Weisel
- Department of Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carsten Bokemeyer
- Department of Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Snjezana Janjetovic
- Department of Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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6
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Steinhardt MJ, Krummenast FC, Rosenwald A, Gerhard-Hartmann E, Heidemeier A, Einsele H, Topp MS, Duell J. R-CHOP intensification with mid-cycle methotrexate and consolidating AraC/TT with BCNU/aHSCT in primary aggressive lymphoma with CNS involvement. J Cancer Res Clin Oncol 2021; 148:205-214. [PMID: 34085097 PMCID: PMC8752544 DOI: 10.1007/s00432-021-03663-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 05/11/2021] [Indexed: 11/30/2022]
Abstract
Purpose Patients suffering from aggressive systemic peripheral lymphoma with primary central nervous system involvement (PCL) are a rare and sparsely investigated population. Recommended treatment regimens include a combination of intrathecal and systemic chemotherapy as well as whole brain radiotherapy while offering relatively poor survival. Methods We conducted a single-center retrospective study that analyzed safety and outcome of 4 + 4 cycles Rituximab (R)-CHOP and R-high-dose Methotrexate (HD-MTX) for newly diagnosed, transplant-eligible patients (“Ping-Pong”), followed by Cytarabine (AraC)/Thiotepa (TT), BCNU/TT, and autologous hematologic stem cell transplantation (aHSCT). We retrospectively analyzed a set of 16 patients with high–intermediate or high-risk IPI status. Results Overall response rate to Ping-Pong was 100% measured by CT/MRI, including 93.75% complete remissions after BCNU/TT followed by PBSCT. One patient failed to qualify for high-dose chemotherapy due to progression when receiving Cytarabine/TT. All patients experienced grade III adverse events, 3 of them a grade IV adverse event. Estimated progression-free survival is 93.75% after a 4.8-year follow-up currently. Conclusion Our study suggests high effectivity of R-CHOP with mid-cycle MTX with aHSCT consolidation towards acceptable OS results in this challenging patient population.
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Affiliation(s)
- Maximilian J Steinhardt
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany.,Department of Internal Medicine II, University Hospital Würzburg, Oberdürrbacher Street 6, 97080, Würzburg, Germany
| | - Franziska C Krummenast
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - Andreas Rosenwald
- Institut für Pathologie der Universität Würzburg, Universitätsklinikum Würzburg, Josef-Schneider-Straße 2, 97080, Würzburg, Germany
| | - Elena Gerhard-Hartmann
- Institut für Pathologie der Universität Würzburg, Universitätsklinikum Würzburg, Josef-Schneider-Straße 2, 97080, Würzburg, Germany
| | - Anke Heidemeier
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - Hermann Einsele
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - Max S Topp
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - Johannes Duell
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany.
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7
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Wu Y, Sun X, Bai X, Qian J, Zhu H, Cui Q, Xing R, Chen Y, Liu Q, Lai W, Li J, Wang Y, Sun S, Ji N, Liu Y. Treatment of secondary central nervous system involvement in systemic aggressive B cell lymphoma using R-MIADD chemotherapy: a single-center study. Chin Neurosurg J 2021; 7:20. [PMID: 33795020 PMCID: PMC8017776 DOI: 10.1186/s41016-021-00238-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 02/06/2021] [Indexed: 12/27/2022] Open
Abstract
Background Secondary central nervous system lymphoma (SCNSL) is defined as lymphoma involvement within the central nervous system (CNS) that originated elsewhere, or a CNS relapse of systemic lymphoma. Prognosis of SCNSL is poor and the most appropriate treatment is still undetermined. Methods We conducted a retrospective study to assess the feasibility of an R-MIADD (rituximab, high-dose methotrexate, ifosfamide, cytarabine, liposomal formulation of doxorubicin, and dexamethasone) regimen for SCNSL patients. Results Nineteen patients with newly diagnosed CNS lesions were selected, with a median age of 58 (range 20 to 72) years. Out of 19 patients, 11 (57.9%) achieved complete remission (CR) and 2 (10.5%) achieved partial remission (PR); the overall response rate was 68.4%. The median progression-free survival after CNS involvement was 28.0 months (95% confidence interval 11.0–44.9), and the median overall survival after CNS involvement was 34.5 months. Treatment-related death occurred in one patient (5.3%). Conclusions These single-centered data underscore the feasibility of an R-MIADD regimen as the induction therapy of SCNSL, further investigation is warranted.
