1
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Du S, Fu DB, A Bota D, Kong XT. Prolonged remission with ibrutinib maintenance therapy following radiation in a patient with relapsed primary CNS lymphoma. CNS Oncol 2024; 13:2345579. [PMID: 38722227 PMCID: PMC11137789 DOI: 10.1080/20450907.2024.2345579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 04/17/2024] [Indexed: 06/01/2024] Open
Abstract
Background: Treatment for refractory or relapsed primary CNS lymphoma (r/r PCNSL) is challenging. Salvage whole-brain radiation therapy (WBRT) is an option but has a short duration of disease control, so additional treatment modalities are warranted. Case: A 75-year-old female with r/r PCNSL who had multiple progressions after multiple lines of treatment underwent salvage WBRT. The patient received ibrutinib, a Bruton's tyrosine kinase inhibitor, as maintenance therapy for 18 months following WBRT with the intention of increasing survival duration after salvage WBRT. She survived 81 months from diagnosis, including 57 months after completion of WBRT. Conclusion: This case presentation describes the experience of using ibrutinib as maintenance therapy in treating r/r PCNSL after salvage WBRT.
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Affiliation(s)
- Steven Du
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA19104, USA
- Department of Neurology, University of California Irvine, Irvine, CA92868, USA
| | - Dan Beverly Fu
- Department of Neurology, University of California Irvine, Irvine, CA92868, USA
| | - Daniela A Bota
- Department of Neurology, University of California Irvine, Irvine, CA92868, USA
- Department of Neurological Surgery, University of California Irvine, Irvine, CA92868, USA
| | - Xiao-Tang Kong
- Department of Neurology, University of California Irvine, Irvine, CA92868, USA
- Department of Neurological Surgery, University of California Irvine, Irvine, CA92868, USA
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2
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Liu Z, Zhuang J, Wei L, Lu A, Hou J, Yang X. A Systematic Review of Cognitive Function, Anxiety, and Depression in Patients With Newly Diagnosed Primary Central Nervous System Lymphoma. Biol Res Nurs 2024; 26:56-67. [PMID: 37540088 DOI: 10.1177/10998004231190073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
OBJECTIVE To retrospectively analyze the effects of different treatments on cognitive functioning, anxiety, and depression in patients with primary central nervous system lymphoma (PCNSL). METHODS A comprehensive literature search was conducted in multiple databases including the Cochrane Library, CINAHL, PubMed, Web of Science, EMBASE, Sino Med, Wei Pu, Wan Fang, CNKI, and Google Scholar. The search included studies published through June 20, 2023, focusing on cognitive function, anxiety, and depression in adult patients newly diagnosed with PCNSL. Various measurement tools and scales were used to assess the primary outcomes. Descriptive systematic reviews were conducted to integrate the literature and summarize the effects of different treatment modalities on cognitive functioning, anxiety, and depression in PCNSL patients. This review was registered with PROSPERO (CRD42022370250). RESULTS A total of 43 studies were included. Induction chemotherapy was associated with improved cognitive function and reduced anxiety and depression in the majority of patients. Whole-brain radiotherapy (WBRT) was found to lead to cognitive impairment, particularly in executive, attention, memory, and motor function. Low-dose WBRT, autologous stem cell transplantation (ASCT), and blood-brain barrier disruption (BBBD) treatments did not result in significant cognitive impairment. Anxiety and depression were observed to decrease over the long term. CONCLUSIONS Overall, the cognitive functioning, anxiety, and depression of patients with PCNSL can be improved with appropriate treatments. However, patients treated with WBRT are at a higher risk of cognitive decline compared to those receiving other treatment modalities. Therefore, special attention should be given to patients undergoing WBRT, and a comprehensive analysis should be conducted to reduce neurotoxicity and address early cognitive problems in these patients.
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Affiliation(s)
- Ziyu Liu
- School of Nursing, Fudan University, Shanghai, China
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jingming Zhuang
- Department of Urology, School of Medicine, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Li Wei
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai, China
| | - Aiwen Lu
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jiangang Hou
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaoli Yang
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai, China
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3
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Miyao K, Yokota H, Sakemura RL. Is CD19-directed chimeric antigen receptor T cell therapy a smart strategy to combat central nervous system lymphoma? Front Oncol 2023; 12:1082235. [PMID: 36686821 PMCID: PMC9850100 DOI: 10.3389/fonc.2022.1082235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 12/02/2022] [Indexed: 01/07/2023] Open
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare form and aggressive type of diffuse large B-cell lymphoma (DLBCL) that occurs in both immunocompetent and immunocompromised adults. While adding rituximab to chemotherapeutic regimens resulted in dramatic improvement in both progression-free survival and overall survival in patients with non-central nervous system (CNS) DLBCL, the outcomes of PCNSL are generally poor due to the immune-privileged tumor microenvironment or suboptimal delivery of systemic agents into tumor tissues. Therefore, more effective therapy for PCNSL generally requires systemic therapy with sufficient CNS penetration, including high-dose intravenous methotrexate with rituximab or high-dose chemotherapy followed by autologous stem cell transplantation. However, overall survival is usually inferior in comparison to non-CNS lymphomas, and treatment options are limited for elderly patients or patients with relapsed/refractory disease. Chimeric antigen receptor T (CAR-T) cell therapy has emerged as a cutting-edge cancer therapy, which led to recent FDA approvals for patients with B-cell malignancies and multiple myeloma. Although CAR-T cell therapy in patients with PCNSL demonstrated promising results without significant toxicities in some small cohorts, most cases of PCNSL are excluded from the pivotal CAR-T cell trials due to the concerns of neurotoxicity after CAR-T cell infusion. In this review, we will provide an overview of PCNSL and highlight current approaches, resistance mechanisms, and future perspectives of CAR-T cell therapy in patients with PCNSL.
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Affiliation(s)
- Kotaro Miyao
- Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan
| | - Hirofumi Yokota
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - R. Leo Sakemura
- T Cell Engineering, Mayo Clinic, Rochester, MN, United States,Division of Hematology, Mayo Clinic, Rochester, MN, United States,*Correspondence: R. Leo Sakemura,
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4
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Hoang-Xuan K, Deckert M, Ferreri AJM, Furtner J, Gallego Perez-Larraya J, Henriksson R, Hottinger AF, Kasenda B, Lefranc F, Lossos A, McBain C, Preusser M, Roth P, Rudà R, Schlegel U, Soffietti R, Soussain C, Taphoorn MJB, Touitou V, Weller M, Bromberg JEC. European Association of Neuro-Oncology (EANO) guidelines for treatment of primary central nervous system lymphoma (PCNSL). Neuro Oncol 2023; 25:37-53. [PMID: 35953526 PMCID: PMC9825335 DOI: 10.1093/neuonc/noac196] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Indexed: 01/12/2023] Open
Abstract
The management of primary central nervous system (PCNSL) is one of the most controversial topics in neuro-oncology because of the complexity of the disease and the limited number of controlled studies available. In 2021, given recent advances and the publication of practice-changing randomized trials, the European Association of Neuro-Oncology (EANO) created a multidisciplinary task force to update the previously published evidence-based guidelines for immunocompetent adult patients with PCNSL and added a section on immunosuppressed patients. The guideline provides consensus considerations and recommendations for the treatment of PCNSL, including intraocular manifestations and specific management of the elderly. The main changes from the previous guideline include strengthened evidence for the consolidation with ASCT in first-line treatment, prospectively assessed chemotherapy combinations for both young and elderly patients, clarification of the role of rituximab even though the data remain inconclusive, of the role of new agents, and the incorporation of immunosuppressed patients and primary ocular lymphoma. The guideline should aid the clinicians in everyday practice and decision making and serve as a basis for future research in the field.
