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Hasner MC, van Opijnen MP, van der Meulen M, Verdijk RM, Maas SLN, Te Boome LCJ, Broekman MLD. Diagnostics and treatment delay in primary central nervous system lymphoma: What the neurosurgeon should know. Acta Neurochir (Wien) 2024; 166:261. [PMID: 38858236 PMCID: PMC11164806 DOI: 10.1007/s00701-024-06138-3] [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: 04/16/2024] [Accepted: 05/19/2024] [Indexed: 06/12/2024]
Abstract
PURPOSE The gold standard for diagnostics in primary central nervous system lymphoma (PCNSL) is histopathological diagnosis after stereotactic biopsy. Yet, PCNSL has a multidisciplinary diagnostic work up, which associated with diagnostic delay and could result in treatment delay. This article offers recommendations to neurosurgeons involved in clinical decision-making regarding (novel) diagnostics and care for patients with PCNSL with the aim to improve uniformity and timeliness of the diagnostic process for patients with PCNSL. METHODS We present a mini review to discuss the role of stereotactic biopsy in the context of novel developments in diagnostics for PCNSL, as well as the role for cytoreductive surgery. RESULTS Cerebrospinal fluid-based diagnostics are supplementary and cannot replace stereotactic biopsy-based diagnostics. CONCLUSION Histopathological diagnosis after stereotactic biopsy of the brain remains the gold standard for diagnosis. Additional diagnostics should not be a cause of diagnostic delay. There is currently no sufficient evidence supporting cytoreductive surgery in PCNSL, with recent studies showing contradictive data and suboptimal study designs.
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Affiliation(s)
- M C Hasner
- Department of Neurosurgery, Haaglanden Medical Centre, The Hague, The Netherlands.
| | - M P van Opijnen
- Department of Neurosurgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - M van der Meulen
- Department of Neurology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - R M Verdijk
- Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - S L N Maas
- Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - L C J Te Boome
- Department of Hematology, Haaglanden Medical Centre, The Hague, The Netherlands
| | - M L D Broekman
- Department of Neurosurgery, Haaglanden Medical Centre, The Hague, The Netherlands
- Department of Neurosurgery, Leiden University Medical Centre, Leiden, The Netherlands
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Nayak L, Bettegowda C, Scherer F, Galldiks N, Ahluwalia M, Baraniskin A, von Baumgarten L, Bromberg JEC, Ferreri AJM, Grommes C, Hoang-Xuan K, Kühn J, Rubenstein JL, Rudà R, Weller M, Chang SM, van den Bent MJ, Wen PY, Soffietti R. Liquid biopsy for improving diagnosis and monitoring of CNS lymphomas: A RANO review. Neuro Oncol 2024; 26:993-1011. [PMID: 38598668 PMCID: PMC11145457 DOI: 10.1093/neuonc/noae032] [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: 12/01/2023] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND The utility of liquid biopsies is well documented in several extracranial and intracranial (brain/leptomeningeal metastases, gliomas) tumors. METHODS The RANO (Response Assessment in Neuro-Oncology) group has set up a multidisciplinary Task Force to critically review the role of blood and cerebrospinal fluid (CSF)-liquid biopsy in CNS lymphomas, with a main focus on primary central nervous system lymphomas (PCNSL). RESULTS Several clinical applications are suggested: diagnosis of PCNSL in critical settings (elderly or frail patients, deep locations, and steroid responsiveness), definition of minimal residual disease, early indication of tumor response or relapse following treatments, and prediction of outcome. CONCLUSIONS Thus far, no clinically validated circulating biomarkers for managing both primary and secondary CNS lymphomas exist. There is need of standardization of biofluid collection, choice of analytes, and type of technique to perform the molecular analysis. The various assays should be evaluated through well-organized central testing within clinical trials.
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Affiliation(s)
- Lakshmi Nayak
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Florian Scherer
- Department of Medicine I, Faculty of Medicine, Medical Center—University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Norbert Galldiks
- Department of Neurology, University of Cologne, Medical Faculty and University Hospital Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), and Institute of Neuroscience and Medicine (INM-3), Research Center Juelich, Juelich, Germany
| | - Manmeet Ahluwalia
- Rose and Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland OH and Miami Cancer Institute, Baptist Health South Florida, International University, Miami, Florida, USA
| | - Alexander Baraniskin
- Department of Hematology, Oncology and Palliative Care, Evangelisches Krankenhaus Hamm, Hamm, Germany
| | - Louisa von Baumgarten
- Department of Neurosurgery, Ludwig-Maximilians—University of Munich, Munich, Germany
- German Cancer Consortium, Partner Site Munich, Munich, Germany
| | | | - Andrés J M Ferreri
- Università Vita-Salute San Raffaele and IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Christian Grommes
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Neurology, Weill Cornell Medical College, New York, New York, USA
| | - Khê Hoang-Xuan
- APHP, Department of Neuro-oncology, Groupe Hospitalier Pitié-Salpêtrière; Sorbonne Université, Paris Brain Institute ICM, Paris, France
| | - Julia Kühn
- Department of Medicine I, Faculty of Medicine, Medical Center University of Freiburg, University of Freiburg, Freiburg, Germany
| | - James L Rubenstein
- UCSF Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, San Francisco, California, USA
| | - Roberta Rudà
- Division of Neuro-Oncology, Department of Neuroscience “Rita Levi Montalcini,” University of Turin, Turin, Italy
| | - Michael Weller
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Susan M Chang
- Department of Neurosurgery and Division of Neuro-Oncology, University of California, San Francisco, California, USA
| | | | - Patrick Y Wen
- Department of Neuroscience “Rita Levi Montalcini,” University of Turin, Turin, Italy
| | - Riccardo Soffietti
- Department of Neuroscience “Rita Levi Montalcini,” University of Turin, Turin, Italy
- Candiolo Cancer Institute, FPO-IRCCS, Turin, Italy
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Zhao C, Song J, Yuan Y, Chu YH, Hsu YC, Huang Q. An improved attention module based on nnU-Net for segmenting primary central nervous system lymphoma (PCNSL) in MRI images1. JOURNAL OF X-RAY SCIENCE AND TECHNOLOGY 2024:XST240016. [PMID: 38728198 DOI: 10.3233/xst-240016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
BACKGROUND Accurate volumetric segmentation of primary central nervous system lymphoma (PCNSL) is essential for assessing and monitoring the tumor before radiotherapy and the treatment planning. The tedious manual segmentation leads to interindividual and intraindividual differences, while existing automatic segmentation methods cause under-segmentation of PCNSL due to the complex and multifaceted nature of the tumor. OBJECTIVE To address the challenges of small size, diffused distribution, poor inter-layer continuity on the same axis, and tendency for over-segmentation in brain MRI PCNSL segmentation, we propose an improved attention module based on nnUNet for automated segmentation. METHODS We collected 114 T1 MRI images of patients in the Huashan Hospital, Shanghai. Then randomly split the total of 114 cases into 5 distinct training and test sets for a 5-fold cross-validation. To efficiently and accurately delineate the PCNSL, we proposed an improved attention module based on nnU-Net with 3D convolutions, batch normalization, and residual attention (res-attention) to learn the tumor region information. Additionally, multi-scale dilated convolution kernels with different dilation rates were integrated to broaden the receptive field. We further used attentional feature fusion with 3D convolutions (AFF3D) to fuse the feature maps generated by multi-scale dilated convolution kernels to reduce under-segmentation. RESULTS Compared to existing methods, our attention module improves the ability to distinguish diffuse and edge enhanced types of tumors; and the broadened receptive field captures tumor features of various scales and shapes more effectively, achieving a 0.9349 Dice Similarity Coefficient (DSC). CONCLUSIONS Quantitative results demonstrate the effectiveness of the proposed method in segmenting the PCNSL. To our knowledge, this is the first study to introduce attention modules into deep learning for segmenting PCNSL based on brain magnetic resonance imaging (MRI), promoting the localization of PCNSL before radiotherapy.
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Affiliation(s)
- Chen Zhao
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Jianping Song
- Department of Neurosurgery, National Center for Neurological Disorders, Huashan Hospital, Fudan University, Shanghai, China
- Department of Neurosurgery, National Regional Medical Center, Huashan Hospital Fujian Campus, Fudan University, Fuzhou, Fujian, China
| | - Yifan Yuan
- Department of Neurosurgery, National Center for Neurological Disorders, Huashan Hospital, Fudan University, Shanghai, China
- Department of Neurosurgery, National Regional Medical Center, Huashan Hospital Fujian Campus, Fudan University, Fuzhou, Fujian, China
| | | | | | - Qiu Huang
- Department of Nuclear Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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de Koning ME, Hof JJ, Jansen C, Doorduijn JK, Bromberg JEC, van der Meulen M. Primary central nervous system lymphoma. J Neurol 2024; 271:2906-2913. [PMID: 38112784 DOI: 10.1007/s00415-023-12143-w] [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: 11/05/2023] [Accepted: 11/30/2023] [Indexed: 12/21/2023]
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare type of non-Hodgkin lymphoma (NHL) manifesting in the brain, spinal cord, cerebrospinal fluid and/or eyes, in the absence of systemic manifestations. With an increasing incidence and a 30% 5-year overall survival if promptly treated, timely diagnosis and subsequent treatment is paramount. The typical MRI appearance for PCNSL is a solitary or multiple T2-hypointense, homogeneous gadolinium-enhancing lesion with restricted diffusion. Dexamethasone treatment might compromise and delay the diagnosis. Hallmark of treatment is induction with intravenous high-dose methotrexate consisting polychemotherapy followed by consolidation treatment. Consolidation treatment consists of either whole brain radiotherapy (WBRT) or autologous stem cell transplantation (ASCT). Given the (cognitive) side effects of WBRT, ASCT is increasingly being used as the first choice of treatment.