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Affiliation(s)
- Yuchen Wu
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuefei Sun
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xueyan Bai
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jun Qian
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hong Zhu
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qu Cui
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ruixian Xing
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuedan Chen
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qing Liu
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wenyuan Lai
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Junhong Li
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yaming Wang
- Department of Neurosurgery, Beijing Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shengjun Sun
- Neuroimaging Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Nan Ji
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuanbo Liu
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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8
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Walburn T, Grover NS, Shen CJ, Ranganathan R, Dittus C, Beaven AW, Wang AZ, Wang K. Consolidative or palliative whole brain radiation for secondary CNS diffuse large B-Cell lymphoma. Leuk Lymphoma 2020; 62:68-75. [PMID: 32935601 DOI: 10.1080/10428194.2020.1821014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
We analyzed 25 patients receiving whole brain radiation (WBRT) for secondary CNS lymphoma (SCNSL), grouped by consolidative intent (after complete/partial response, n = 13) vs. palliative intent (initial CNS treatment, primary refractory disease, or CNS progression, n = 12). Median WBRT dose for the consolidative and palliative cohorts were 24 Gy and 30 Gy, respectively. For 13 patients receiving consolidative WBRT, median OS was 24 months from WBRT and 2-year OS was 64%. Three patients had CNS relapse at 2, 9, and 24 months after consolidative WBRT. For 12 patients receiving palliative WBRT, median OS was 3 months from WBRT and two-year OS was 8%. All 10 patients with neurologic symptoms had documented improvement. In conclusion, consolidative WBRT after chemotherapy response led to reasonable long-term survival and may be an effective strategy for SCNSL, especially transplant-ineligible patients and/or isolated CNS recurrence. Palliative WBRT effectively improved neurologic symptoms, but survival was usually only months.
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Affiliation(s)
- Tyler Walburn
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Natalie S Grover
- Department of Medicine, Division of Hematology, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Colette J Shen
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Raghuveer Ranganathan
- Department of Medicine, Division of Hematology, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Christopher Dittus
- Department of Medicine, Division of Hematology, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Anne W Beaven
- Department of Medicine, Division of Hematology, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Andrew Z Wang
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Kyle Wang
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, USA
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9
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Perry C, Ben Barouch S, Goldschmidt N, Sarid N, Herishanu Y, Shvidel L, Bairey O, Lavi N, Horowitz N, Avigdor A, Lebel E, Sofer O, Ram R, Avivi I. Characteristics, management and outcome of DLBCL patients, presenting with simultaneous systemic and CNS disease at diagnosis: A retrospective multicenter study. Am J Hematol 2019; 94:992-1001. [PMID: 31211434 DOI: 10.1002/ajh.25558] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 06/08/2019] [Accepted: 06/12/2019] [Indexed: 02/01/2023]
Abstract
The incidence of systemic diffuse large B cell lymphoma (DLBCL) concurrently involving the central nervous system (CNS) at diagnosis, is very low and data regarding the clinical course of these patients are scarce. We investigated characteristics, efficacy of treatment regimens including consolidative autologous stem cell transplantation and outcome of patients presenting with concomitant systemic and CNS DLBCL. The records of 44 patients, diagnosed between 2004 and 2017, who fulfilled the inclusion criteria, were retrospectively reviewed. CNS involvement was diagnosed as solely parenchymal in 41%, solely leptomeningeal in 43%, and paranchymal with leptomeningeal in 11% of the patients. Induction regimens were anthracycline-based combined with high-dose methotrexate (HD-MTX) in 80% (n = 35) of patients, anthracycline-based combined with intrathecal MTX in 3, cytarabine-based (without antracyclines) in 2, HD-MTX in 1 and palliative in three. Five of 41 patients treated with chemotherapy died of treatment-related toxicity, all due to infections. Nineteen patients had consolidative autologous transplantation. Overall response rate following induction was 80% (complete responses 66% and partial responses 15%). All relapses (n = 11) occurred within less than 2 years. Within a median follow-up of 26.8 months, 3-years projected overall survival (OS) and progression free survival rates for the entire cohort were 56% ± 8.3 and 42% ± 8.9, respectively. In multivariate analysis, RCHOP-HD MTX-based induction [HR = 0.228, (0.054-0.964)], administration of 3.5 g/m2 MTX [HR = 0.735 (0.620-0.871)], and attaining CR following induction [HR = 0.185, (0.051-0.667)] predicted longer OS. RCHOP-HD MTX can provide prolonged remissions in DLBCL patients presenting with concomitant systemic and CNS involvement whereas role of autograft remains uncertain.