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Affiliation(s)
- Khê Hoang-Xuan
- APHP, Department of Neurology, Groupe Hospitalier Pitié-Salpêtrière; Sorbonne Université; IHU; ICM. Paris, France
| | - Martina Deckert
- Institute of Neuropathology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | | | - Julia Furtner
- Department of Biomedical and Imaging Image-guided Therapy Medical University of Vienna, Vienna, Austria
| | - Jaime Gallego Perez-Larraya
- Health Research Institute of Navarra (IdiSNA), Program in Solid Tumors, Foundation for the Applied Medical Research, Department of Neurology, Clinica Universidad de Navarra, Pamplona, Navarra, Spain
| | - Roger Henriksson
- Department of Radiation Sciences, Oncology, University of Umeå, S-901 85 Umea, Sweden
| | - Andreas F Hottinger
- Department of Oncology and Clinical Neurosciences, CHUV University Hospital Lausanne and University of Lausanne, LausanneSwitzerland
| | - Benjamin Kasenda
- Department of Hematology/Oncology and Palliative Care, Klinikum Stuttgart, Stuttgart, Germany
| | - Florence Lefranc
- Department of Neurosurgery, Hôpital Erasme, Université Libre de Bruxelles, Belgium
| | - Alexander Lossos
- Head, Leslie and Michael Gaffin Center for Neuro-Oncology; Department of Oncology and Neurology; Hadassah-Hebrew University Medical Center; Jerusalem, Israel
| | - Catherine McBain
- Department of Clinical Oncology, The Christie NHS FT; Manchester; United Kingdom
| | - Matthias Preusser
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna,Austria
| | - Patrick Roth
- Department of Neurology & Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Roberta Rudà
- Department of Neurology, Castelfranco Veneto/Treviso Hospital, Italy
- Division of Neuro-Oncology, Department of Neuroscience, University of Turin, and City of Health and Science University Hospital, Turin, Italy
| | - Uwe Schlegel
- Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Germany
| | - Riccardo Soffietti
- Division of Neuro-Oncology, Department of Neuroscience, University of Turin, and City of Health and Science University Hospital, Turin, Italy
| | - Carole Soussain
- Department of Hematology, Institut Curie, Site Saint-Cloud, France and INSERM U932 Institut Curie, PSL Research University, Paris, France
| | - Martin J B Taphoorn
- Department of Neurology, Leiden University Medical Center and Department of Neurology, Haaglanden Medical Center The Hague, The Netherlands
| | - Valérie Touitou
- APHP, Department of Ophtalmology, Groupe Hospitalier Pitié-Salpêtrière; Sorbonne Université. Paris, France
| | - Michael Weller
- Department of Neurology & Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Jacoline E C Bromberg
- Department of Neuro-Oncology, Erasmus MC University Medical Center Cancer Institute, Rotterdam. The Netherlands
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5
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Liu J, Guo J, Sun X, Liu Y, Gao C. Efficacy and Safety of Autologous Stem-Cell Transplantation as Part of First-Line Treatment for Newly Diagnosed Primary Central Nervous System Lymphoma: A Systematic Review and Meta-Analysis. Front Oncol 2022; 11:799721. [PMID: 35096600 PMCID: PMC8790123 DOI: 10.3389/fonc.2021.799721] [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: 10/22/2021] [Accepted: 12/14/2021] [Indexed: 11/23/2022] Open
Abstract
Objective The reviewed literature supports a treatment regimen for primary central nervous system lymphoma (PCNSL) that includes induction chemotherapy, followed by one consolidation therapy. High-dose chemotherapy supported by autologous stem-cell transplantation (ASCT) is the most studied option, but its effects are controversial. The aim of this study was to evaluate the efficacy and safety of ASCT for newly diagnosed PCNSL by means of a meta-analysis. Methods The PubMed, Embase, and Cochrane Library databases were systematically searched for studies published until May 20, 2021. Included studies were prospective studies of patients with newly diagnosed PCNSL treated with ASCT. The pooled rates and 95% confidence intervals (CIs) were determined for all outcomes. Subgroup analysis was conducted to compare the relative risk (RR) with 95% CIs for the complete remission (CR) rate and the hazard ratios (HRs) with 95% CIs for progression-free survival (PFS) and overall survival (OS). Results Thirteen prospective studies including 348 patients were analyzed. The pooled CR rate, overall response rate, and relapse rate were 80% (95% CI, 71–88%, I2 = 67.06%, p = 0.00), 95% (95% CI, 87–100%, I2 = 73.65%, p= 0.00), and 19% (95% CI, 15–24%, I2 = 76.18%, p = 0.00), respectively. The pooled 2- and 5-year PFS and OS rates were 74% (95% CI, 68–80%, I2 = 3.90%), 65% (95% CI, 51–77%, I2 = 74.61%), 80% (95% CI, 72–88%, I2 = 57.54%), and 69% (95% CI, 53–83%, I2 = 83.89%), respectively. Hematological toxicity and infections were more common adverse events above grade 3. The pooled treatment-related mortality was 3% (95% CI, 1–6%, I2 = 28.18%, p = 0.16). In the group analysis of ASCT compared with whole-brain radiotherapy, there were no significant differences in the CR rate (RR, 1.00, 95% CI, 0.88–1.14, p = 0.971), relapse rate (RR, 0.44, 95% CI, 0.06–3.10, p = 0.408), PFS (HR, 1.28, 95% CI, 0.81–2.01, p = 0.29), or OS (HR, 1.62, 95% CI, 0.97–2.69, p = 0.06). Cognitive functions were preserved or improved after ASCT. Conclusions ASCT is a feasible approach for consolidation with good tolerability for newly diagnosed PCNSL patients. High-quality randomized controlled trials are still needed to confirm the effects of ASCT. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier CRD42021268422.
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Affiliation(s)
- Jing Liu
- Senior Department of Hematology, The Fifth Medical Center of People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Jiayuan Guo
- School of Medicine, Nankai University, Tianjin, China
| | - Xuefei Sun
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuanbo Liu
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chunji Gao
- Senior Department of Hematology, The Fifth Medical Center of People's Liberation Army (PLA) General Hospital, Beijing, China
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6
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Partanen A, Kuittinen O, Turunen A, Valtola J, Pyorala M, Kuitunen H, Vasala K, Kuittinen T, Mantymaa P, Pelkonen J, Jantunen E, Varmavuo V. Blood Graft and Outcome After Autologous Stem Cell Transplantation in Patients With Primary Central Nervous System Lymphoma. J Hematol 2022; 10:246-254. [PMID: 35059086 PMCID: PMC8734492 DOI: 10.14740/jh939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 11/30/2021] [Indexed: 11/22/2022] Open
Abstract
Background Autologous stem cell transplantation (auto-SCT) is a treatment option for patients with primary central nervous system lymphoma (PCNSL). Methods In this prospective multicenter study, the effects of blood graft cellular content on hematologic recovery and outcome were analyzed in 17 PCNSL patients receiving auto-SCT upfront. Results The infused viable CD34+ cell count > 1.7 × 106/kg correlated with more rapid platelet engraftment (10 vs. 31 days, P = 0.027) and with early neutrophil recovery (day + 15) (5.4 vs. 1.6 × 109/L, P = 0.047). A higher number of total collected CD34+ cells > 3.3 × 106/kg infused predicted worse 5-year progression-free survival (PFS) (33% vs. 100%, P = 0.028). In addition, CD3+CD8+ T cells > 78 × 106/kg in the infused graft impacted negatively on the 5-year PFS (0% vs. 88%, P = 0.016). Conclusion The cellular composition of infused graft seems to impact on the hematologic recovery and PFS post-transplant. Further studies are needed to verify the optimal autograft cellular content in PCNSL.
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Affiliation(s)
- Anu Partanen
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Outi Kuittinen
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.,Department of Oncology, Kuopio University Hospital, Kuopio, Finland.,Department of Oncology, Oulu University Hospital, Oulu, Finland
| | - Antti Turunen
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Jaakko Valtola
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Marja Pyorala
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Hanne Kuitunen
- Department of Oncology, Oulu University Hospital, Oulu, Finland
| | - Kaija Vasala
- Department of Oncology, Central Hospital of Central Finland, Jyvaskyla, Finland
| | - Taru Kuittinen
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | | | - Jukka Pelkonen
- Eastern Finland Laboratory Centre, Kuopio, Finland.,Department of Clinical Microbiology, University of Eastern Finland, Kuopio, Finland
| | - Esa Jantunen
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland.,Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.,Department of Medicine, North Karelia Hospital District, Joensuu, Finland
| | - Ville Varmavuo
- Department of Medicine, Kymenlaakso Central Hospital, Kotka, Finland
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7
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Keane C, Hamad N, Barraclough A, Lee YY, Talaulikar D, Ku M, Wight J, Tatarczuch M, Swain F, Gregory GP. Diagnosis and management of primary central nervous system lymphoma: a Consensus Practice Statement from the Australasian Lymphoma Alliance. Intern Med J 2021; 52:1624-1632. [PMID: 34927329 DOI: 10.1111/imj.15658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 10/24/2021] [Accepted: 12/05/2021] [Indexed: 11/28/2022]
Abstract
Primary central nervous system lymphoma is a clinicopathological disease entity that accounts for 1 % of all non-Hodgkin lymphoma (NHL). Advanced patient age, adverse disease biology and complexities of diagnosis and treatment render outcomes markedly inferior to systemic NHL. Despite this, an increasing evidence base including limited randomised controlled clinical trial data is informing optimal therapeutic strategies with methotrexate-based induction chemotherapy schedules and intensified consolidation in selected patients. This practice statement represents an evidence-based review of the literature and has been devised to assist healthcare professionals in the diagnosis and management of this disease. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- C Keane
- Division of Cancer Services, Princess Alexandra Hospital, Brisbane, Australia.,University of Queensland, Brisbane, Australia
| | - N Hamad
- Department of Haematology, St Vincent's Hospital Sydney, Australia.,School of Medicine, Sydney, University of Notre Dame, Australia.,St Vincent's Clinical School, Sydney, University of New South, UK
| | - A Barraclough
- Department of Haematology, Fiona Stanley Hospital, Western Australia, Australia
| | - Y Y Lee
- Radiation Oncology, Division of Cancer Services, Princess Alexandra Hospital, Queensland, Australia
| | - D Talaulikar
- Department of Haematology, Canberra Hospital, ACT, Australia
| | - M Ku
- Department of Clinical Haematology, St Vincent's Hospital Melbourne, Fitzroy, Australia.,University of Melbourne, Victoria, Australia
| | - J Wight
- Department of Haematology, Townsville Hospital, Australia
| | - M Tatarczuch
- Monash Haematology, Monash Health, Clayton, Australia.,School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia
| | - F Swain
- Division of Cancer Services, Princess Alexandra Hospital, Australia
| | - G P Gregory
- Monash Haematology, Monash Health, Clayton, Australia.,School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia
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8
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Ibrutinib Monotherapy as Bridge-to-Transplant for Relapsed/Refractory Primary Oculo-Cerebral Lymphoma. J Clin Med 2021; 10:jcm10194483. [PMID: 34640501 PMCID: PMC8509719 DOI: 10.3390/jcm10194483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 09/24/2021] [Accepted: 09/27/2021] [Indexed: 12/21/2022] Open
Abstract
Introduction. Primary central nervous system lymphoma is an uncommon form of extranodal non-Hodgkin’s lymphoma, with increasing incidence, a relatively aggressive course and a poor 5-year survival. Because of its localization, the therapeutic compounds used in this disease must be able to pass through the blood-brain barrier. Chemotherapy regimens based on high-dose methotrexate are currently the standard of care for all patients who can tolerate such drugs. Autologous stem cell transplantation is indicated for malignant lymphomas in the relapsed/refractory setting. Methods. Three patients, with a median age of 60 years, range 53–64, were diagnosed with primary CNS lymphoma, and treated with ibrutinib monotherapy in the Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj-Napoca, Romania, between September 2018 and November 2020 All the patients were relapsed–refractory following high-dose methotrexate chemotherapy. We present our experience using ibrutinib monotherapy-based treatment as a bridge-to-transplant option on a single-center case series and a review of the literature in this field. Results. Two of the patients were given ibrutinib as a second line therapy, both achieving complete remission and being eligible for an autologous stem cell transplantation. The third patient achieved a short remission using six cycles of systemic chemotherapy, but was started on ibrutinib monotherapy, with limited results. Conclusion. Our data is limited, and these results should be confirmed by multicentric clinical trials and should be regarded as a single-center case series, with all its limitations. Still, it brings forward a new therapeutic option for this rare subtype of malignant lymphomas, which if left untreated has a dismal prognosis.