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Affiliation(s)
- Myrthe E de Koning
- Department of Neurology, Medisch Spectrum Twente, Enschede, The Netherlands.
| | - Jurrit J Hof
- Department of Radiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Casper Jansen
- Laboratory of Pathology Eastern Netherlands, Hengelo, The Netherlands
| | - Jeanette K Doorduijn
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jacoline E C Bromberg
- Department of Neurology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Chávez EE, Arce JCD, Perea EDB, Pedraza AG, Ávila AIJ, Quezada DEA, Suárez PDG. Primary central nervous system lymphoma: A mirror type presentation in an immunocompetent patient. Surg Neurol Int 2024; 15:143. [PMID: 38741983 PMCID: PMC11090529 DOI: 10.25259/sni_65_2024] [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: 01/27/2024] [Accepted: 04/03/2024] [Indexed: 05/16/2024] Open
Abstract
Background Primary central nervous system (CNS) lymphoma is a very rare extranodal non-Hodgkin lymphoma. The bilateral pattern, as we call it "mirror type", has been identified in other CNS lesions such as gliomas, metastases, and demyelinating lesions, so the differential diagnosis includes imaging studies such as magnetic resonance imaging contrasted with spectroscopy, ruling out immunodeficiency or metastatic disease. Case Description A 65-year-old female presented progressing headache, loss of memory and language alterations, as well as sensory alterations. Neuroimaging showed the presence of two equidistant periventricular lesions at the level of both ventricular atria, a spectroscopy study suggestive of malignancy. Serological studies showed no evidence of immunodeficiency or the presence of positive tumor markers; however, a biopsy was performed, which revealed a histopathological result of primary lymphoma of the CNS. Conclusion In neuro-oncology, primary CNS tumors with multiple lesions are rare, even more, the "mirror type" lesions. Lymphomas are lesions that can present in different ways on imaging and clinical presentation. These tumors that present a vector effect due to their size, perilesional edema, or that lead to loss of neurological function are highly discussed in diagnostic and surgical treatment. Due to their prognosis, action on diagnosis and treatment must be taken as quickly as hospital resources allow.
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Affiliation(s)
- Elizabeth Escamilla Chávez
- Department of Neurosurgery, Arturo Montiel Rojas Medical Center, Instituto de Seguridad Social del Estado de México y Municipios, Metepec, Mexico
| | - Julio César Delgado Arce
- Department of Neurosurgery, Arturo Montiel Rojas Medical Center, Instituto de Seguridad Social del Estado de México y Municipios, Metepec, Mexico
| | - Edinson David Berrio Perea
- Department of Neurosurgery, Arturo Montiel Rojas Medical Center, Instituto de Seguridad Social del Estado de México y Municipios, Metepec, Mexico
| | - Abraham Gallegos Pedraza
- Department of Neurosurgery, Arturo Montiel Rojas Medical Center, Instituto de Seguridad Social del Estado de México y Municipios, Metepec, Mexico
| | - Ana Itiel Jimenez Ávila
- Department of Neurosurgery, Arturo Montiel Rojas Medical Center, Instituto de Seguridad Social del Estado de México y Municipios, Metepec, Mexico
| | | | - Pablo David Guerrero Suárez
- Department of Neurosurgery, Arturo Montiel Rojas Medical Center, Instituto de Seguridad Social del Estado de México y Municipios, Metepec, Mexico
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von Roemeling C, Ferreri AJM, Soussain C, Tun HW, Grommes C. Targets and treatments in primary CNS lymphoma. Leuk Lymphoma 2024:1-13. [PMID: 38659230 DOI: 10.1080/10428194.2024.2342560] [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: 02/29/2024] [Accepted: 04/08/2024] [Indexed: 04/26/2024]
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare and highly aggressive lymphoma entirely localized in the central nervous system or vitreoretinal space. PCNSL generally initially responds to methotrexate-containing chemotherapy regimens, but progressive or relapsing disease is common, and the prognosis is poor for relapsed or refractory (R/R) patients. PCNSL is often characterized by activation of nuclear factor kappa B (NF-κB) due to mutations in the B-cell receptor (BCR) or toll-like receptor (TLR) pathways, as well as immune evasion. Targeted treatments that inhibit key PCNSL mechanisms and pathways are being evaluated; inhibition of Bruton's tyrosine kinase (BTK) downstream of BCR activation has demonstrated promising results in treating R/R disease. This review will summarize the evidence and potential for targeted therapeutic agents to improve treatment outcomes in PCNSL. This includes immunotherapeutic and immunomodulatory approaches and inhibitors of the key pathways driving PCNSL, such as aberrant BCR and TLR signaling.
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Affiliation(s)
- Christina von Roemeling
- Preston A. Wells Center for Brain Tumor Therapy, Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Andrés J M Ferreri
- Department of Onco-Hematology, University Vita-Salute San Raffaele, Milano, Italy
- Department of Onco-Hematology, Lymphoma Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Carole Soussain
- Institut Curie, Service d'Hématologie, site de Saint-Cloud, France
- INSERM U932, Institut Curie, PSL Research University, Paris, France
| | - Han W Tun
- Department of Hematology, Mayo Clinic, Jacksonville, Florida, USA
| | - Christian Grommes
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Neurology, Weill Cornell Medical College, New York, New York, USA
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Liu Y, Cai L, Zhou Y. A case of primary central-nervous system lymphoma with no obvious effect of hormone therapy. Asian J Surg 2024; 47:2008-2009. [PMID: 38212218 DOI: 10.1016/j.asjsur.2023.12.206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 12/29/2023] [Indexed: 01/13/2024] Open
Affiliation(s)
- Yongsheng Liu
- Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Lize Cai
- Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Youxin Zhou
- Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China.
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Haran A, Even-Zohar NG, Haran M, Lebel E, Aumann S, Shaulov A, Gatt M, Nachmias B. Impact of Folinic Acid Dosing on Efficacy and Toxicity of High-Dose Methotrexate in Central Nervous System Lymphoma. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024; 24:187-193.e1. [PMID: 38008594 DOI: 10.1016/j.clml.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 10/24/2023] [Accepted: 10/29/2023] [Indexed: 11/28/2023]
Abstract
INTRODUCTION High-dose methotrexate (HDMTX)-based regimens are the treatment of choice in primary central nervous system lymphoma (PCNSL). Folinic acid (FA) rescue is used to mitigate the toxic effects of MTX on normal cells. However, the optimal dosing of FA in PCNSL remains uncertain. METHODS We analyzed the relationship between FA dosing and treatment efficacy and toxicity in a cohort of 36 PCNSL patients treated at our institute between the years 2014 and 2022. A combination of univariate and multivariate analyses using known prognostic factors were used to determine the association between FA dosing and treatment outcomes. RESULTS We found that higher per-treatment cumulative FA doses were associated with inferior progression-free survival (PFS), with a hazard ratio (HR) of 2.2 for each 100 mg/m2 increase in FA dose. We identified a threshold of 350 mg/m2/treatment, above which there was a significant reduction in PFS. Notably, lower FA doses did not result in increased toxicity. CONCLUSION Our findings suggest that optimizing FA dosing to avoid very high rescue doses may improve treatment outcomes in PCNSL patients receiving HDMTX. Further prospective studies are warranted to validate these findings.