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Affiliation(s)
- Chava Perry
- Sourasky Medical CenterInstitute of Hematology Tel‐Aviv Israel
- Sourasky Faculty of MedicineTel‐Aviv University Tel‐Aviv Israel
| | | | - Neta Goldschmidt
- Department of HematologyHadassah Medical Center Jerusalem Israel
| | - Nadav Sarid
- Sourasky Medical CenterInstitute of Hematology Tel‐Aviv Israel
- Sourasky Faculty of MedicineTel‐Aviv University Tel‐Aviv Israel
| | - Yair Herishanu
- Sourasky Medical CenterInstitute of Hematology Tel‐Aviv Israel
- Sourasky Faculty of MedicineTel‐Aviv University Tel‐Aviv Israel
| | - Lev Shvidel
- Department of HematologyKaplan Medical Centre Rehovot Israel
| | - Osnat Bairey
- Davidoff Cancer Center, Rabin Medical CenterInstitute of Hematology Petah‐Tikva Israel
| | - Noa Lavi
- Department of Hematology and Bone Marrow TransplantationRambam Health Care Campus Haifa Israel
| | - Netanel Horowitz
- Department of Hematology and Bone Marrow TransplantationRambam Health Care Campus Haifa Israel
| | - Avraham Avigdor
- Division of Hematology and Bone Marrow TransplantationChaim Sheba Medical Center Tel Hashomer Israel
| | - Eyal Lebel
- Department of HematologyHadassah Medical Center Jerusalem Israel
| | - Orit Sofer
- Hillel Yaffe Medical CenterInstitute of Hematology Hadera Israel
| | - Ron Ram
- Sourasky Medical CenterInstitute of Hematology Tel‐Aviv Israel
- Sourasky Faculty of MedicineTel‐Aviv University Tel‐Aviv Israel
| | - Irit Avivi
- Sourasky Medical CenterInstitute of Hematology Tel‐Aviv Israel
- Sourasky Faculty of MedicineTel‐Aviv University Tel‐Aviv Israel
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10
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Decker DP, Egan PC, Zayac AS, Treaba DO, Olszewski AJ. Treatment strategies and risk of central nervous system recurrence in high-grade B-cell and Burkitt lymphoma. Leuk Lymphoma 2019; 61:198-201. [PMID: 31432717 DOI: 10.1080/10428194.2019.1654097] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Dominic P Decker
- The Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Medicine, Rhode Island Hospital, Providence, RI, USA
| | - Pamela C Egan
- The Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Medicine, Rhode Island Hospital, Providence, RI, USA.,Division of Hematology-Oncology, Rhode Island Hospital, Providence, RI, USA
| | - Adam S Zayac
- The Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Medicine, Rhode Island Hospital, Providence, RI, USA.,Division of Hematology-Oncology, Rhode Island Hospital, Providence, RI, USA
| | - Diana O Treaba
- The Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Pathology, Rhode Island Hospital, Providence, RI, USA
| | - Adam J Olszewski
- The Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Medicine, Rhode Island Hospital, Providence, RI, USA.,Division of Hematology-Oncology, Rhode Island Hospital, Providence, RI, USA
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11
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Wight JC, Yue M, Keane C, Johnston A, Linton K, Chin C, Wai SH, Talaulikar D, Gasiorowski R, Cheah CY, Gregory GP, Dickinson M, Minson A, Coombes C, Ku M, Lam S, Hawkes EA. Outcomes of synchronous systemic and central nervous system (CNS) involvement of diffuse large B‐cell lymphoma are dictated by the CNS disease: a collaborative study of the Australasian Lymphoma Alliance. Br J Haematol 2019; 187:174-184. [DOI: 10.1111/bjh.16064] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 04/23/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Joel C. Wight