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9
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Young PA, Gaut D, Kimaiyo DK, Grotts J, Romero T, Chute J, Schiller G, de Vos S, Eradat HA, Timmerman J. Durable Survival Outcomes in Primary and Secondary Central Nervous System Lymphoma After High-dose Chemotherapy and Autologous Stem Cell Transplantation Using a Thiotepa, Busulfan, and Cyclophosphamide Conditioning Regimen. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2020; 20:468-479. [PMID: 32229199 PMCID: PMC7138188 DOI: 10.1016/j.clml.2020.02.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/31/2020] [Accepted: 02/09/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND High-dose chemotherapy (HDC) with autologous stem cell transplantation (ASCT) has been investigated in patients with primary central nervous system lymphoma (PCNSL) and non-Hodgkin lymphoma (NHL) with CNS involvement and has shown promising results. PATIENTS AND METHODS A retrospective analysis was performed of 48 consecutive patients who had undergone HDC/ASCT with TBC (thiotepa, busulfan, cyclophosphamide) conditioning for PCNSL (27 patients), secondary CNS lymphoma (SCNSL) (8 patients), or relapsed disease with CNS involvement (13 patients) from July 2006 to December 2017. Of the 27 patients with PCNSL, 21 had undergone ASCT at first complete remission (CR1). RESULTS The 2-year progression-free survival (PFS) rate was 80.5% (95% confidence interval [CI], 69.9-92.9) and the 2-year overall survival (OS) rate was 80.1% (95% CI, 69.2%-92.7%) among all patients. The 2-year PFS and OS rate for patients with PCNSL in CR1 was 95.2% (95% CI, 86.6%-100%) and 95.2% (95% CI, 86.6%-100%), respectively. On univariate analysis of the patients with PCNSL, ASCT in CR1 was the only variable statistically significant for outcome (P = .007 for PFS; P = .008 for OS). Among patients with SCNSL or CNS relapse, the 2-year PFS and OS rate were comparable at 75.9% (95% CI, 59.5%-96.8%) and 75.3% (95% CI, 58.6%-98.6%), respectively. The most common side effects were febrile neutropenia (89.6%; of which 66.7% had an infectious etiology identified), nausea/vomiting (85.4%), diarrhea (93.8%), mucositis (89.6%), and electrolyte abnormalities (89.6%). Four patients (8.3%) died of treatment-related overwhelming infection; of these patients, 3 had SCNSL. CONCLUSION HDC and ASCT using TBC conditioning for both PCNSL and secondary CNS NHL appears to have encouraging long-term efficacy with manageable side effects.
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Affiliation(s)
- Patricia A Young
- Division of Hematology and Oncology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.
| | - Daria Gaut
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Davis K Kimaiyo
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Jonathan Grotts
- Division of General Internal Medicine and Health Services Research, Department of Medicine Statistics Core, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Tahmineh Romero
- Division of General Internal Medicine and Health Services Research, Department of Medicine Statistics Core, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - John Chute
- Division of Hematology and Oncology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Gary Schiller
- Division of Hematology and Oncology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Sven de Vos
- Division of Hematology and Oncology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Herbert A Eradat
- Division of Hematology and Oncology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - John Timmerman
- Division of Hematology and Oncology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
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10
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Autologous Stem Cell Transplantation in Central Nervous System Lymphoma: A Multicenter Retrospective Series and a Review of the Literature. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 19:e273-e280. [DOI: 10.1016/j.clml.2019.02.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 01/15/2019] [Accepted: 02/15/2019] [Indexed: 11/23/2022]
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11
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Gaut D, Schiller GJ. Hematopoietic stem cell transplantation in primary central nervous system lymphoma: a review of the literature. Int J Hematol 2019; 109:260-277. [PMID: 30671909 DOI: 10.1007/s12185-019-02594-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 12/14/2018] [Accepted: 01/08/2019] [Indexed: 12/26/2022]
Abstract
Primary central nervous system lymphoma (PCNSL) is an uncommon variant of extranodal non-Hodgkin lymphoma (NHL) with an aggressive course and worse outcomes compared with other lymphomas of similar tumor burden and histologic subtype. High-dose chemotherapy supported by autologous stem cell transplantation (HDC/ASCT) is an option for therapy for this disease in both the relapse setting and as post-remission consolidation. Data are currently limited to only several single-arm phase II trials with small sample sizes, but randomized trials are now ongoing. In this review, we discuss the efficacy, feasibility, and toxicity of HDC/ASCT for PCNSL and its role in the treatment of this aggressive malignancy, both in the first-line and relapse settings. We also bring to attention the current data on allogeneic stem cell transplantation (allo-SCT) in PCNSL.
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Affiliation(s)
- Daria Gaut
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Gary J Schiller
- Hematological Malignancies/Stem Cell Transplantation Unit, Division of Hematology/Oncology, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 10833 Le Conte Ave, Room 42-121 CHS, Los Angeles, CA, 90095, USA.
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12
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Cai Q, Fang Y, Young KH. Primary Central Nervous System Lymphoma: Molecular Pathogenesis and Advances in Treatment. Transl Oncol 2019; 12:523-538. [PMID: 30616219 PMCID: PMC6371000 DOI: 10.1016/j.tranon.2018.11.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 11/26/2018] [Accepted: 11/26/2018] [Indexed: 12/11/2022] Open
Abstract
Primary central nervous system lymphoma (PCNSL) is a group of extranodal non-Hodgkin lymphoma that exhibits specific biological characteristics and clinical behavior, with an aggressive disease course and unsatisfactory patient outcomes. It is of great importance to identify aberrant genetic loci and important molecular pathways that might suggest potential targets for new therapeutics and provide prognostic information. In this review, we listed various genetic and epigenetic alterations that are involved in PCNSL pathogenesis. In the aspect of treatment, we summarized the related literatures and evaluated the efficacy of surgery, induction chemotherapy, radiotherapy, intrathecal chemotherapy, and autologous stem cell transplantation in PCNSL. We also proposed the possible new agents for recurrent and relapse PCNSL based on the result of recent clinical researches.
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Affiliation(s)
- Qingqing Cai
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, P.R China.
| | - Yu Fang
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, P.R China
| | - Ken H Young
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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13
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Alnahhas I, Jawish M, Alsawas M, Zukas A, Prokop L, Murad MH, Malkin M. Autologous Stem-Cell Transplantation for Primary Central Nervous System Lymphoma: Systematic Review and Meta-analysis. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 19:e129-e141. [PMID: 30584023 DOI: 10.1016/j.clml.2018.11.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 11/11/2018] [Accepted: 11/17/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Primary central nervous system lymphoma (PCNSL) is an aggressive form of non-Hodgkin lymphoma. Methotrexate is first-line chemotherapy. Autologous stem-cell transplantation (ASCT) is increasingly used as an alternative consolidative treatment to whole-brain radiotherapy. METHODS A systematic search of several databases was conducted up through January 10, 2018. Two investigators independently assessed study eligibility and extracted the data. Studies that reported survival outcomes after ASCT were included. RESULTS We screened 1517 references and included 43 studies. ASCT was used as consolidative treatment or as salvage treatment/at relapse. Thiotepa, busulfan, and cyclophosphamide and carmustine/thiotepa were commonly used conditioning regimens. In the consolidation setting, 94% of patients experienced or maintained complete or partial response after ASCT. The rates of overall survival (OS) and progression-free survival (PFS) were 94%, 86%, 82%, and 70% and 79%, 70%, 64%, and 54% after 1, 2, 3, and 5 years, respectively. The overall risk of relapse at 5 years was 24%. In the salvage/relapse settings, 85% of patients experienced or maintained complete response or partial response after ASCT. The rates of OS and PFS were 75%, 63%, 56%, and 54% and 85%, 62%, 59%, and 54% after 1, 2, 3, and 5 years, respectively. The risk of relapse at 5 years was 29%. Subgroup analysis showed that the use of carmustine and thiotepa as a conditioning regimen carried the lowest risk of transplant-related mortality. The thiotepa, busulfan, and cyclophosphamide regimen, on the other hand, showed numerically superior OS and PFS rates. CONCLUSION This review provides estimates for response and survival to aid in decision making when considering ASCT for patients with PCNSL.