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Affiliation(s)
- Arnon Haran
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, POB 12000, Jerusalem, 91120, Israel.
| | - Noa Gross Even-Zohar
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, POB 12000, Jerusalem, 91120, Israel
| | - Michal Haran
- Department of Hematology, Kaplan Medical Center, Rehovot, Israel
| | - Eyal Lebel
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, POB 12000, Jerusalem, 91120, Israel
| | - Shlomzion Aumann
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, POB 12000, Jerusalem, 91120, Israel
| | - Adir Shaulov
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, POB 12000, Jerusalem, 91120, Israel
| | - Moshe Gatt
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, POB 12000, Jerusalem, 91120, Israel
| | - Boaz Nachmias
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, POB 12000, Jerusalem, 91120, Israel
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Rinaldi I, Muthalib A, Gondhowiardjo S, Setiawan T, Gunawan A, Susanto N, Magdalena L, Winston K, Disamantiji A, Wirawan B. Relapsed isolated CNS lymphoma treated with radiotherapy and intrathecal methotrexate followed by high-dose intravenous methotrexate, rituximab, and temozolomide: A case report. Clin Case Rep 2024; 12:e8409. [PMID: 38435502 PMCID: PMC10907348 DOI: 10.1002/ccr3.8409] [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: 07/28/2023] [Revised: 12/09/2023] [Accepted: 12/18/2023] [Indexed: 03/05/2024] Open
Abstract
Key Clinical Message Optimized treatments for relapsed isolated CNS lymphoma (RI-SCNSL) remains under investigation. Temozolomide combination-based therapy, which is often used in glioblastoma may be used as potential treatment in RI-SCNSL. Abstract One of the most common types of non-Hodgkin lymphoma (NHL) is diffuse large B-cell lymphoma (DLBCL). Despite advances in treatment, relapsed isolated CNS lymphoma (RI-SCNSL) from DLBCL remains an issue. The optimal approach in RI-SCNSL remains an area of active investigation as currently there is no high level of evidence for the treatments due to lack of randomized studies. In this case report, we present a DLBCL patient with CNS recurrence treated radiotherapy and intrathecal methotrexate (MTX) followed by intravenous high-dose MTX, rituximab, and temozolomide. To the best of our knowledge, this is the first case report describing RI-SCNSL treated with the regiments above which also include temozolomide which is used for glioblastoma.
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Affiliation(s)
- Ikhwan Rinaldi
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Cipto Mangunkusumo National General Hospital, Faculty of MedicineUniversitas IndonesiaJakartaIndonesia
- Department of Internal MedicineGading Pluit HospitalJakartaIndonesia
| | - Abdul Muthalib
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Cipto Mangunkusumo National General Hospital, Faculty of MedicineUniversitas IndonesiaJakartaIndonesia
- Department of Internal MedicineGading Pluit HospitalJakartaIndonesia
| | | | - Tjondro Setiawan
- Department of Internal MedicineGading Pluit HospitalJakartaIndonesia
| | - Andhika Gunawan
- Department of Nuclear MedicineGading Pluit HospitalJakartaIndonesia
| | - Nelly Susanto
- Department of RadiologyGading Pluit HospitalJakartaIndonesia
| | | | - Kevin Winston
- Hospital MedicineBhakti Medicare HospitalCicurugIndonesia
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Zhang Y, Ye J, Chen H, Zhou D, Ji C. Efficacy and Safety of BTKis in Central Nervous System Lymphoma: A Systematic Review and Meta-Analysis. Cancers (Basel) 2024; 16:860. [PMID: 38473226 DOI: 10.3390/cancers16050860] [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: 12/13/2023] [Revised: 01/31/2024] [Accepted: 02/07/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND This systematic review and meta-analysis aimed to evaluate the efficacy and safety of Bruton tyrosine kinase inhibitors (BTKis) for central nervous system lymphoma (CNSL). METHODS A systematic review was carried out to identify relevant studies from the PubMed, Embase, Cochrane Library, Web of Science, WanFang, CNKI, and CBM databases. The studies included patients with CNSL who received BTKis and reported the overall response (OR), complete remission (CR), and partial response (PR). An overall effect analysis was performed using STATA 15.0. A random-effects model was utilized to calculate the pooled rates, and 95% confidence intervals (CI) were determined for all outcomes. RESULTS A total of 21 studies involving 368 patients were included in the meta-analysis. For newly diagnosed CNSL, due to the small simple size, we conducted a quantitative description, and the ORR could reach up to 100%. For relapsed/refractory patients, the pooled ORR was 72% (95% CI: 64-80%, I2 = 54.89%, p = 0.00), with a pooled CR and PR of 43% (95% CI: 33-54%, I2 = 65.40%, p = 0.00) and 23% (95% CI: 13-35%, I2 = 78.05%, p = 0.00), respectively. Most adverse events were hematology-related and generally manageable. CONCLUSION BTKis showed acceptable efficacy and safety in treating patients with CNSL. However, large and well-designed trials are still required to confirm BTKis as a treatment for CNSL.
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Affiliation(s)
- Yan Zhang
- Department of Hematology, Peking Union Medical College Hospital, Beijing 100730, China
| | - Jingjing Ye
- Department of Hematology, Qilu Hospital of Shandong University, Jinan 250012, China
| | - Hao Chen
- College of Acupuncture and Chinese Tuina, Nanjing University of Chinese Medicine, Nanjing 210023, China
| | - Daobin Zhou
- Department of Hematology, Peking Union Medical College Hospital, Beijing 100730, China
| | - Chunyan Ji
- Department of Hematology, Qilu Hospital of Shandong University, Jinan 250012, China
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11
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Heger JM, Mattlener J, Schneider J, Gödel P, Sieg N, Ullrich F, Lewis R, Bucaciuc-Mracica T, Schwarz RF, Rueß D, Ruge MI, Montesinos-Rongen M, Deckert M, Blau T, Kutsch N, Balke-Want H, Weiss J, Becker K, Reinhardt HC, Hallek M, Borchmann P, von Tresckow B, Borchmann S. Entirely noninvasive outcome prediction in central nervous system lymphomas using circulating tumor DNA. Blood 2024; 143:522-534. [PMID: 37946299 DOI: 10.1182/blood.2023022020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/19/2023] [Accepted: 10/19/2023] [Indexed: 11/12/2023] Open
Abstract
ABSTRACT State-of-the-art response assessment of central nervous system lymphoma (CNSL) by magnetic resonance imaging is challenging and an insufficient predictor of treatment outcomes. Accordingly, the development of novel risk stratification strategies in CNSL is a high unmet medical need. We applied ultrasensitive circulating tumor DNA (ctDNA) sequencing to 146 plasma and cerebrospinal fluid (CSF) samples from 67 patients, aiming to develop an entirely noninvasive dynamic risk model considering clinical and molecular features of CNSL. Our ultrasensitive method allowed for the detection of CNSL-derived mutations in plasma ctDNA with high concordance to CSF and tumor tissue. Undetectable plasma ctDNA at baseline was associated with favorable outcomes. We tracked tumor-specific mutations in plasma-derived ctDNA over time and developed a novel CNSL biomarker based on this information: peripheral residual disease (PRD). Persistence of PRD after treatment was highly predictive of relapse. Integrating established baseline clinical risk factors with assessment of radiographic response and PRD during treatment resulted in the development and independent validation of a novel tool for risk stratification: molecular prognostic index for CNSL (MOP-C). MOP-C proved to be highly predictive of outcomes in patients with CNSL (failure-free survival hazard ratio per risk group of 6.60; 95% confidence interval, 3.12-13.97; P < .0001) and is publicly available at www.mop-c.com. Our results highlight the role of ctDNA sequencing in CNSL. MOP-C has the potential to improve the current standard of clinical risk stratification and radiographic response assessment in patients with CNSL, ultimately paving the way toward individualized treatment.