- Austin Health Heidelberg Victoria Australia
- Olivia Newton John Cancer Research Institute Heidelberg Victoria Australia
- The University of Melbourne Melbourne Victoria Australia
| | - Mimi Yue
- Princess Alexandra Hospital Brisbane Queensland Australia
- University of Queensland Brisbane Queensland Australia
| | - Colm Keane
- Princess Alexandra Hospital Brisbane Queensland Australia
- University of Queensland Brisbane Queensland Australia
| | - Anna Johnston
- The Christie NHS Foundation Trust Manchester UK
- Royal Hobart Hospital Hobart Australia
| | - Kim Linton
- The Christie NHS Foundation Trust Manchester UK
- The Manchester Cancer Research Centre Manchester UK
| | - Collin Chin
- Sir Charles Gardiner Hospital Perth Western Australia Australia
| | | | - Dipti Talaulikar
- Canberra Hospital Canberra Australian Capital Territory Australia
- Australian National University Medical School Canberra Australian Capital Territory Australia
| | - Robin Gasiorowski
- Concord Hospital Sydney New South Wales Australia
- University of Sydney Sydney New South Wales Australia
| | - Chan Yoon Cheah
- Sir Charles Gardiner Hospital Perth Western Australia Australia
- University of Western Australia Medical School Melbourne Victoria Australia
| | - Gareth P. Gregory
- Monash Health Clayton Victoria Australia
- School of Clinical Sciences at Monash Health Monash University Melbourne Victoria Australia
| | - Michael Dickinson
- Clinical Haematology Peter MacCallum Cancer Centre and Royal Melbourne Hospital Melbourne Victoria Australia
- The Sir Peter MacCallum Department of Oncology University of Melbourne Melbourne Victoria Australia
| | - Adrian Minson
- Clinical Haematology Peter MacCallum Cancer Centre and Royal Melbourne Hospital Melbourne Victoria Australia
| | - Caitlin Coombes
- Canberra Hospital Canberra Australian Capital Territory Australia
| | - Matthew Ku
- St Vincent’s Hospital Melbourne Melbourne Victoria Australia
| | - Stephanie Lam
- Royal Perth Hospital Perth Western Australia Australia
| | - Eliza A. Hawkes
- Austin Health Heidelberg Victoria Australia
- Olivia Newton John Cancer Research Institute Heidelberg Victoria Australia
- The University of Melbourne Melbourne Victoria Australia
- La Trobe University Melbourne Victoria Australia
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12
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Yamashita A, Tokuda M, Matsuo M, Irie J, Tateishi Y, Mutsukura K. [A case of secondary central nervous system lymphoma presenting marked hypoglycorrhachia]. Rinsho Shinkeigaku 2019; 59:365-370. [PMID: 31142712 DOI: 10.5692/clinicalneurol.cn-001284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 67-year-old male was transferred to our hospital with diplopia, decreased deep tendon reflex and ataxia. He had been suspected Fisher syndrome because of previous upper respiratory tract infection. A cerebrospinal fluid examination showed marked hypoglycorrhachia, pleocytosis and elevated protein, and cytological examination suggested malignant lymphoma. Abdominal computed tomography revealed a left adrenal mass. A biopsy of the left adrenal mass revealed diffuse large B-cell lymphoma. He was treated with a combination of R-CHOP (rituximab, cyclophosphamide, doxorubicin hydrochloride, oncovin and prednisolone) and intrathecal administration of methotrexate, cytarabine and prednisolone. Neurological symptoms were gradually improved. Malignancy should be considered in addition to bacterial, fungal or tuberculous meningitis in a case with marked hypoglycorrhachia.