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Affiliation(s)
- Iyad Alnahhas
- Division of Neuro-oncology, The Ohio State University, Columbus, OH.
| | | | - Mouaz Alsawas
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN
| | - Alicia Zukas
- Division of Neuro-oncology, Virginia Commonwealth University, Richmond, VA
| | - Larry Prokop
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN
| | - Mark Malkin
- Division of Neuro-oncology, Virginia Commonwealth University, Richmond, VA
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14
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Mao C, Chen F, Li Y, Jiang X, Liu S, Guo H, Huang L, Wei X, Liang Z, Li W, Tang K. Characteristics and Outcomes of Primary Central Nervous System Lymphoma: A Retrospective Study of 91 Cases in a Chinese Population. World Neurosurg 2018; 123:e15-e24. [PMID: 30326304 DOI: 10.1016/j.wneu.2018.10.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/03/2018] [Accepted: 10/04/2018] [Indexed: 01/15/2023]
Abstract
BACKGROUND Primary central nervous system lymphoma (PCNSL) is a rare disease affecting the brain, leptomeninges, spinal cord, cerebrospinal fluid, or vitreoretinal compartment, without evidence of systemic disease. Prognosis is still poor after intensive methotrexate-based chemotherapy. METHODS Clinical data of 91 patients treated in a tertiary referral center during a 13-year period were retrospectively reviewed. RESULTS The estimated median progression-free survival and overall survival (OS) for the entire cohort were 39.1 months (95% confidence interval [CI], 14.1-64.0 months) and 54.5 months (95% CI, 28.9-80.1 months), respectively. Estimated 5-year progression-free survival and OS were 37.0% ± 6.5% and 47.5% ± 7.5%. Survival was associated with cycles of methotrexate only in multivariate analysis. Seventy-four patients received methotrexate-based chemotherapy after diagnosis. Thirty-nine patients experienced disease progression. Patients with relapsed/refractory disease had a poor survival, with median second OS (calculated from the date of first disease progression to the time of death from any cause) being 7.2 months (95% CI, 2.5-12.00 months). Three patients responded to ibrutinib after disease progression and incurred no fungal infection. CONCLUSIONS The outcomes of patients with PCNSL treated in our cohort are still poor. Relapse or refractory PCNSL and those not tolerating aggressive chemotherapy urgently require new approaches to improve their still dismal prognosis. Novel agents such as ibrutinib have shown promising clinical activity. Future studies should focus on the predictive biomarkers for the treatment of PCNSL with novel agents to provide precision medicine for PCNSL.
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Affiliation(s)
- Chengliang Mao
- Division of Neurosurgery, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Feili Chen
- Division of Lymphoma, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Yanwen Li
- Division of Neurosurgery, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Xinmiao Jiang
- Division of Lymphoma, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Sichu Liu
- Division of Lymphoma, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Hanguo Guo
- Division of Lymphoma, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Ling Huang
- Division of Lymphoma, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Xiaojuan Wei
- Division of Lymphoma, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Zhanli Liang
- Division of Lymphoma, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Wenyu Li
- Division of Lymphoma, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Kai Tang
- Division of Neurosurgery, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China.
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15
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Löw S, Han CH, Batchelor TT. Primary central nervous system lymphoma. Ther Adv Neurol Disord 2018; 11:1756286418793562. [PMID: 30305848 PMCID: PMC6174646 DOI: 10.1177/1756286418793562] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 07/10/2018] [Indexed: 12/12/2022] Open
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare and aggressive extranodal non-Hodgkin lymphoma (NHL), confined to the brain, eyes, spinal cord or leptomeninges without systemic involvement. Overall prognosis, diagnosis and management of PCNSL differ from other types of NHL. Prompt diagnosis and initiation of treatment are vital to improving clinical outcomes. PCNSL is responsive to radiation therapy, however whole-brain radiotherapy (WBRT) inadequately controls the disease when used alone and its delayed neurotoxicity causes neurocognitive impairment, especially in elderly patients. High-dose methotrexate (HD-MTX)-based induction chemotherapy with or without autologous stem cell transplantation (ASCT) or reduced-dose WBRT leads to durable disease control and less neurotoxicity. The optimal treatment has yet to be defined, however HD-MTX-based induction chemotherapy is considered standard for newly diagnosed PCNSL. Ongoing randomized trials address the role of rituximab, and of consolidative treatment using ASCT or reduced-dose WBRT. Despite high tumor response rates to initial treatment, many patients have relapsing disease with very poor prognosis. The optimal treatment for refractory or relapsed PCNSL is poorly defined. The choice of salvage treatment depends on age, previous treatment and response, performance status and comorbidities at the time of relapse. Novel therapeutics targeting underlying tumor biology include small molecule inhibitors of B-cell receptor, cereblon, and mammalian target of rapamycin signaling, and immunotherapy programmed cell death 1 receptor inhibitors and chimeric antigen receptor T cells.
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Affiliation(s)
- Sarah Löw
- Neurology Clinic and National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | - Catherine H Han
- Auckland Cancer Society Research Centre, School of Medical Sciences, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Tracy T Batchelor
- Stephen E. and Catherine Pappas Center for Neuro-Oncology, Yawkey 9E, 55 Fruit Street, Boston, MA 02114, USA
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16
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Abstract
PURPOSE OF REVIEW Primary central nervous system (CNS) lymphoma is a rare and aggressive extranodal non-Hodgkin lymphoma confined to the brain, eyes, spinal cord, or leptomeninges without systemic involvement. This article provides an overview of the clinical features, diagnosis, and management of primary CNS lymphoma in patients who are immunocompetent, focusing on recent advances in treatment. RECENT FINDINGS Primary CNS lymphoma is sensitive to radiation therapy; however, whole-brain radiation therapy inadequately controls the disease when used alone and causes delayed neurotoxicity with significant neurocognitive impairment, especially in patients who are elderly. A number of clinical trials have demonstrated durable disease control and less neurotoxicity with methotrexate-based induction chemotherapy with or without autologous stem cell transplantation or reduced-dose whole-brain radiation therapy. SUMMARY Prompt diagnosis and initiation of treatment are vital to improving clinical outcomes in patients with primary CNS lymphoma. The optimal treatment has yet to be defined, but high-dose methotrexate-based induction chemotherapy is considered standard for newly diagnosed primary CNS lymphoma. Ongoing randomized trials will attempt to address the roles of rituximab and consolidative treatment using autologous stem cell transplantation or reduced-dose whole-brain radiation therapy. Despite high tumor response rates to initial treatment, many patients will relapse. The choice of salvage treatment will depend on age, previous treatment and response, performance status, and comorbidities at the time of relapse.
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17
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Nagle SJ, Shah NN, Ganetsky A, Landsburg DJ, Nasta SD, Mato A, Schuster SJ, Reshef R, Tsai DE, Svoboda J. Long-term outcomes of rituximab, temozolomide and high-dose methotrexate without consolidation therapy for lymphoma involving the CNS. Int J Hematol Oncol 2018; 6:113-121. [PMID: 30302232 PMCID: PMC6171986 DOI: 10.2217/ijh-2017-0020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 10/16/2017] [Indexed: 11/21/2022] Open
Abstract
Aim To describe the long-term outcomes of patients with lymphoma in the CNS treated with rituximab, temozolomide and high-dose methotrexate without consolidation therapy. Patients & methods A retrospective cohort study of 46 consecutive patients with primary CNS lymphoma (PCNSL, 27 patients) or secondary CNS involvement of diffuse large B-cell lymphoma (DLBCL, 19 patients) who were treated with rituximab on day 1 in combination with high-dose methotrexate (days 1 and 15) and temozolomide (days 1-5) in 28-day cycles without further consolidation. Results Median follow-up was 21.2 months. Patients received a median of five cycles (range 1-15). Median overall survival (OS) was 26 months and median progression-free survival was 8.6 months. At 3 years, 37% of patients were alive and without evidence of disease. The patients with PCNSL had a significantly higher response rates (ORR 81 vs 47%; p = 0.015) and longer median OS (55.3 vs 4.8 months; p < 0.01) than those with secondary CNS DLBCL. Toxicities were mild and manageable. Conclusion The rituximab, temozolomide and methotrexate regimen is an effective therapy for patients with PCNSL without the toxicities typically associated with consolidation therapy.
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Affiliation(s)
- Sarah J Nagle
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, 2 West Pavilion, Philadelphia, PA 19104, USA.,Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, 2 West Pavilion, Philadelphia, PA 19104, USA
| | - Nirav N Shah
- Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI 53226, USA.,Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI 53226, USA
| | - Alex Ganetsky
- Department of Pharmacy, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.,Department of Pharmacy, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Daniel J Landsburg
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, 2 West Pavilion, Philadelphia, PA 19104, USA.,Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, 2 West Pavilion, Philadelphia, PA 19104, USA
| | - Sunita D Nasta
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, 2 West Pavilion, Philadelphia, PA 19104, USA.,Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, 2 West Pavilion, Philadelphia, PA 19104, USA
| | - Anthony Mato
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, 2 West Pavilion, Philadelphia, PA 19104, USA.,Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, 2 West Pavilion, Philadelphia, PA 19104, USA
| | - Stephen J Schuster
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, 2 West Pavilion, Philadelphia, PA 19104, USA.,Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, 2 West Pavilion, Philadelphia, PA 19104, USA
| | - Ran Reshef
- Division of Hematology/Oncology & the Columbia Center for Translational Immunology, Department of Medicine, Columbia University Medical Center, New York, NY 10032, USA.,Division of Hematology/Oncology & the Columbia Center for Translational Immunology, Department of Medicine, Columbia University Medical Center, New York, NY 10032, USA
| | - Donald E Tsai
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, 2 West Pavilion, Philadelphia, PA 19104, USA.,Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, 2 West Pavilion, Philadelphia, PA 19104, USA
| | - Jakub Svoboda
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, 2 West Pavilion, Philadelphia, PA 19104, USA.,Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, 2 West Pavilion, Philadelphia, PA 19104, USA
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18
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Miralles P, Navarro JT, Berenguer J, Gómez Codina J, Kwon M, Serrano D, Díez-Martín JL, Villà S, Rubio R, Menárguez J, Ribera Santasusana JM. GESIDA/PETHEMA recommendations on the diagnosis and treatment of lymphomas in patients infected by the human immunodeficiency virus. Med Clin (Barc) 2018; 151:39.e1-39.e17. [PMID: 29357988 DOI: 10.1016/j.medcli.2017.11.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 10/21/2017] [Accepted: 11/02/2017] [Indexed: 01/20/2023]
Abstract
The incidence of non-Hodgkin's lymphoma and Hodgkin's lymphoma is higher in patients with HIV infection than in the general population. Following the introduction of combination antiretroviral therapy (cART), the prognostic significance of HIV-related variables has decreased, and lymphoma-related factors have become more pronounced. Currently, treatments for lymphomas in HIV-infected patients do not differ from those used in the general population. However, differentiating characteristics of seropositive patients, such as the need for cART and specific prophylaxis and treatment of certain opportunistic infections, should be considered. This document updates recommendations on the diagnosis and treatment of lymphomas in HIV infected patients published by GESIDA/PETHEMA in 2008.