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Affiliation(s)
- Jan-Michel Heger
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
- Cancer Center Cologne Essen (CCCE), Cologne, Germany
- Cologne Lymphoma Working Group, Cologne, Germany
| | - Julia Mattlener
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
- Cancer Center Cologne Essen (CCCE), Cologne, Germany
- German Hodgkin Study Group, Cologne, Germany
| | - Jessica Schneider
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
- Cancer Center Cologne Essen (CCCE), Cologne, Germany
| | - Philipp Gödel
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
- Cologne Lymphoma Working Group, Cologne, Germany
| | - Noëlle Sieg
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
- Cancer Center Cologne Essen (CCCE), Cologne, Germany
- Cologne Lymphoma Working Group, Cologne, Germany
| | - Fabian Ullrich
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center and German Cancer Consortium (Deutsches Konsortium für Translationale Krebsforschung partner site Essen), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- CCCE, Essen, Germany
| | - Richard Lewis
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
- Cancer Center Cologne Essen (CCCE), Cologne, Germany
- Cologne Lymphoma Working Group, Cologne, Germany
| | - Teodora Bucaciuc-Mracica
- Institute for Computational Cancer Biology, Center for Integrated Oncology, Cancer Research Center Cologne Essen, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Roland F Schwarz
- Institute for Computational Cancer Biology, Center for Integrated Oncology, Cancer Research Center Cologne Essen, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Berlin Institute for the Foundations of Learning and Data, Berlin, Germany
| | - Daniel Rueß
- Department of Stereotaxy and Functional Neurosurgery, Center of Neurosurgery, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Maximilian I Ruge
- Department of Stereotaxy and Functional Neurosurgery, Center of Neurosurgery, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Manuel Montesinos-Rongen
- Institute of Neuropathology, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
| | - Martina Deckert
- Institute of Neuropathology, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
| | - Tobias Blau
- Institute of Neuropathology, University of Duisburg-Essen, University Hospital Essen, Essen, Germany
| | - Nadine Kutsch
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
- Cancer Center Cologne Essen (CCCE), Cologne, Germany
- Cologne Lymphoma Working Group, Cologne, Germany
| | - Hyatt Balke-Want
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
- Cancer Center Cologne Essen (CCCE), Cologne, Germany
- Cologne Lymphoma Working Group, Cologne, Germany
- Stanford Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, CA
| | - Jonathan Weiss
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
| | - Kerstin Becker
- West German Genome Center, University of Cologne, Cologne, Germany
| | - H Christian Reinhardt
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center and German Cancer Consortium (Deutsches Konsortium für Translationale Krebsforschung partner site Essen), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- CCCE, Essen, Germany
| | - Michael Hallek
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
- Cancer Center Cologne Essen (CCCE), Cologne, Germany
| | - Peter Borchmann
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
- German Hodgkin Study Group, Cologne, Germany
| | | | - Sven Borchmann
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany
- Cancer Center Cologne Essen (CCCE), Cologne, Germany
- Cologne Lymphoma Working Group, Cologne, Germany
- German Hodgkin Study Group, Cologne, Germany
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12
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Liu X, Liu J. Aided Diagnosis Model Based on Deep Learning for Glioblastoma, Solitary Brain Metastases, and Primary Central Nervous System Lymphoma with Multi-Modal MRI. BIOLOGY 2024; 13:99. [PMID: 38392317 PMCID: PMC10887006 DOI: 10.3390/biology13020099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/26/2024] [Accepted: 01/27/2024] [Indexed: 02/24/2024]
Abstract
(1) Background: Diagnosis of glioblastoma (GBM), solitary brain metastases (SBM), and primary central nervous system lymphoma (PCNSL) plays a decisive role in the development of personalized treatment plans. Constructing a deep learning classification network to diagnose GBM, SBM, and PCNSL with multi-modal MRI is important and necessary. (2) Subjects: GBM, SBM, and PCNSL were confirmed by histopathology with the multi-modal MRI examination (study from 1225 subjects, average age 53 years, 671 males), 3.0 T T2 fluid-attenuated inversion recovery (T2-Flair), and Contrast-enhanced T1-weighted imaging (CE-T1WI). (3) Methods: This paper introduces MFFC-Net, a classification model based on the fusion of multi-modal MRIs, for the classification of GBM, SBM, and PCNSL. The network architecture consists of parallel encoders using DenseBlocks to extract features from different modalities of MRI images. Subsequently, an L1-norm feature fusion module is applied to enhance the interrelationships among tumor tissues. Then, a spatial-channel self-attention weighting operation is performed after the feature fusion. Finally, the classification results are obtained using the full convolutional layer (FC) and Soft-max. (4) Results: The ACC of MFFC-Net based on feature fusion was 0.920, better than the radiomics model (ACC of 0.829). There was no significant difference in the ACC compared to the expert radiologist (0.920 vs. 0.924, p = 0.774). (5) Conclusions: Our MFFC-Net model could distinguish GBM, SBM, and PCNSL preoperatively based on multi-modal MRI, with a higher performance than the radiomics model and was comparable to radiologists.
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Affiliation(s)
- Xiao Liu
- School of Computer and Information Technology, Beijing Jiaotong University, Beijing 100044, China
| | - Jie Liu
- School of Computer and Information Technology, Beijing Jiaotong University, Beijing 100044, China
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13
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Flospergher E, Marino F, Calimeri T, Cangi MG, Ferreri AJM, Ponzoni M, Bongiovanni L. Primary central nervous system marginal zone lymphoma. Br J Haematol 2024; 204:31-44. [PMID: 38054330 DOI: 10.1111/bjh.19238] [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: 07/20/2023] [Revised: 11/13/2023] [Accepted: 11/21/2023] [Indexed: 12/07/2023]
Abstract
Marginal zone lymphoma (MZL) is the most common indolent lymphoma primarily arising in the central nervous system (CNS). To date, 207 cases of primary CNS MZL (PCNSMZL) were published, mostly as single case reports or small case series. It most commonly presents as extra-axial dural-based masses, more frequently in middle-aged women, displaying an insidious onset, with a long history of symptoms preceding the diagnosis. PCNSMZL can be radiographically mistaken for meningioma. PCNSMZL consists of CD20+ , CD3- small B lymphocytes with varying degrees of plasmacytic differentiation and low proliferation index. Trisomy 3, but not MALT1 or IgH translocation, is a common genetic abnormality. Other recurrent genetic abnormalities involve TNFAIP3 and NOTCH2. Ethiopathogenesis was poorly investigated. Due to its rarity, standard of care remains to be defined; it exhibits an excellent prognosis after varied treatments, such as surgery, radiotherapy, chemotherapy or their combinations. Nevertheless, each treatment should be considered after an accurate analysis of overtreatment risk. Short follow-up is a major limitation in reported PCNSMZL cases, which restrains our knowledge on long-term results and iatrogenic sequels. This review was focussed on presentation, differential diagnoses, pathological findings, treatment options and clinical outcomes of PCNSMZL; recommendations for best clinical practice are provided.
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Affiliation(s)
- Elena Flospergher
- Lymphoma Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabrizio Marino
- Lymphoma Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Teresa Calimeri
- Lymphoma Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Andrés José María Ferreri
- Lymphoma Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Ateneo Vita-Salute San Raffaele University, Milan, Italy
| | - Maurilio Ponzoni
- Pathology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Ateneo Vita-Salute San Raffaele University, Milan, Italy
| | - Lucia Bongiovanni
- Pathology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Ateneo Vita-Salute San Raffaele University, Milan, Italy
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14
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Rice ML, Barreto EF, Rule AD, Martin CE, Truong HL, Mara KC, Kashani KB, Thompson CA, Witzig TE, Barreto JN. Development and validation of a model to predict acute kidney injury following high-dose methotrexate in patients with lymphoma. Pharmacotherapy 2024; 44:4-12. [PMID: 37926860 DOI: 10.1002/phar.2889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 11/07/2023]
Abstract
STUDY OBJECTIVE To develop and validate a model for predicting acute kidney injury (AKI) after high-dose methotrexate (HDMTX) exposure. DESIGN Retrospective analysis. SETTING Multisite integrated health system throughout Minnesota and Wisconsin. PATIENTS Adult patients with lymphoma who received HDMTX as a 4-h infusion. MEASUREMENTS AND MAIN RESULTS LASSO methodology was used to identify factors available at the outset of therapy that predicted incident AKI within 7 days following HDMTX. The model was then validated in an independent cohort. The incidence of AKI within 7 days following HDMTX was 21.6% (95% confidence interval (CI) 18.4%-24.8%) in the derivation cohort (435 unique patients who received a total of 1642 doses of HDMTX) and 15.6% (95% CI 5.3%-24.8%) in the validation cohort (55 unique patients who received a total of 247 doses of HDMTX). Factors significantly associated with AKI after HDMTX in the multivariable model included age ≥ 55 years, male sex, and lower HDMTX dose number. Other factors that were not found to be significantly associated with AKI on multivariable analysis, but were included in the final model, were body surface area, Charlson Comorbidity Index, and estimated glomerular filtration rate. The c-statistic of the model was 0.72 (95% CI 0.69-0.75) in the derivation cohort and 0.72 (95% CI 0.60-0.84) in the validation cohort. CONCLUSION This model utilizing identified sociodemographic and clinical factors is predictive of AKI following HDMTX administration in adult patients with lymphoma.
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Affiliation(s)
- Mikhaila L Rice
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew D Rule
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Huong L Truong
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Carrie A Thompson
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas E Witzig
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason N Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
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15
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Aboubakr O, Houillier C, Choquet S, Dupont S, Hoang-Xuan K, Mathon B. Epileptic seizures in patients with primary central nervous system lymphoma: A systematic review. Rev Neurol (Paris) 2023:S0035-3787(23)01116-5. [PMID: 38042665 DOI: 10.1016/j.neurol.2023.08.021] [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: 07/15/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND Primary central nervous system lymphoma (PCNSL) accounts for less than 5% of primary brain tumors. Epileptic seizures are a common manifestation of brain tumors; however, literature on the prevalence, characteristics, and oncological implications of seizures in patients with PCNSL is limited, and the management of antiepileptic drugs (AEDs) is unclear. This review aimed to summarize the existing knowledge on seizures in PCNSL, their potential association with surgery, oncological treatment, survival rates, and management of AEDs. METHODS A systematic review was performed according to the PRISMA recommendations and included articles published between 1953 and 2023 describing seizures in patients with PCNSL. RESULTS The search identified 282 studies, of which 21 were included. Up to 33% of patients with PCNSL developed seizures, mostly at the initial presentation. Little information was found on changes in seizure incidence through the course of the disease, and no details were found on seizure frequency, the percentage of treatment-resistant patients, or the evolution of seizures at remission. Younger age, cortical location, and immunodeficiency have been identified as potential risk factors for seizures, but evidence is very limited. The growing use of vigorous treatments including intensive chemotherapy with autologous stem cell transplantation and immunotherapy with CAR-T cells is associated with a higher incidence of seizures. The association between seizure development and patient mortality in PCNSL remains unknown. There are no data on AED prophylaxis or the use of specific AEDs in PCNSL. CONCLUSIONS Further studies are needed to investigate seizures in larger cohorts of PCNSL, to clarify their prevalence, better characterize them, identify risk factors, analyze survival rates, and make recommendations on AED management. We recommend following general practice guidelines for seizures symptomatic of brain tumors and not to prescribe AED prophylaxis in PCNSL.