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Affiliation(s)
- Aya Yamashita
- Department of Neurology, Nagasaki Harbor Medical Center
| | | | | | - Junji Irie
- Department of Pathology, Nagasaki Harbor Medical Center
| | - Yohei Tateishi
- Department of Neurology and Strokology, Nagasaki University Hospital
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13
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Wight JC, Chong G, Grigg AP, Hawkes EA. Prognostication of diffuse large B-cell lymphoma in the molecular era: moving beyond the IPI. Blood Rev 2018; 32:400-415. [PMID: 29605154 DOI: 10.1016/j.blre.2018.03.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 03/21/2018] [Accepted: 03/22/2018] [Indexed: 12/21/2022]
Abstract
Diffuse large B-cell lymphoma (DLBCL) is a heterogeneous disease with variable outcomes. Despite the majority of patients being cured with combination chemoimmunotherapy, up to 30% eventually succumb to the disease. Until recently, baseline prognostic assessment has centred on the International Prognostic Index (IPI), although this index is yet to impact strongly on treatment choice. Molecular features such as cell of origin, MYC and BCL-2 genetic alterations and protein overexpression were identified over a decade ago, yet their prognostic value is still not fully elucidated. Adding complexity are the plethora of new clinical, biological and molecular prognostic markers described in the recent literature, most of which lack independent validation, likely act as surrogate markers for those already in common use and have yet to substantially impact on therapeutic decision making. This review comprehensively assesses the value of individual prognostic markers in the clinical setting and their potential to predict response to novel agents, and ways to optimise their use in future research.
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Affiliation(s)
- Joel C Wight
- Olivia Newton John Cancer Research and Wellness Centre, Austin Health, Heidelberg, Australia.
| | - Geoffrey Chong
- Olivia Newton John Cancer Research and Wellness Centre, Austin Health, Heidelberg, Australia.
| | - Andrew P Grigg
- Olivia Newton John Cancer Research and Wellness Centre, Austin Health, Heidelberg, Australia; University of Melbourne, Melbourne, Australia.
| | - Eliza A Hawkes
- Olivia Newton John Cancer Research and Wellness Centre, Austin Health, Heidelberg, Australia; University of Melbourne, Melbourne, Australia; Eastern Health, Box Hill, Australia.