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Affiliation(s)
- Pilar Miralles
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, España.
| | - José Tomás Navarro
- Institut Català d'Oncologia, Hospital Universitari Germans Trias i Pujol, Institut de Recerca Josep Carreras, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
| | - Juan Berenguer
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, España
| | | | - Mi Kwon
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, España
| | - David Serrano
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, España
| | - José Luis Díez-Martín
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, España
| | - Salvador Villà
- Institut Català d'Oncologia, Hospital Universitari Germans Trias i Pujol, Institut de Recerca Josep Carreras, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
| | | | - Javier Menárguez
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, España
| | - José-María Ribera Santasusana
- Institut Català d'Oncologia, Hospital Universitari Germans Trias i Pujol, Institut de Recerca Josep Carreras, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
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19
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Ichikawa T. Primary CNS Lymphoma Treatment : Current Status and Future Directions. ACTA ACUST UNITED AC 2018. [DOI: 10.7887/jcns.27.99] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Tomotsugu Ichikawa
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences
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20
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Han CH, Batchelor TT. Diagnosis and management of primary central nervous system lymphoma. Cancer 2017; 123:4314-4324. [DOI: 10.1002/cncr.30965] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 07/06/2017] [Accepted: 07/11/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Catherine H. Han
- Department of Neurology, Division of Hematology/Oncology; Massachusetts General Hospital Cancer Center and Harvard Medical School; Boston Massachusetts
- Auckland Cancer Society Research Centre, School of Medical Sciences, Faculty of Medical and Health Sciences; University of Auckland; Auckland New Zealand
| | - Tracy T. Batchelor
- Department of Neurology, Division of Hematology/Oncology; Massachusetts General Hospital Cancer Center and Harvard Medical School; Boston Massachusetts
- Department of Radiation Oncology, Division of Hematology/Oncology; Massachusetts General Hospital Cancer Center and Harvard Medical School; Boston Massachusetts
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21
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DeFilipp Z, Li S, El-Jawahri A, Armand P, Nayak L, Wang N, Batchelor TT, Chen YB. High-dose chemotherapy with thiotepa, busulfan, and cyclophosphamide and autologous stem cell transplantation for patients with primary central nervous system lymphoma in first complete remission. Cancer 2017; 123:3073-3079. [PMID: 28369839 DOI: 10.1002/cncr.30695] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 03/07/2017] [Accepted: 03/08/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND High-dose chemotherapy and autologous stem cell transplantation (HDC-ASCT) is a therapeutic option for patients with primary central nervous system lymphoma (PCNSL). To the authors' knowledge, data are limited regarding its use among patients in first complete remission (CR1) with the CNS-directed conditioning regimen of thiotepa, busulfan, and cyclophosphamide (TBC). METHODS A retrospective analysis of patients with PCNSL in CR1 who underwent transplantation using a TBC-based conditioning regimen at 2 academic institutions was performed. RESULTS Forty-six consecutive patients who underwent HDC-ASCT while in CR1 were identified. The most common induction regimen was high-dose methotrexate plus temozolomide and rituximab (59%). No patients received whole-brain radiotherapy. A total of 40 patients (87%) received cytarabine before undergoing ASCT as either induction intensification, early consolidation therapy, or mobilization. The median time from diagnosis to transplantation was 6 months (range, 4-15 months). The median age of the patients at the time of transplantation was 59 years (range, 27-69 years). With a median follow-up of 2.7 years after ASCT (range, 6 months-7.5 years), the Kaplan-Meier estimates of 2-year overall survival and progression-free survival were 95% (95% confidence interval [95% CI], 80%-99%) and 92% (95% CI, 77%-97%), respectively. The most common toxicities were severe mucositis (35%) and bacterial infections occurring within 100 days of transplantation (35%). The estimated 2-year nonrecurrence mortality rate was 2.9% (95% CI, 0.2%-13.4%). CONCLUSIONS HDC-ASCT with a CNS-directed conditioning regimen such as TBC should be considered for patients with PCNSL who are in CR1 because this approach is associated with encouraging disease control and survival in this select patient population. Cancer 2017;123:3073-79. © 2017 American Cancer Society.
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Affiliation(s)
- Zachariah DeFilipp
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Shuli Li
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Areej El-Jawahri
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Philippe Armand
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lakshmi Nayak
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Nancy Wang
- Stephen E. and Catherine Pappas Center for Neuro-Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Tracy T Batchelor
- Stephen E. and Catherine Pappas Center for Neuro-Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Yi-Bin Chen
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts
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22
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Kerbauy MN, Moraes FY, Lok BH, Ma J, Kerbauy LN, Spratt DE, Santos FPS, Perini GF, Berlin A, Chung C, Hamerschlak N, Yahalom J. Challenges and opportunities in primary CNS lymphoma: A systematic review. Radiother Oncol 2017; 122:352-361. [PMID: 28104300 DOI: 10.1016/j.radonc.2016.12.033] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 12/29/2016] [Accepted: 12/29/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Historically, high-dose methotrexate (HD-MTX) plus consolidation chemotherapy and/or whole brain radiotherapy (WBRT) has been the gold standard on Primary Central Nervous System Lymphoma (PCNSL) management. We sought to examine and summarize the data, on clinical trial (CT) setting, investigating multi-modality treatment to PCNSL. METHODS We performed a systematic review of electronic databases (Medline, EMBASE, Cochrane Database and clinicaltrials.gov) and a manual search to identify original PCNSL phase 2 and phase 3 CT from the last 10years. After a 4stage Prisma based selection process, 32 published (3 Randomized CT and 29 phases 2 CT) studies ultimately were selected for review. Four ongoing clinical trials found on clinicaltrial.gov were reviewed. Two investigators reviewed titles, abstracts, and articles independently. Two investigators abstracted data sequentially and evaluated each study independently. FINDINGS Treatment of PCNSL requires a multidisciplinary approach. HD-MTX represents the most accepted standard of care induction therapy for newly diagnosed PCNSL. When HD-MTX is given with WBRT for consolidation delayed neurotoxicity can be an important complication, particularly in elderly patients. Studies have suggested that WBRT may be deferred until relapse without compromising survival and deferring WBRT may be the best approach in elderly patients. Results from dose-reduced WBRT and consolidative HD-Ara-C are encouraging. High-dose chemotherapy in combination with autologous stem cell transplantation (HDC-ASCT) as chemotherapy alone has emerged as an important consolidative treatment for selected population. The optimal salvage therapy is still to be defined. CONCLUSION WBRT for consolidation is a well-studied modality; however emerging options to selected population such as HDC-ASCT, dose-reduced WBRT or chemotherapy alone are associated with similar survival outcome and less neurotoxicity in selected series. Ongoing and future clinical trials will better define the best approach on this rare disease.
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Affiliation(s)
- Mariana N Kerbauy
- Department of Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Fabio Y Moraes
- Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo, Brazil; Department of Radiation Oncology, University of Toronto, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.
| | - Benjamin H Lok
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Jennifer Ma
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Lucila N Kerbauy
- Department of Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan Medical Center, Ann Arbor, USA
| | - Fabio P S Santos
- Department of Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Guilherme F Perini
- Department of Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Caroline Chung
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, USA
| | - Nelson Hamerschlak
- Department of Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Joachim Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
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Glass J, Won M, Schultz CJ, Brat D, Bartlett NL, Suh JH, Werner-Wasik M, Fisher BJ, Liepman MK, Augspurger M, Bokstein F, Bovi JA, Solhjem MC, Mehta MP. Phase I and II Study of Induction Chemotherapy With Methotrexate, Rituximab, and Temozolomide, Followed By Whole-Brain Radiotherapy and Postirradiation Temozolomide for Primary CNS Lymphoma: NRG Oncology RTOG 0227. J Clin Oncol 2016; 34:1620-5. [PMID: 27022122 DOI: 10.1200/jco.2015.64.8634] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE This study investigated the treatment of primary CNS lymphoma with methotrexate, temozolomide (TMZ), and rituximab, followed by hyperfractionated whole-brain radiotherapy (hWBRT) and subsequent TMZ. The primary phase I end point was the maximum tolerated dose of TMZ. The primary phase II end point was the 2-year overall survival (OS) rate. Secondary end points were preirradiation response rates, progression-free survival (PFS), neurologic toxicities, and quality of life. PATIENTS AND METHODS The phase I study increased TMZ doses from 100 to 150 to 200 mg/m(2). Patients were treated with rituximab 375 mg/m(2) 3 days before cycle 1; methotrexate 3.5 g/m(2) with leucovorin on weeks 1, 3, 5, 7, and 9; TMZ daily for 5 days on weeks 4 and 8; hWBRT 1.2 Gy twice-daily on weeks 11 to 13 (36 Gy); and TMZ 200 mg/m(2) daily for 5 days every 28 days on weeks 14 to 50. RESULTS Thirteen patients (one ineligible) were enrolled in phase I of the study. The maximum tolerated dose of TMZ was 100 mg/m(2). Dose-limiting toxicities were hepatic and renal. In phase II, 53 patients were treated. Median follow-up for living eligible patients was 3.6 years, and 2-year OS and PFS were 80.8% and 63.6%, respectively. Compared with historical controls from RTOG-9310, 2-year OS and PFS were significantly improved (P = .006 and .030, respectively). In phase II, the objective response rate was 85.7%. Among patients, 66% (35 of 53) had grade 3 and 4 toxicities before hWBRT, and 45% (24 of 53) of patients experienced grade 3 and 4 toxicities attributable to post-hWBRT chemotherapy. Cognitive function and quality of life improved or stabilized after hWBRT. CONCLUSION This regimen is safe, with the best 2-year OS and PFS achieved in any Radiation Therapy Oncology Group primary CNS lymphoma trial. Randomized trials that incorporate this regimen are needed to determine its efficacy compared with other strategies.