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Affiliation(s)
- O Aboubakr
- Sorbonne University, Department of Neurosurgery, la Pitié-Salpêtrière Hospital, AP-HP, 75013 Paris, France
| | - C Houillier
- Department of Neurology 2 Mazarin, la Pitié-Salpêtrière Hospital, IHU, ICM, AP-HP, Sorbonne University, 75013 Paris, France
| | - S Choquet
- Department of Hematology, la Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, 75013 Paris, France
| | - S Dupont
- Epileptology Unit, Department of Rehabilitation, AP-HP, La Pitié-Salpêtrière Hospital, Sorbonne University, 75013 Paris, France
| | - K Hoang-Xuan
- Department of Neurology 2 Mazarin, la Pitié-Salpêtrière Hospital, IHU, ICM, AP-HP, Sorbonne University, 75013 Paris, France
| | - B Mathon
- Sorbonne University, Department of Neurosurgery, la Pitié-Salpêtrière Hospital, AP-HP, 75013 Paris, France; Paris Brain Institute, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne University, UMRS 1127, 75013 Paris, France; GRC 23, Brain Machine Interface, la Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, 75013 Paris, France.
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16
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Bairey O, Lebel E, Buxbaum C, Porges T, Taliansky A, Gurion R, Goldschmidt N, Shina TT, Zektser M, Hofstetter L, Siegal T. A retrospective study of 222 patients with newly diagnosed primary central nervous system lymphoma-Outcomes indicative for improved survival overtime. Hematol Oncol 2023; 41:838-847. [PMID: 37403752 DOI: 10.1002/hon.3198] [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: 03/19/2023] [Accepted: 06/12/2023] [Indexed: 07/06/2023]
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare disease with an incidence of 0.4/per 100,000 person-years. As there is a limited number of prospective randomized trials in PCNSL, large retrospective studies on this rare disease may yield information that might prove useful for the future design of randomized clinical trials. We retrospectively analyzed the data of 222 newly diagnosed PCNSL patients treated in five referral centers in Israel between 2001 and 2020. During this period, combination therapy became the treatment of choice, rituximab has been added to the induction therapy, and consolidation with irradiation was largely laid off and was mostly replaced by high-dose chemotherapy with or without autologous stem cell transplantation (HDC-ASCT). Patients older than 60 comprised 67.5% of the study population. First-line treatment included high-dose methotrexate (HD-MTX) in 94% of patients with a median MTX dose of 3.5 g/m2 (range 1.14-6 g/m2 ) and a median cycle number of 5 (range 1-16). Rituximab was given to 136 patients (61%) and consolidation treatment to 124 patients (58%). Patients treated after 2012 received significantly more treatment with HD-MTX and rituximab, more consolidation treatments, and autologous stem cell transplantation. The overall response rate was 85% and the complete response (CR)/unconfirmed CR rate was 62.1%. After a median follow-up of 24 months, the median progression-free survival (PFS) and overall survival (OS) were 21.9 and 43.5 months respectively with a significant improvement since 2012 (PFS: 12.5 vs. 34.2 p = 0.006 and OS: 19.9 vs. 77.3 p = 0.0003). A multivariate analysis found that the most important factors related to OS were obtaining a CR followed by rituximab treatment and Eastern Cooperative Oncology Group performance status. The observed improvement in outcomes may be due to multiple components such as an intention to treat all patients regardless of age with HD-MTX-based combination chemotherapy, treatment in dedicated centers, and more aggressive consolidation with the introduction of HDC-ASCT.
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Affiliation(s)
- Osnat Bairey
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Lebel
- Department of Hematology, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Chen Buxbaum
- Institute of Oncology, Neuro-Oncology Unit, Rambam Health Care Campus, Haifa, Israel
| | - Tzvika Porges
- Institute of Hematology, Soroka Medical Center, Beer-Sheva, Israel
| | - Alisa Taliansky
- Institute of Oncology, Neuro-Oncology Unit, Sheba Medical Center, Ramat Gan, Israel
| | - Ronit Gurion
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Neta Goldschmidt
- Department of Hematology, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Tzahala Tzuk Shina
- Institute of Oncology, Neuro-Oncology Unit, Rambam Health Care Campus, Haifa, Israel
| | - Miri Zektser
- Institute of Hematology, Soroka Medical Center, Beer-Sheva, Israel
| | - Liron Hofstetter
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tali Siegal
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Neuro-Oncology Center, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel
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17
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Staub-Bartelt F, Rittenauer J, Sabel M, Rapp M. Functional Outcome and Overall Survival in Patients with Primary or Secondary CNS Lymphoma after Surgical Resection vs. Biopsy. Cancers (Basel) 2023; 15:5266. [PMID: 37958439 PMCID: PMC10647498 DOI: 10.3390/cancers15215266] [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: 10/02/2023] [Revised: 10/22/2023] [Accepted: 10/31/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Central nervous system lymphoma (CNSL) is rare form of brain tumour. It manifests either as primary CNS lymphoma (pCNSL) originating within the central nervous system or as secondary CNS lymphoma (sCNSL), arising as cerebral metastases of systemic lymphoma. For a significant period, surgical resection was considered obsolete due to the favourable response to chemotherapy and the associated risk of postoperative deficits. The objective of the present study was to demonstrate the benefits of resection in CNSL patients, including extended survival and improved postoperative function. METHODS A retrospective study involving patients diagnosed with either PCNSL or SCNSL that were surgically approached at our neurosurgical department between 2010 and 2022 was conducted. Patients were categorised into three subgroups based on their neurosurgical approach: (1) stereotactical biopsy, (2) open biopsy, (3) resection. We then performed statistical analyses to assess overall survival (OS) and progression-free survival (PFS). Additionally, we examined various secondary factors such as functional outcome via Karnofsky Performance Index (KPS) and prognosis scoring. RESULTS 157 patients diagnosed with PCNSL or SCNSL were enclosed in the study. Of these, 101 underwent stereotactic biopsy, 21 had open biopsy, and 35 underwent resection. Mean age of the cohort was 64.94 years, with majority of patients being female (54.1%). The resection group showed longest OS at 44 months (open biopsy = 13 months, stereotactic biopsy = 9 months). Calculated median follow-up was 34.5 months. In the Cox regression model, postoperative KPS 70% (p < 0.001) and resection vs. stereotactic biopsy (p = 0.040) were identified as protective factors, whereas older age at diagnosis was identified as a risk factor (p < 0.001). In the one-way analysis of variance, differences in postoperative KPS were found among all groups (p = 0.021), while there was no difference in preoperative KPS among the groups. CONCLUSIONS Our data show a favourable outcome when resection is compared to either stereotactic or open biopsy. Additionally, the marginally improved postoperative functional status observed in patients who underwent resection, as opposed to in those who underwent biopsy, provides further evidence in favour of the advantages of surgical resection for enhancing neurological deficits.
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Affiliation(s)
- Franziska Staub-Bartelt
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany (M.S.); (M.R.)