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14
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El-Galaly TC, Cheah CY, Bendtsen MD, Nowakowski GS, Kansara R, Savage KJ, Connors JM, Sehn LH, Goldschmidt N, Shaulov A, Farooq U, Link BK, Ferreri AJM, Calimeri T, Cecchetti C, Dann EJ, Thompson CA, Inbar T, Maurer MJ, Gade IL, Juul MB, Hansen JW, Holmberg S, Larsen TS, Cordua S, Mikhaeel NG, Hutchings M, Seymour JF, Clausen MR, Smith D, Opat S, Gilbertson M, Thanarajasingam G, Villa D. Treatment strategies, outcomes and prognostic factors in 291 patients with secondary CNS involvement by diffuse large B-cell lymphoma. Eur J Cancer 2018; 93:57-68. [PMID: 29477102 DOI: 10.1016/j.ejca.2018.01.073] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 12/24/2017] [Accepted: 01/09/2018] [Indexed: 12/17/2022]
Abstract
PURPOSE Secondary CNS involvement (SCNS) is a profoundly adverse complication of diffuse large B-cell lymphoma. Evidence from older series indicated a median overall survival (OS) < 6 months; however, data from the immunochemotherapy era are limited. METHODS Patients diagnosed with SCNS during or after first-line immunochemotherapy were identified from databases and/or regional/national registries from three continents. Clinical information was retrospectively collected from medical records. RESULTS In total, 291 patients with SCNS were included. SCNS occurred as part of first relapse in 254 (87%) patients and 113 (39%) had concurrent systemic relapse. With a median post-SCNS follow-up of 48 months, the median post-SCNS OS was 3.9 months and 2-year OS rate was 20% (95% CI: 15-25). In multivariable analysis of 173 patients treated with curative/intensive therapy (such as high-dose methotrexate [HDMTX] or platinum-containing regimens), age ≤60 years, performance status 0-1, absence of combined leptomeningeal and parenchymal involvement, and SCNS occurring after completion of first-line therapy were associated with superior outcomes. Patients ≤60 years with performance status 0-1 and treated with HDMTX-based regimens for isolated parenchymal SCNS had a 2-year OS of 62% (95% CI: 36-80). In patients with isolated SCNS, the addition of rituximab to HDMTX-based regimens was associated with improved OS. Amongst patients with isolated SCNS in CR following intensive treatment, high-dose chemotherapy and autologous stem cell transplantation did not improve OS (P = 0.9). CONCLUSIONS In this large international cohort of patients treated with first-line immunochemotherapy, outcomes following SCNS remain poor. However, a moderate proportion of patients with isolated SCNS who received intensive therapies achieved durable remissions.
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Affiliation(s)
| | - Chan Yoon Cheah
- Department of Haematology, Sir Charles Gairdner Hospital, Perth, Australia
| | | | | | - Roopesh Kansara
- Section of Medical Oncology and Hematology, Cancer Care Manitoba, Department of Internal Medicine, University of Manitoba, Winnipeg, Canada; Division of Medical Oncology and Centre for Lymphoid Cancer, British Columbia Cancer Agency, Vancouver, BC, Canada
| | - Kerry J Savage
- Division of Medical Oncology and Centre for Lymphoid Cancer, British Columbia Cancer Agency, Vancouver, BC, Canada
| | - Joseph M Connors
- Division of Medical Oncology and Centre for Lymphoid Cancer, British Columbia Cancer Agency, Vancouver, BC, Canada
| | - Laurie H Sehn
- Division of Medical Oncology and Centre for Lymphoid Cancer, British Columbia Cancer Agency, Vancouver, BC, Canada
| | - Neta Goldschmidt
- Hematology Department, Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
| | - Adir Shaulov
- Hematology Department, Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
| | - Umar Farooq
- Division of Hematology, Oncology, Blood & Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Brian K Link
- Division of Hematology, Oncology, Blood & Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Andrés J M Ferreri
- Unit of Lymphoid Malignancies, Department of OncoHematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Teresa Calimeri
- Unit of Lymphoid Malignancies, Department of OncoHematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Caterina Cecchetti
- Unit of Lymphoid Malignancies, Department of OncoHematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Eldad J Dann
- Rambam Health Care Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | | | | | - Matthew J Maurer
- Department of Health Sciences Research, Mayo Clinic, Rochester, USA
| | - Inger Lise Gade
- Department of Hematology, Aalborg University Hospital, Aalborg, Denmark
| | - Maja Bech Juul
- Department of Hematology, Vejle Hospital, Vejle, Denmark
| | - Jakob W Hansen