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Affiliation(s)
- Jon Glass
- Jon Glass and Maria Werner-Wasik, Thomas Jefferson University; Minhee Won, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Christopher J. Schultz and Joseph A. Bovi, Medical College of Wisconsin, Milwaukee, WI; Daniel Brat, Emory University, Atlanta, GA; Nancy L. Bartlett, Washington University School of Medicine, St Louis, MO; John H. Suh, Cleveland Clinic, Cleveland, OH; Barbara Jean Fisher, London Regional Cancer Program, London, Ontario, Canada; Marcia K. Liepman, Kalamazoo CCOP-West Michigan Cancer Center, Kalamazoo, MI; Mark Augspurger, Florida Radiation Oncology Group and Baptist Regional, Jacksonville, FL; Felix Bokstein, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Matthew C. Solhjem, Columbia River CCOP, Portland, OR; and Minesh P. Mehta, University of Maryland Medical Systems, Baltimore, MD.
| | - Minhee Won
- Jon Glass and Maria Werner-Wasik, Thomas Jefferson University; Minhee Won, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Christopher J. Schultz and Joseph A. Bovi, Medical College of Wisconsin, Milwaukee, WI; Daniel Brat, Emory University, Atlanta, GA; Nancy L. Bartlett, Washington University School of Medicine, St Louis, MO; John H. Suh, Cleveland Clinic, Cleveland, OH; Barbara Jean Fisher, London Regional Cancer Program, London, Ontario, Canada; Marcia K. Liepman, Kalamazoo CCOP-West Michigan Cancer Center, Kalamazoo, MI; Mark Augspurger, Florida Radiation Oncology Group and Baptist Regional, Jacksonville, FL; Felix Bokstein, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Matthew C. Solhjem, Columbia River CCOP, Portland, OR; and Minesh P. Mehta, University of Maryland Medical Systems, Baltimore, MD
| | - Christopher J Schultz
- Jon Glass and Maria Werner-Wasik, Thomas Jefferson University; Minhee Won, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Christopher J. Schultz and Joseph A. Bovi, Medical College of Wisconsin, Milwaukee, WI; Daniel Brat, Emory University, Atlanta, GA; Nancy L. Bartlett, Washington University School of Medicine, St Louis, MO; John H. Suh, Cleveland Clinic, Cleveland, OH; Barbara Jean Fisher, London Regional Cancer Program, London, Ontario, Canada; Marcia K. Liepman, Kalamazoo CCOP-West Michigan Cancer Center, Kalamazoo, MI; Mark Augspurger, Florida Radiation Oncology Group and Baptist Regional, Jacksonville, FL; Felix Bokstein, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Matthew C. Solhjem, Columbia River CCOP, Portland, OR; and Minesh P. Mehta, University of Maryland Medical Systems, Baltimore, MD
| | - Daniel Brat
- Jon Glass and Maria Werner-Wasik, Thomas Jefferson University; Minhee Won, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Christopher J. Schultz and Joseph A. Bovi, Medical College of Wisconsin, Milwaukee, WI; Daniel Brat, Emory University, Atlanta, GA; Nancy L. Bartlett, Washington University School of Medicine, St Louis, MO; John H. Suh, Cleveland Clinic, Cleveland, OH; Barbara Jean Fisher, London Regional Cancer Program, London, Ontario, Canada; Marcia K. Liepman, Kalamazoo CCOP-West Michigan Cancer Center, Kalamazoo, MI; Mark Augspurger, Florida Radiation Oncology Group and Baptist Regional, Jacksonville, FL; Felix Bokstein, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Matthew C. Solhjem, Columbia River CCOP, Portland, OR; and Minesh P. Mehta, University of Maryland Medical Systems, Baltimore, MD
| | - Nancy L Bartlett
- Jon Glass and Maria Werner-Wasik, Thomas Jefferson University; Minhee Won, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Christopher J. Schultz and Joseph A. Bovi, Medical College of Wisconsin, Milwaukee, WI; Daniel Brat, Emory University, Atlanta, GA; Nancy L. Bartlett, Washington University School of Medicine, St Louis, MO; John H. Suh, Cleveland Clinic, Cleveland, OH; Barbara Jean Fisher, London Regional Cancer Program, London, Ontario, Canada; Marcia K. Liepman, Kalamazoo CCOP-West Michigan Cancer Center, Kalamazoo, MI; Mark Augspurger, Florida Radiation Oncology Group and Baptist Regional, Jacksonville, FL; Felix Bokstein, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Matthew C. Solhjem, Columbia River CCOP, Portland, OR; and Minesh P. Mehta, University of Maryland Medical Systems, Baltimore, MD
| | - John H Suh
- Jon Glass and Maria Werner-Wasik, Thomas Jefferson University; Minhee Won, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Christopher J. Schultz and Joseph A. Bovi, Medical College of Wisconsin, Milwaukee, WI; Daniel Brat, Emory University, Atlanta, GA; Nancy L. Bartlett, Washington University School of Medicine, St Louis, MO; John H. Suh, Cleveland Clinic, Cleveland, OH; Barbara Jean Fisher, London Regional Cancer Program, London, Ontario, Canada; Marcia K. Liepman, Kalamazoo CCOP-West Michigan Cancer Center, Kalamazoo, MI; Mark Augspurger, Florida Radiation Oncology Group and Baptist Regional, Jacksonville, FL; Felix Bokstein, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Matthew C. Solhjem, Columbia River CCOP, Portland, OR; and Minesh P. Mehta, University of Maryland Medical Systems, Baltimore, MD
| | - Maria Werner-Wasik
- Jon Glass and Maria Werner-Wasik, Thomas Jefferson University; Minhee Won, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Christopher J. Schultz and Joseph A. Bovi, Medical College of Wisconsin, Milwaukee, WI; Daniel Brat, Emory University, Atlanta, GA; Nancy L. Bartlett, Washington University School of Medicine, St Louis, MO; John H. Suh, Cleveland Clinic, Cleveland, OH; Barbara Jean Fisher, London Regional Cancer Program, London, Ontario, Canada; Marcia K. Liepman, Kalamazoo CCOP-West Michigan Cancer Center, Kalamazoo, MI; Mark Augspurger, Florida Radiation Oncology Group and Baptist Regional, Jacksonville, FL; Felix Bokstein, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Matthew C. Solhjem, Columbia River CCOP, Portland, OR; and Minesh P. Mehta, University of Maryland Medical Systems, Baltimore, MD
| | - Barbara Jean Fisher
- Jon Glass and Maria Werner-Wasik, Thomas Jefferson University; Minhee Won, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Christopher J. Schultz and Joseph A. Bovi, Medical College of Wisconsin, Milwaukee, WI; Daniel Brat, Emory University, Atlanta, GA; Nancy L. Bartlett, Washington University School of Medicine, St Louis, MO; John H. Suh, Cleveland Clinic, Cleveland, OH; Barbara Jean Fisher, London Regional Cancer Program, London, Ontario, Canada; Marcia K. Liepman, Kalamazoo CCOP-West Michigan Cancer Center, Kalamazoo, MI; Mark Augspurger, Florida Radiation Oncology Group and Baptist Regional, Jacksonville, FL; Felix Bokstein, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Matthew C. Solhjem, Columbia River CCOP, Portland, OR; and Minesh P. Mehta, University of Maryland Medical Systems, Baltimore, MD
| | - Marcia K Liepman
- Jon Glass and Maria Werner-Wasik, Thomas Jefferson University; Minhee Won, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Christopher J. Schultz and Joseph A. Bovi, Medical College of Wisconsin, Milwaukee, WI; Daniel Brat, Emory University, Atlanta, GA; Nancy L. Bartlett, Washington University School of Medicine, St Louis, MO; John H. Suh, Cleveland Clinic, Cleveland, OH; Barbara Jean Fisher, London Regional Cancer Program, London, Ontario, Canada; Marcia K. Liepman, Kalamazoo CCOP-West Michigan Cancer Center, Kalamazoo, MI; Mark Augspurger, Florida Radiation Oncology Group and Baptist Regional, Jacksonville, FL; Felix Bokstein, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Matthew C. Solhjem, Columbia River CCOP, Portland, OR; and Minesh P. Mehta, University of Maryland Medical Systems, Baltimore, MD
| | - Mark Augspurger
- Jon Glass and Maria Werner-Wasik, Thomas Jefferson University; Minhee Won, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Christopher J. Schultz and Joseph A. Bovi, Medical College of Wisconsin, Milwaukee, WI; Daniel Brat, Emory University, Atlanta, GA; Nancy L. Bartlett, Washington University School of Medicine, St Louis, MO; John H. Suh, Cleveland Clinic, Cleveland, OH; Barbara Jean Fisher, London Regional Cancer Program, London, Ontario, Canada; Marcia K. Liepman, Kalamazoo CCOP-West Michigan Cancer Center, Kalamazoo, MI; Mark Augspurger, Florida Radiation Oncology Group and Baptist Regional, Jacksonville, FL; Felix Bokstein, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Matthew C. Solhjem, Columbia River CCOP, Portland, OR; and Minesh P. Mehta, University of Maryland Medical Systems, Baltimore, MD
| | - Felix Bokstein