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18
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Kamp MA, von Sass C, Januzi D, Dibué M, Libourius K, Lawson McLean AC, Baumgarten P, Lawson McLean A, Dinc N, Senft CA. Frequency of social burden and underage children in neuro-oncological patients. J Cancer Res Clin Oncol 2023; 149:15911-15922. [PMID: 37679652 PMCID: PMC10620259 DOI: 10.1007/s00432-023-05338-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/24/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVE Brain tumours can cause significant burden for patients and their families, including physical, psychological, and social challenges. This burden can be particularly difficult for patients with malignant brain tumours and those with underage children. However, the frequency of social burden among neuro-oncological patients and the proportion of patients with underaged children is currently unknown. The aim of this retrospective study is to determine the frequency of social and family dysfunction among neuro-oncological patients, the percentage of such patients who have underage children, and to assess their associated burden. METHODS During a 22-month period, all brain tumour patients were asked to complete a short questionnaire that included epidemiological data, the EORTC-qlq-C30 and -BN20 questionnaire, and the distress thermometer. Data were collected and analysed using Prism 9 for macOS (version 9, GraphPad Prism). RESULTS Our analysis included 881 brain tumour patients, of which 540 were female. Median age was 61 years (ranging from 16 to 88 years). Of all patients, 228 suffered from malignant intracranial tumours. More than half of all patients and more than 65% of patients with malignant tumours reported that their illness or medical treatment interfered with their social activities and family life. Almost 30% of patients reported moderate or severe complaints. About 27% of all patients (and 31% of patients with malignancies) expressed moderate or major concerns that their family life could be disrupted. Among the patients with malignancies, 83.5% of patients had a total of 318 children at the time of tumour diagnosis, with a mean age of 33 ± 0.9. Of these patients with malignancies, 38 (17.9%) had a total of 56 underage children at the time of tumour diagnosis, and currently have 53 underage children. Patients with minor children had more financial worries but less interference of their disease with social activities, less psycho-oncological distress, and a more positive outlook into the future (each, p < 0.0001). They evaluated their general health status and quality of life in the week prior to their current appointment significantly better (each p < 0.0001). CONCLUSION Our study found that 17.9% of patients with malignant brain tumours have underage children. However, having underage children may actually be a positive resource for these patients, as they show lower distress values and better quality of life.
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Affiliation(s)
- Marcel A Kamp
- Centre of Neuro-Oncology, Department of Neurosurgery, Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany.
| | - Christiane von Sass
- Centre of Neuro-Oncology, Department of Neurosurgery, Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Donjetë Januzi
- Centre of Neuro-Oncology, Department of Neurosurgery, Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Maxine Dibué
- Centre of Neuro-Oncology, Department of Neurosurgery, Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Katharina Libourius
- Centre of Neuro-Oncology, Department of Neurosurgery, Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Anna C Lawson McLean
- Centre of Neuro-Oncology, Department of Neurosurgery, Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Peter Baumgarten
- Centre of Neuro-Oncology, Department of Neurosurgery, Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Aaron Lawson McLean
- Centre of Neuro-Oncology, Department of Neurosurgery, Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Nazife Dinc
- Centre of Neuro-Oncology, Department of Neurosurgery, Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Christian A Senft
- Centre of Neuro-Oncology, Department of Neurosurgery, Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
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19
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Ko MK, Kwak YK, Choi BO, Jeun SS, Park JS, Ahn S, Song JH. Is reduced-dose whole-brain radiotherapy also feasible in primary CNS lymphoma for curative or salvage purpose? J Neurooncol 2023; 165:321-328. [PMID: 37964132 DOI: 10.1007/s11060-023-04504-2] [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: 10/13/2023] [Accepted: 11/06/2023] [Indexed: 11/16/2023]
Abstract
PURPOSE Recently, reduced-dose whole-brain radiotherapy (WBRT) has been used to treat primary central nervous system lymphoma (PCNSL). However, whether reduced-dose WBRT is also an acceptable option for curative or salvage purposes has not yet been reported. We analyzed the clinical outcomes of patients with PCNSL who received radiotherapy for curative or salvage purposes and compared the clinical outcomes according to the WBRT dose. METHODS A total of 66 patients were divided into two groups: those treated with 30 Gy (2 Gy per fraction) or less WBRT (low-dose WBRT, n = 34) and those treated with more than 30 Gy WBRT (high-dose WBRT, n = 32). The median WBRT dose was 25.2 and 49.6 Gy in low-dose and high-dose WBRT groups, respectively. The median total radiotherapy dose, including the boost dose, was 50 Gy (range, 36.0-55.8 Gy). RESULTS The 3-year overall survival and progression-free survival were 77.8% and 29.8%, respectively. Intracranial relapse occurred in 31 patients (47.0%) at a median of 27 months after RT. Overall survival and progression-free survival did not differ between the two groups. The 3-year intracranial disease control rate did not differ between the two groups (35.2% vs. 41.6%, p = 0.300). Grade 3 or higher neurological toxicities were observed in six patients, of whom five were in the high-dose WBRT group. CONCLUSION Reduced-dose WBRT in curative and salvage treatments for PCNSL had no significant negative effect on the intracranial disease control rate or survival. Therefore, without impaired efficacy, use of reduced-dose WBRT appears promising for reduction of neurotoxicity.
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Affiliation(s)
- Min-Kyun Ko
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Yoo-Kang Kwak
- Department of Radiation Oncology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 56, Dongsuro, Bupyung-gu, Incheon, 21431, Republic of Korea
| | - Byung-Ock Choi
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Sin-Soo Jeun
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Jae-Sung Park
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Stephen Ahn
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Jin-Ho Song
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.
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20
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Zhan J, Yang S, Zhang W, Zhou D, Zhao D, Zhang Y, Wang W, Wei C. Evaluation of progression-free survival as a surrogate end point in primary CNS lymphoma: a systematic review and meta-analysis. Future Oncol 2023; 19:2123-2133. [PMID: 37882339 DOI: 10.2217/fon-2023-0529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023] Open
Abstract
Purpose: To evaluate progression-free survival (PFS) as early surrogate endpoints for overall survival (OS) in primary CNS lymphoma (PCNSL). Methods: PubMed, Embase and Cochrane Central Library were searched up to 7 June 2022. Trial-level analyses were performed by weighted linear regression of logarithmic hazard ratios for PFS and OS. Treatment arm-level analyses were performed between PFS rates and 3- or 5-year OS rates. Results: 1471 PCNSL patients in nine randomized control trials were included. PFS was associated with OS (r = 0.750; 95% CI: 0.228-0.937). Strong linear correlations existed between 1-, 2- and 3-year PFS and 3-year OS (r = 0.896-0.928), moderate or weak correlations existed between 3- to 6-month PFS and 3-year OS, 3-month to 5-year PFS and 5-year OS. Conclusion: Short-term PFS can validly substitute for long-term OS in PCNSL.
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Affiliation(s)
- Jing Zhan
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Shijie Yang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100029, China
| | - Wei Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Daobin Zhou
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Danqing Zhao
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Yan Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Wei Wang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Chong Wei
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
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21
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Rozenblum L, Galanaud D, Houillier C, Soussain C, Baptiste A, Belin L, Edeline V, Naggara P, Soret M, Causse-Lemercier V, Willems L, Choquet S, Ursu R, Hoang-Xuan K, Kas A. [18F]FDG PET-MRI provides survival biomarkers in primary central nervous system lymphoma in the elderly: an ancillary study from the BLOCAGE trial of the LOC network. Eur J Nucl Med Mol Imaging 2023; 50:3684-3696. [PMID: 37462774 DOI: 10.1007/s00259-023-06334-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/05/2023] [Indexed: 10/04/2023]
Abstract
PURPOSE Primary central nervous system lymphoma (PCNSL) incidence is rising among elderly patients, presenting challenges due to poor prognosis and treatment-related toxicity risks. This study explores the potential of combining [18F]fluorodeoxyglucose ([18F]FDG) PET scans and multimodal MRI for improving management in elderly patients with de novo PCNSL. METHODS Immunocompetent patients over 60 years with de novo PCNSL were prospectively enrolled in a multicentric study between January 2016 and April 2021. Patients underwent brain [18F]FDG PET-MRI before receiving high-dose methotrexate-based chemotherapy. Relationships between extracted PET (metabolic tumor volume (MTV), sum of MTV for up to five lesions (sumMTV), metabolic imaging lymphoma aggressiveness score (MILAS)) and MRI parameters (tumor contrast-enhancement size, cerebral blood volume (CBV), cerebral blood flow (CBF), apparent diffusion coefficient (ADC)) and treatment response and outcomes were analyzed. RESULTS Of 54 newly diagnosed diffuse large B-cell PCNSL patients, 52 had positive PET and MRI with highly [18F]FDG-avid and contrast-enhanced disease (SUVmax: 27.7 [22.8-36]). High [18F]FDG uptake and metabolic volume were significantly associated with low ADCmean values and high CBF at baseline. Among patients, 69% achieved an objective response at the end of induction therapy, while 17 were progressive. Higher cerebellar SUVmean and lower sumMTV at diagnosis were significant predictors of complete response: 6.4 [5.7-7.7] vs 5.4 [4.5-6.6] (p = 0.04) and 5.5 [2.1-13.3] vs 15.9 [4.2-19.5] (p = 0.01), respectively. Two-year overall survival (OS) was 71%, with a median progression-free survival (PFS) of 29.6 months and a median follow-up of 37 months. Larger tumor volumes on PET or enhanced T1-weighted MRI were significant predictors of poorer OS, while a high MILAS score at diagnosis was associated with early death (< 1 year). CONCLUSION Baseline cerebellar metabolism and sumMTV may predict response to end of chemotherapy in PCNSL. Tumor volume and MILAS at baseline are strong prognostic factors.
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Affiliation(s)
- Laura Rozenblum
- Department of Nuclear Medicine, Groupe Hospitalier Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France.