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Staffan Holmberg
- Department of Hematology, Herlev Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Sabrina Cordua
- Department of Hematology, Zealand University Hospital, Denmark
| | - N George Mikhaeel
- Department of Clinical Oncology, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - Martin Hutchings
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | - Daniel Smith
- Department of Clinical Oncology, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - Stephen Opat
- Monash Health and Monash University, Melbourne, Australia
| | | | | | - Diego Villa
- Division of Medical Oncology and Centre for Lymphoid Cancer, British Columbia Cancer Agency, Vancouver, BC, Canada
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15
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Waldera-Lupa DM, Etemad-Parishanzadeh O, Brocksieper M, Kirchgaessler N, Seidel S, Kowalski T, Montesinos-Rongen M, Deckert M, Schlegel U, Stühler K. Proteomic changes in cerebrospinal fluid from primary central nervous system lymphoma patients are associated with protein ectodomain shedding. Oncotarget 2017; 8:110118-110132. [PMID: 29299134 PMCID: PMC5746369 DOI: 10.18632/oncotarget.22654] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 10/27/2017] [Indexed: 01/01/2023] Open
Abstract
Primary central nervous system lymphomas (PCNSLs) are mature B-cell lymphomas confined to the central nervous system (CNS). Blood-brain barrier (BBB) dysfunction drastically alters the cerebrospinal fluid (CSF) proteome in PCNSL patients. To reveal the interaction of PCNSL tumors with CNS structures and the vasculature, we conducted a whole-proteome analysis of CSF from PCNSL patients (n = 17 at initial diagnosis) and tumor-free controls (n = 10) using label-free quantitative mass spectrometry. We identified 601 proteins in the CSF proteome using a one-step approach without further prefractionation, and quantified 438 proteins in detail using the Hi-N method. An immunoassay revealed that 70% of the patients in our unselected PCNSL patient cohort had BBB dysfunction. Correlation analysis indicated that 127 (30%) of the quantified proteins were likely increased in PCSNL patients due to BBB dysfunction. After the exclusion of these proteins, 66 were found to differ in abundance (fold-change > 2.0, p < 0.05) between PCNSL and control CSF proteomes, and most of those were associated with the CNS. These data also provide the first evidence that proteomic changes in CSF from PCNSL patients are mainly associated with protein ectodomain shedding, and that shedding of human leukocyte antigen class 2 proteins is a mechanism of tumor-cell immune evasion.
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Affiliation(s)
- Daniel Michael Waldera-Lupa
- Molecular Proteomics Laboratory, Institute of Molecular Medicine, Universitaetsklinikum Düsseldorf, Düsseldorf, Germany
| | - Omid Etemad-Parishanzadeh
- Molecular Proteomics Laboratory, Institute of Molecular Medicine, Universitaetsklinikum Düsseldorf, Düsseldorf, Germany
| | - Mareike Brocksieper
- Molecular Proteomics Laboratory, Institute of Molecular Medicine, Universitaetsklinikum Düsseldorf, Düsseldorf, Germany
| | - Nina Kirchgaessler
- Molecular Proteomics Laboratory, Institute of Molecular Medicine, Universitaetsklinikum Düsseldorf, Düsseldorf, Germany
| | - Sabine Seidel
- Department of Neurology, Knappschaftskrankenhaus, Ruhr-University Bochum, Bochum, Germany
| | - Thomas Kowalski
- Department of Neurology, Knappschaftskrankenhaus, Ruhr-University Bochum, Bochum, Germany
| | | | - Martina Deckert
- Institute of Neuropathology, University of Cologne, Cologne, Germany
| | - Uwe Schlegel
- Department of Neurology, Knappschaftskrankenhaus, Ruhr-University Bochum, Bochum, Germany
| | - Kai Stühler
- Molecular Proteomics Laboratory, Institute of Molecular Medicine, Universitaetsklinikum Düsseldorf, Düsseldorf, Germany.,Biologisch-Medizinisches Forschungszentrum, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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16
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Barraclough AA, Cheah CY. Three different hematologists, three different answers: how should we treat concurrent systemic and central nervous system lymphoma? Leuk Lymphoma 2017; 58:1-3. [DOI: 10.1080/10428194.2017.1307364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Allison A. Barraclough
- Department of Haematology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Chan Yoon Cheah
- Department of Haematology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
- The Medical School, University of Western Australia, Crawley, Western Australia, Australia
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