- Jon Glass and Maria Werner-Wasik, Thomas Jefferson University; Minhee Won, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Christopher J. Schultz and Joseph A. Bovi, Medical College of Wisconsin, Milwaukee, WI; Daniel Brat, Emory University, Atlanta, GA; Nancy L. Bartlett, Washington University School of Medicine, St Louis, MO; John H. Suh, Cleveland Clinic, Cleveland, OH; Barbara Jean Fisher, London Regional Cancer Program, London, Ontario, Canada; Marcia K. Liepman, Kalamazoo CCOP-West Michigan Cancer Center, Kalamazoo, MI; Mark Augspurger, Florida Radiation Oncology Group and Baptist Regional, Jacksonville, FL; Felix Bokstein, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Matthew C. Solhjem, Columbia River CCOP, Portland, OR; and Minesh P. Mehta, University of Maryland Medical Systems, Baltimore, MD
| | - Joseph A Bovi
- Jon Glass and Maria Werner-Wasik, Thomas Jefferson University; Minhee Won, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Christopher J. Schultz and Joseph A. Bovi, Medical College of Wisconsin, Milwaukee, WI; Daniel Brat, Emory University, Atlanta, GA; Nancy L. Bartlett, Washington University School of Medicine, St Louis, MO; John H. Suh, Cleveland Clinic, Cleveland, OH; Barbara Jean Fisher, London Regional Cancer Program, London, Ontario, Canada; Marcia K. Liepman, Kalamazoo CCOP-West Michigan Cancer Center, Kalamazoo, MI; Mark Augspurger, Florida Radiation Oncology Group and Baptist Regional, Jacksonville, FL; Felix Bokstein, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Matthew C. Solhjem, Columbia River CCOP, Portland, OR; and Minesh P. Mehta, University of Maryland Medical Systems, Baltimore, MD
| | - Matthew C Solhjem
- Jon Glass and Maria Werner-Wasik, Thomas Jefferson University; Minhee Won, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Christopher J. Schultz and Joseph A. Bovi, Medical College of Wisconsin, Milwaukee, WI; Daniel Brat, Emory University, Atlanta, GA; Nancy L. Bartlett, Washington University School of Medicine, St Louis, MO; John H. Suh, Cleveland Clinic, Cleveland, OH; Barbara Jean Fisher, London Regional Cancer Program, London, Ontario, Canada; Marcia K. Liepman, Kalamazoo CCOP-West Michigan Cancer Center, Kalamazoo, MI; Mark Augspurger, Florida Radiation Oncology Group and Baptist Regional, Jacksonville, FL; Felix Bokstein, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Matthew C. Solhjem, Columbia River CCOP, Portland, OR; and Minesh P. Mehta, University of Maryland Medical Systems, Baltimore, MD
| | - Minesh P Mehta
- Jon Glass and Maria Werner-Wasik, Thomas Jefferson University; Minhee Won, NRG Oncology Statistics and Data Management Center, Philadelphia, PA; Christopher J. Schultz and Joseph A. Bovi, Medical College of Wisconsin, Milwaukee, WI; Daniel Brat, Emory University, Atlanta, GA; Nancy L. Bartlett, Washington University School of Medicine, St Louis, MO; John H. Suh, Cleveland Clinic, Cleveland, OH; Barbara Jean Fisher, London Regional Cancer Program, London, Ontario, Canada; Marcia K. Liepman, Kalamazoo CCOP-West Michigan Cancer Center, Kalamazoo, MI; Mark Augspurger, Florida Radiation Oncology Group and Baptist Regional, Jacksonville, FL; Felix Bokstein, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Matthew C. Solhjem, Columbia River CCOP, Portland, OR; and Minesh P. Mehta, University of Maryland Medical Systems, Baltimore, MD
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24
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Nakasu Y, Mitsuya K, Hayashi N, Okamura I, Mori K, Enami T, Tatara R, Nakasu S, Ikeda T. Response-adapted treatment with upfront high-dose chemotherapy followed by autologous stem-cell transplantation rescue or consolidation phase high-dose methotrexate for primary central nervous system lymphoma: a long-term mono-center study. SPRINGERPLUS 2016; 5:307. [PMID: 27066340 PMCID: PMC4786507 DOI: 10.1186/s40064-016-1954-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 02/29/2016] [Indexed: 11/23/2022]
Abstract
Treatment regimens for primary central nervous system lymphoma (PCNSL) include high-dose methotrexate (HD-MTX)-based chemotherapy, with or without radiotherapy and are based on studies of selected patient groups. This retrospective study assessed a consistent strategy of response-adapted protocol applied for patients including age >65 years in a cancer center for 10 years longitudinally. Case notes were studied of 61 consecutively treated patients with PCNSL histologically diagnosed between 2003 and 2013. Clinical follow-up during and after treatment included neurologic examination and magnetic resonance imaging. Of the patients studied, 14.8 % (9/61) were clinically unfit for chemotherapy; the remaining 85.2 % (52/61) of patients were treated with HD-MTX. Of these patients, 58 % (30/52) achieved an initial complete response, with a median survival of 100.1 months. Of these response-adapted patients, 33 % (10/30) were <65 years and were treated with upfront high-dose chemotherapy and autologous stem-cell transplantation (HDC-ASCT). The remaining response-adapted patients included 53 % (16/30) who were ≥65 years underwent consolidation with HD-MTX, and 14 % (4/30) who chose radiotherapy. The median survival of patients with HDC-ASCT had not yet been reached compared with 67.6 months for patients with HD-MTX consolidation treatment (p = 0.26). At the end of the study, 75 % (39/52) of patients had died mainly owing to progression or relapse of PCNSL. Multivariate analysis showed that age younger than 65 years (p = 0.02) and complete response for up-front HD-MTX (p = 0.001) were independent prognostic indicators of overall survival. In conclusion, this single-center retrospective clinical study has shown that treatment of PCNSL with upfront HDC-ASCT and consolidation phase HD-MTX monotherapy may be feasible, even for elderly patients in a routine clinical setting, using the three-step selection by eligibility and response to initial HD-MTX, and age threshold of 65 years for ASCT.
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Affiliation(s)
- Yoko Nakasu
- Division of Neurosurgery, Shizuoka Cancer Center, Nagaizumi, Sunto, Shizuoka, 4118777 Japan
| | - Koichi Mitsuya
- Division of Neurosurgery, Shizuoka Cancer Center, Nagaizumi, Sunto, Shizuoka, 4118777 Japan
| | - Nakamasa Hayashi
- Division of Neurosurgery, Shizuoka Cancer Center, Nagaizumi, Sunto, Shizuoka, 4118777 Japan
| | - Ikue Okamura
- Division of Stem Cell Transplantation, Shizuoka Cancer Center, Nagaizumi, Sunto, Shizuoka, 4118777 Japan
| | - Keita Mori
- Division of Biostatics, Shizuoka Cancer Center, Nagaizumi, Sunto, Shizuoka, 4118777 Japan
| | - Terukazu Enami
- Division of Stem Cell Transplantation, Shizuoka Cancer Center, Nagaizumi, Sunto, Shizuoka, 4118777 Japan
| | - Raine Tatara
- Division of Stem Cell Transplantation, Shizuoka Cancer Center, Nagaizumi, Sunto, Shizuoka, 4118777 Japan
| | - Satoshi Nakasu
- Division of Neurooncology, Kusatsu General Hospital, Yabase, Kusatsu, Shiga, 5250066 Japan
| | - Takashi Ikeda
- Division of Stem Cell Transplantation, Shizuoka Cancer Center, Nagaizumi, Sunto, Shizuoka, 4118777 Japan
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25
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Hoang-Xuan K, Bessell E, Bromberg J, Hottinger AF, Preusser M, Rudà R, Schlegel U, Siegal T, Soussain C, Abacioglu U, Cassoux N, Deckert M, Dirven CMF, Ferreri AJM, Graus F, Henriksson R, Herrlinger U, Taphoorn M, Soffietti R, Weller M. Diagnosis and treatment of primary CNS lymphoma in immunocompetent patients: guidelines from the European Association for Neuro-Oncology. Lancet Oncol 2015; 16:e322-32. [DOI: 10.1016/s1470-2045(15)00076-5] [Citation(s) in RCA: 221] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 01/17/2015] [Accepted: 01/23/2015] [Indexed: 10/23/2022]
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26
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Annaloro C, Costa A, Fracchiolla NS, Mometto G, Artuso S, Saporiti G, Tagliaferri E, Grifoni F, Onida F, Cortelezzi A. Severe fludarabine neurotoxicity after reduced intensity conditioning regimen to allogeneic hematopoietic stem cell transplantation: a case report. Clin Case Rep 2015; 3:650-5. [PMID: 26273463 PMCID: PMC4527817 DOI: 10.1002/ccr3.308] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 04/22/2015] [Accepted: 05/13/2015] [Indexed: 12/27/2022] Open
Abstract
We present a case of severe, irreversible neurotoxicity in a 55-year-old-patient with myelofibrosis undergoing hematopoietic stem cell transplantation following a reduced intensity conditioning including fludarabine. The patient developed progressive sensory-motor, visual and consciousness disturbances, eventually leading to death. MRI imaging pattern was unique and attributable to fludarabine neurotoxicity.