- Sorbonne Université, INSERM, CNRS, Laboratoire d'Imagerie Biomédicale, LIB, Paris, France.
| | - Damien Galanaud
- Sorbonne Université, INSERM, CNRS, Laboratoire d'Imagerie Biomédicale, LIB, Paris, France
- Department of Neuroradiology, Groupe Hospitalier Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
| | - Caroline Houillier
- Deparrment of Neurology 2 Mazarin, APHP, Hôpitaux Universitaires La Pitié Salpêtrière - Charles Foix, Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau, ICM, Paris, France
| | - Carole Soussain
- Department of Hematology, Institut Curie, Site Saint-Cloud and INSERM U932 Institut Curie, Université PSL, 75005, Paris, France
| | - Amandine Baptiste
- Department of Public Health, Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie Et de Santé Publique, AP-HP, Hôpitaux Universitaires Pitié-Salpêtrière - Charles Foix, Paris, France
| | - Lisa Belin
- Department of Public Health, Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie Et de Santé Publique, AP-HP, Hôpitaux Universitaires Pitié-Salpêtrière - Charles Foix, Paris, France
| | | | - Philippe Naggara
- Department of Nuclear Medicine, Groupe Hospitalier Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
| | - Marine Soret
- Department of Nuclear Medicine, Groupe Hospitalier Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
- Sorbonne Université, INSERM, CNRS, Laboratoire d'Imagerie Biomédicale, LIB, Paris, France
| | - Valérie Causse-Lemercier
- Department of Nuclear Medicine, Groupe Hospitalier Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
| | - Lise Willems
- Department of Hematology, Cochin Hospital, APHP, Paris, France
| | - Sylvain Choquet
- Department of Hematology, Groupe Hospitalier Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
| | - Renata Ursu
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Louis, Service de Neurologie, Paris, France
| | - Khê Hoang-Xuan
- Deparrment of Neurology 2 Mazarin, APHP, Hôpitaux Universitaires La Pitié Salpêtrière - Charles Foix, Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau, ICM, Paris, France
| | - Aurélie Kas
- Department of Nuclear Medicine, Groupe Hospitalier Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
- Sorbonne Université, INSERM, CNRS, Laboratoire d'Imagerie Biomédicale, LIB, Paris, France
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22
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Bertucci A, Harlay V, Chinot O, Tabouret E. Primary central nervous system lymphoma (PCNSL) in older patients. Curr Opin Oncol 2023; 35:373-381. [PMID: 37498077 DOI: 10.1097/cco.0000000000000981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Primary central nervous system lymphoma (PCNSL) is a rare, chemo and radio-sensitive tumor limited to the central nervous system. The incidence of PCSNL increases notably in the elderly population which represented approximately half of the patients. The limit of 'elderly' population remained debated and nonuniform, including 60 years as a cutoff for brain radiotherapy, 65 years for autologous stem-cell transplantation, and 70 years for the last clinical trials. Current therapeutic options include first line treatment based on high-dose methotrexate based polychemotherapy, consolidation chemotherapy, and adapted autologous stem cell transplantation for highly selected patients. At relapse, single agent targeted therapies or salvage chemotherapy followed by intensive consolidation are promising therapeutic options. Nevertheless, improving management of elderly patients is an urgent medical need that currently remains unresolved. OBJECTIVE We will focus on elderly patients with PCNSL and their specificities including clinical presentations, available therapeutic options and adaptations to be made. CONCLUSION To improve survival, it will be necessary to personalized and adapt the treatments, to each patient and his comorbidities, to increase their effectiveness and limit their toxicity in this frail population. Finally, inclusion of these patients in clinical trials is one of the major challenges to significantly change PCNSL elderly patient prognosis.
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Affiliation(s)
| | | | - Olivier Chinot
- APHM, CHU Timone, Service de Neurooncologie
- Aix-Marseille University, CNRS, INP, Inst Neurophysiopathol, Marseille, France
| | - Emeline Tabouret
- APHM, CHU Timone, Service de Neurooncologie
- Aix-Marseille University, CNRS, INP, Inst Neurophysiopathol, Marseille, France
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23
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Kaulen LD, Denisova E, Hinz F, Hai L, Friedel D, Henegariu O, Hoffmann DC, Ito J, Kourtesakis A, Lehnert P, Doubrovinskaia S, Karschnia P, von Baumgarten L, Kessler T, Baehring JM, Brors B, Sahm F, Wick W. Integrated genetic analyses of immunodeficiency-associated Epstein-Barr virus- (EBV) positive primary CNS lymphomas. Acta Neuropathol 2023; 146:499-514. [PMID: 37495858 PMCID: PMC10412493 DOI: 10.1007/s00401-023-02613-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 07/28/2023]
Abstract
Immunodeficiency-associated primary CNS lymphoma (PCNSL) represents a distinct clinicopathological entity, which is typically Epstein-Barr virus-positive (EBV+) and carries an inferior prognosis. Genetic alterations that characterize EBV-related CNS lymphomagenesis remain unclear precluding molecular classification and targeted therapies. In this study, a comprehensive genetic analysis of 22 EBV+ PCNSL, therefore, integrated clinical and pathological information with exome and RNA sequencing (RNASeq) data. EBV+ PCNSL with germline controls carried a median of 55 protein-coding single nucleotide variants (SNVs; range 24-217) and 2 insertions/deletions (range 0-22). Genetic landscape was largely shaped by aberrant somatic hypermutation with a median of 41.01% (range 31.79-53.49%) of SNVs mapping to its target motifs. Tumors lacked established SNVs (MYD88, CD79B, PIM1) and copy number variants (CDKN2A, HLA loss) driving EBV- PCNSL. Instead, EBV+ PCNSL were characterized by SOCS1 mutations (26%), predicted to disinhibit JAK/STAT signaling, and mutually exclusive gain-of-function NOTCH pathway SNVs (26%). Copy number gains were enriched on 11q23.3, a locus directly targeted for chromosomal aberrations by EBV, that includes SIK3 known to protect from cytotoxic T-cell responses. Losses covered 5q31.2 (STING), critical for sensing viral DNA, and 17q11 (NF1). Unsupervised clustering of RNASeq data revealed two distinct transcriptional groups, that shared strong expression of CD70 and IL1R2, previously linked to tolerogenic tumor microenvironments. Correspondingly, deconvolution of bulk RNASeq data revealed elevated M2-macrophage, T-regulatory cell, mast cell and monocyte fractions in EBV+ PCNSL. In addition to novel insights into the pathobiology of EBV+ PCNSL, the data provide the rationale for the exploration of targeted therapies including JAK-, NOTCH- and CD70-directed approaches.
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Affiliation(s)
- Leon D Kaulen
- Department of Neurology, University Hospital Heidelberg, Heidelberg University, Heidelberg, Germany.
- Clinical Cooperation Unit (CCU) Neuro-Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - Evgeniya Denisova
- Division of Applied Bioinformatics, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Felix Hinz
- Department of Neuropathology, Heidelberg University Hospital, Heidelberg, Germany
- Clinical Cooperation Unit (CCU) Neuropathology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
| | - Ling Hai
- Clinical Cooperation Unit (CCU) Neuro-Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Dennis Friedel
- Department of Neuropathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Octavian Henegariu
- Department of Neurosurgery, Yale School of Medicine, New Haven, USA
- Department of Genetics, Yale School of Medicine, New Haven, USA
| | - Dirk C Hoffmann
- Department of Neurology, University Hospital Heidelberg, Heidelberg University, Heidelberg, Germany
- Clinical Cooperation Unit (CCU) Neuro-Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Faculty of Biosciences, Heidelberg University, Heidelberg, Germany
| | - Jakob Ito
- Clinical Cooperation Unit (CCU) Neuro-Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Alexandros Kourtesakis
- Clinical Cooperation Unit (CCU) Neuro-Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Pascal Lehnert
- Clinical Cooperation Unit (CCU) Neuro-Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Sofia Doubrovinskaia
- Department of Neurology, University Hospital Heidelberg, Heidelberg University, Heidelberg, Germany
| | - Philipp Karschnia
- Department of Neurosurgery, Munich University Hospital, Ludwig Maximilians University (LMU) Munich, and German Cancer Consortium (DKTK) Partner Site, Munich, Germany
| | - Louisa von Baumgarten
- Department of Neurosurgery, Munich University Hospital, Ludwig Maximilians University (LMU) Munich, and German Cancer Consortium (DKTK) Partner Site, Munich, Germany
| | - Tobias Kessler
- Department of Neurology, University Hospital Heidelberg, Heidelberg University, Heidelberg, Germany
- Clinical Cooperation Unit (CCU) Neuro-Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Joachim M Baehring
- Department of Neurosurgery, Yale School of Medicine, New Haven, USA
- Department of Neurology, Yale School of Medicine, New Haven, USA
| | - Benedikt Brors
- Division of Applied Bioinformatics, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Felix Sahm
- Department of Neuropathology, Heidelberg University Hospital, Heidelberg, Germany.