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Affiliation(s)
- Claudio Annaloro
- Hematology and BMT Unit, IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Italy
| | - Antonella Costa
- Neuroradiology Unit, IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Italy
| | - Nicola S Fracchiolla
- Hematology and BMT Unit, IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Italy
| | - Gabriella Mometto
- Hematology and BMT Unit, IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Italy
| | - Silvia Artuso
- Hematology and BMT Unit, IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Italy
| | - Giorgia Saporiti
- Hematology and BMT Unit, IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Italy
| | - Elena Tagliaferri
- Hematology and BMT Unit, IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Italy
| | - Federica Grifoni
- Hematology and BMT Unit, IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Italy
| | - Francesco Onida
- Hematology and BMT Unit, IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Italy ; Faculty of Medicine, University of Milan Milan, Italy
| | - Agostino Cortelezzi
- Hematology and BMT Unit, IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Italy ; Faculty of Medicine, University of Milan Milan, Italy
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Bojic M, Berghoff AS, Troch M, Agis H, Sperr WR, Widhalm G, Wöhrer A, Kalhs P, Preusser M, Rabitsch W. Haematopoietic stem cell transplantation for treatment of primary CNS lymphoma: single-centre experience and literature review. Eur J Haematol 2015; 95:75-82. [DOI: 10.1111/ejh.12482] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Marija Bojic
- Unit for Bone Marrow and Stem Cell Transplantation; Department of Medicine I; Medical University of Vienna; Vienna Austria
| | - Anna S. Berghoff
- Department of Medicine I; Clinical Division of Oncology; Medical University of Vienna; Vienna Austria
| | - Marlene Troch
- Unit for Bone Marrow and Stem Cell Transplantation; Department of Medicine I; Medical University of Vienna; Vienna Austria
| | - Hermine Agis
- Department of Medicine I; Clinical Division of Oncology; Medical University of Vienna; Vienna Austria
| | - Wolfgang R. Sperr
- Department of Medicine I; Clinical Division of Haematology and Hemostaseology; Medical University of Vienna; Vienna Austria
| | - Georg Widhalm
- Department of Neurosurgery; Medical University of Vienna; Vienna Austria
| | - Adelheid Wöhrer
- Institute of Neurology; Medical University of Vienna; Vienna Austria
| | - Peter Kalhs
- Unit for Bone Marrow and Stem Cell Transplantation; Department of Medicine I; Medical University of Vienna; Vienna Austria
| | - Matthias Preusser
- Department of Medicine I; Clinical Division of Oncology; Medical University of Vienna; Vienna Austria
| | - Werner Rabitsch
- Unit for Bone Marrow and Stem Cell Transplantation; Department of Medicine I; Medical University of Vienna; Vienna Austria
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Bellefqih S, Mezouri I, Khalil J, Bazine A, Diakité A, El Kacimi H, Kebdani T, Benjaafar N. [Primary central nervous lymphoma: what is the role for radiotherapy?]. Cancer Radiother 2014; 18:685-92. [PMID: 25451676 DOI: 10.1016/j.canrad.2014.06.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 05/23/2014] [Accepted: 06/06/2014] [Indexed: 10/24/2022]
Abstract
Primary central nervous system lymphoma is a rare extranodal form of non-Hodgkin lymphoma with an aggressive course and unsatisfactory outcome. Historically, whole-brain radiotherapy was the sole treatment for patients with primary central nervous system lymphoma, with high response rates but typically, this did not result in long-lasting remissions. The addition of high-dose methotrexate-based chemotherapy regimens to whole-brain radiotherapy has significantly improved patients' outcome, but has resulted in a higher incidence of late neurotoxicity, particularly in elderly patients. To date, the role of consolidation radiotherapy is controversial, and some investigators have developed alternative strategies aiming at avoiding immediate irradiation or using a reduced radiotherapy dose to the whole-brain with promising results.
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Affiliation(s)
- S Bellefqih
- Service de radiothérapie, Institut national d'oncologie, avenue Allal El-Fassi, 10100 Rabat, Maroc; Université Mohammed-V Souissi, 10100 Rabat, Maroc.
| | - I Mezouri
- Service de radiothérapie, Institut national d'oncologie, avenue Allal El-Fassi, 10100 Rabat, Maroc; Université Mohammed-V Souissi, 10100 Rabat, Maroc
| | - J Khalil
- Service de radiothérapie, Institut national d'oncologie, avenue Allal El-Fassi, 10100 Rabat, Maroc; Université Mohammed-V Souissi, 10100 Rabat, Maroc
| | - A Bazine
- Service de radiothérapie, Institut national d'oncologie, avenue Allal El-Fassi, 10100 Rabat, Maroc; Université Mohammed-V Souissi, 10100 Rabat, Maroc
| | - A Diakité
- Service de radiothérapie, Institut national d'oncologie, avenue Allal El-Fassi, 10100 Rabat, Maroc; Université Mohammed-V Souissi, 10100 Rabat, Maroc
| | - H El Kacimi
- Service de radiothérapie, Institut national d'oncologie, avenue Allal El-Fassi, 10100 Rabat, Maroc; Université Mohammed-V Souissi, 10100 Rabat, Maroc
| | - T Kebdani
- Service de radiothérapie, Institut national d'oncologie, avenue Allal El-Fassi, 10100 Rabat, Maroc; Université Mohammed-V Souissi, 10100 Rabat, Maroc
| | - N Benjaafar
- Service de radiothérapie, Institut national d'oncologie, avenue Allal El-Fassi, 10100 Rabat, Maroc; Université Mohammed-V Souissi, 10100 Rabat, Maroc
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29
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Iams W, Reddy NM. Consolidative autologous hematopoietic stem-cell transplantation in first remission for non-Hodgkin lymphoma: current indications and future perspective. Ther Adv Hematol 2014; 5:153-67. [PMID: 25324956 DOI: 10.1177/2040620714547327] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The non-Hodgkin lymphomas (NHLs) are a heterogeneous group of diseases with variable clinical outcomes. Autologous hematopoietic stem-cell transplantation (ASCT) as frontline, consolidative therapy has been evaluated based upon histological subtype of NHL. In this review, we summarize the major clinical trials guiding the use of frontline ASCT in NHL. With the constantly changing landscape of upfront therapy and multiple promising novel agents, the ability to conduct randomized trials to evaluate the benefit of consolidative ASCT is not only challenging but may be considered by some an inept utilization of resources. Our recommendation for consolidative ASCT is based on analyzing the current available data.
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Affiliation(s)
- Wade Iams
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nishitha M Reddy
- Vanderbilt University Medical Center, 3927 The Vanderbilt Clinic, Vanderbilt-Ingram Cancer Center, Nashville, TN 37232, USA
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30
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Upfront autologous stem-cell transplantation with melphalan, cyclophosphamide, etoposide, and dexamethasone (LEED) in patients with newly diagnosed primary central nervous system lymphoma. Int J Hematol 2014; 100:152-8. [PMID: 24947495 DOI: 10.1007/s12185-014-1608-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 05/22/2014] [Accepted: 05/28/2014] [Indexed: 10/25/2022]
Abstract
Treatment of primary central nervous system lymphoma (PCNSL) improved in recent years. However, the high neurotoxicity and low survival rates associated with this condition remain unresolved. We report 13 consecutive patients with PCNSL for whom upfront melphalan, cyclophosphamide, etoposide, and dexamethasone (known as LEED) followed by autologous stem-cell transplantation (ASCT) was planned at the Anjo Kosei Hospital. All patients were pathologically diagnosed with diffuse large B-cell lymphoma and were negative for human immunodeficiency virus. All patients were to receive three cycles of high-dose methotrexate-based induction chemotherapy, two cycles of high-dose AraC-based chemotherapy, and LEED followed by ASCT. All 13 patients achieved a partial response, and the 3-year overall survival (OS) rate was 76.2 %. Seven of the 13 patients were alive at the last follow-up, without any adverse events, including neurotoxicity. Six of the 13 (46.2 %) patients underwent ASCT and the 3-year OS rate was 80.0 %. Although this study included only a limited number of patients, these preliminary signs of efficacy and tolerability merit further consideration. To make further improvements in survival, the rate of patients undergoing ASCT should be increased. Other prospective studies involving greater numbers of patients are required to confirm these findings.
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Kokolo MB, Fergusson D, O'Neill J, Tay J, Tinmouth AT, Stewart D, Bredeson C. Effectiveness and safety of thiotepa as conditioning treatment prior to stem cell transplant in patients with central nervous system lymphoma. Leuk Lymphoma 2014; 55:2712-20. [PMID: 24491026 DOI: 10.3109/10428194.2014.889825] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Thiothepa is a cytostatic agent used in managing solid malignancies, and also as conditioning treatment before hematopoietic stem cell transplantation [HSCT]. This systematic review summarizes evidence on its effectiveness and safety, in patients with central nervous system [CNS] lymphoma. METHODS We searched 3 databases for clinical studies. When feasible, we performed meta-analyses. RESULTS We identified 13 eligible studies, none of which with a priori controls. So data synthesis focused on the 226 patients who received thiotepa. Based on pooled estimates, 75.9% of thiotepa-treated patients achieved a complete remission (95% confidence interval [CI] = 67.5-82.8), and 61.7% had a progression-free survival for up to 125 months post-treatment (95% CI = 49.4-72.7). However, 25.5% relapsed, 24.6% experienced infection, and 13.2% experienced neurotoxicity. DISCUSSION Thiotepa-based conditioning followed by HSCT may be effective in most CNS lymphoma patients, with a manageable toxicity profile. But adequately powered randomized trials are needed to better evaluate and isolate the effects of thiotepa.
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Abstract
OPINION STATEMENT Therapeutic options are limited in primary central nervous system lymphoma (PCNSL) with no uniform consensus on optimal management and few published, randomized trials. High-dose methotrexate in combination with other chemotherapeutic agents forms the mainstay of treatment. There hasn't been much progress beyond high-dose methotrexate in this disease, and although results from trials using high-dose chemotherapy and autologous stem-cell transplant seem promising, these need to be further validated. Moreover, the role of whole brain radiation in the upfront setting remains to be determined. However, international efforts in this direction are underway, with ongoing randomized trials in newly diagnosed PCNSL, more research on the molecular pathogenesis and biomarkers, and the use of novel agents in salvage therapy. There also is emphasis on quality of life parameters and neurocognitive status. Future treatment options should optimize high-efficacy rates while minimizing the risk of neurotoxicity.
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Affiliation(s)
- Lakshmi Nayak
- Dana-Farber Cancer Institute, Center for Neuro-Oncology, Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215 USA
| | - Tracy T. Batchelor
- Stephen E. and Catherine Pappas Center for Neuro-Oncology, Division of Hematology and Oncology, Department of Neurology, Massachusetts General Hospital Cancer Center, Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
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Current World Literature. Curr Opin Oncol 2013; 25:205-208. [DOI: 10.1097/cco.0b013e32835ec49f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Current world literature. Curr Opin Organ Transplant 2013; 18:111-30. [PMID: 23299306 DOI: 10.1097/mot.0b013e32835daf68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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