- Clinical Cooperation Unit (CCU) Neuropathology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany.
| | - Wolfgang Wick
- Department of Neurology, University Hospital Heidelberg, Heidelberg University, Heidelberg, Germany.
- Clinical Cooperation Unit (CCU) Neuro-Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
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Fiedler AM, Filho PMM, Morassutti AL, Rottenfusser R, Varela DL. Primary central nervous system lymphoma in elderly: An illustrative case of the new role of surgery and integrative medical management. Surg Neurol Int 2023; 14:310. [PMID: 37810284 PMCID: PMC10559532 DOI: 10.25259/sni_431_2023] [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: 05/19/2023] [Accepted: 08/17/2023] [Indexed: 10/10/2023] Open
Abstract
Background Primary central nervous system lymphoma (PCNSL) is a rare, aggressive non-Hodgkin lymphoproliferative neoplasm. Surgery is traditionally limited to biopsy due to past studies, but recent strong evidence continues to challenge this status quo in selected patients. Here, the authors characterize a case to illustrate the potential role of surgery and foster research on integrative medical management approaches for this disease. Case Description A 73-year-old woman was admitted to the hospital with aphasia and confusion. Neuroimaging suggested a lymphoproliferative process. The patient underwent cytoreductive surgery to resect the lesion. Microscopically, large infiltrating lymphoid cells that induced brain tissue damage were observed, and a diagnosis of diffuse large B-cell lymphoma was made based on immunohistochemistry. The patient evolved clinically post surgery. A complete response to further chemotherapy maintained the patient's clinical recovery. Conclusion This rare case highlights the potential of surgical intervention in the management of selected patients with PCNSL. The authors also underscore the recent, meta-analytic evidence on surgery followed by combined chemotherapy for the management of specific cases. The reported recovery in an elderly patient is noteworthy and adds to the literature on this rare subtype of brain tumors. Future research should consider investigating a potential profile of candidates for resection and combined chemotherapy in PCNSL.
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Affiliation(s)
- Augusto Müller Fiedler
- Department of Neurological Surgery, University of Miami Hospital, Miami, Florida, United States
| | - Paulo Moacir Mesquita Filho
- Department of Neurosurgery, Affiliated Hospital of Atitus Education School of Medicine, Rio Grande do Sul, Brazil
| | - Alessandra Loureiro Morassutti
- Department of Pathology, School of Medicine and Postgraduate Program in Dentistry, University of Passo Fundo, Passo Fundo, Rio Grande do Sul, Brazil
| | - Robson Rottenfusser
- Department of Radiology, Affiliated Hospital of Atitus Education School of Medicine, Passo Fundo, Rio Grande do Sul, Brazil
| | - Daniel Lima Varela
- Department of Neurology, Affiliated Hospital of Atitus Education School of Medicine, Passo Fundo, Rio Grande do Sul, Brazil
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25
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Schenone L, Alcantara M, Houillier C, Soussain C. First line treatments in primary central nervous system lymphomas in young patients. Curr Opin Oncol 2023; 35:357-363. [PMID: 37498049 DOI: 10.1097/cco.0000000000000975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
PURPOSE OF REVIEW The aim of this review is to provide an update on current first-line treatments as well as on-going studies in immunocompetent patients with primary central nervous system lymphomas. RECENT FINDINGS High-dose methotrexate (HD-MTX)-based polychemotherapy is widely used in induction treatment (IT). Among HD-MTX-based regimens, the best association is not yet defined. IT should be followed by a consolidation or a maintenance according to patient's age and performance status. Thiotepa-based intensive chemotherapy (IC) followed by autologous stem cell transplantation (ASCT) has improved survival in eligible patients compared to a nonmyeloablative consolidation. Because of the high risk of neurotoxicity, conventional whole brain radiotherapy (WBRT; 36-40 Gy) has been abandoned. Reduced-WBRT (23.4 Gy) is an alternative option in patients under 60 years-old in complete response after IT. Its safety remains to be demonstrated in elderly patients. The benefit of maintenance strategies to reduce the risk of relapse is being assessed in several studies in patients beyond 70 years-old. SUMMARY HD-MTX-based polychemotherapy remains the corner stone of the IT, but the best regimen is not yet defined. Clinical trials assessing new IT regimens are ongoing. Intensive consolidation with IC + ASCT benefits patients up to 70 years-old. Predictive factors are under investigation to better define therapeutic response and guide treatment adjustment.
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Affiliation(s)
- Laurence Schenone
- Department of Hematology, CHRU de Nancy, Hôpitaux de Brabois
- Department of Neurology, CHRU de Nancy, Hôpital Central, Nancy
| | - Marion Alcantara
- Center for Cancer Immunotherapy, INSERM Unité 932, Institut Curie, PSL Research University, Paris
- Clinical Hematology Unit, Institut Curie, St Cloud
| | - Caroline Houillier
- Neuro-Oncology Department, Hôpital Pitié Salpêtrière, APHP, Sorbonne Université, IHU, ICM, Paris, France
| | - Carole Soussain
- Center for Cancer Immunotherapy, INSERM Unité 932, Institut Curie, PSL Research University, Paris
- Clinical Hematology Unit, Institut Curie, St Cloud
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26
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Scheichel F, Popadic B, Pinggera D, Jaskolski DJ, Lubrano V, Foroglou N, Netuka D, Iliescu B, Novak L, Sherif C, Marhold F, Freyschlag CF. European survey on neurosurgical management of primary central nervous system lymphomas and preoperative corticosteroid therapy. BRAIN & SPINE 2023; 3:101791. [PMID: 38020980 PMCID: PMC10668066 DOI: 10.1016/j.bas.2023.101791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/29/2023] [Accepted: 08/11/2023] [Indexed: 12/01/2023]
Abstract
Introduction Preoperative corticosteroid therapy (CST) is common in primary central nervous system lymphoma (PCNSL) and may complicate histopathological diagnosis. There is an ongoing debate on the best management after preoperative CST. Research question We aimed to survey how different European neurosurgical units treat PCNSL patients after preoperative CST. Methods An English-language survey consisting of 21 questions addressing the management of patients with suspected PCNSL and preoperative CST was sent to European hospitals. The survey also included three clinical cases to assess the decision-making process in a clinical setting. Results The survey was completed by 74 European hospitals. There was no clear consensus on how to treat a patient with PCNSL after CST. Accordingly, 24.3% responded that they would generally defer surgery regardless of a possible radiological response, 47.3% would defer surgery only if there is regression in preoperative MRI and the remaining 28.4% would defer surgery only if the tumor had completely vanished. Furthermore, there were distinct discrepancies in responses of neurosurgical units regarding their general management approach and their case-based decision in the three example cases. The results of our survey also showed regional differences and differences in treatment decisions between high-, intermediate- and low-volume centers. Discussion and conclusion There was no clear consensus on how to treat patients with suspected PCNSL and preoperative CST. Furthermore, most centers also showed inconsistencies in their responses regarding their general approach as well as individual patient treatment. More high-quality evidence-based recommendations are needed to improve consensus and thus patient care.
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Affiliation(s)
- Florian Scheichel
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Department of Neurosurgery, University Hospital St. Poelten, St. Poelten, Austria
| | - Branko Popadic
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Department of Neurosurgery, University Hospital St. Poelten, St. Poelten, Austria
| | - Daniel Pinggera
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Dariusz J. Jaskolski
- Department of Neurosurgery and Neurooncology Medical University of Lodz, Norbert Barlicki University Hospital, Lodz, Poland
| | - Vincent Lubrano
- Clinique de l'Union, Saint Jean, France
- ToNIC, Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Nicolas Foroglou
- Aristotle University of Thessaloniki, School of Medicine, Thessaloniki, Greece
| | - David Netuka
- Central Military Hospital, Prague, Czech Republic
| | - Bogdan Iliescu
- Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Laszlo Novak
- Department of Neurosurgery, Clinical Centre, University of Debrecen, Debrecen, Hungary
| | - Camillo Sherif
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Department of Neurosurgery, University Hospital St. Poelten, St. Poelten, Austria
| | - Franz Marhold
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Department of Neurosurgery, University Hospital St. Poelten, St. Poelten, Austria
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Rachdi A, Hernandez-Tost H, Herzi D, Morales-Martinez A, Hernández-Verdin I, Houillier C, Alentorn A, Hoang-Xuan K. Recent advances in the diagnosis and the treatment of primary CNS lymphoma. Rev Neurol (Paris) 2023; 179:481-489. [PMID: 37045615 DOI: 10.1016/j.neurol.2023.03.012] [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: 03/06/2023] [Accepted: 03/11/2023] [Indexed: 04/14/2023]
Abstract
This review focuses on the recent progress in the management of primary central nervous system lymphoma (PCNSL). Multiomic analyses allowed to better understand the tumorigenesis of PCNSL and to establish a molecular classification with prognostic value that will optimize patient management and guide future targeted approaches. Cooperative clinical trials have demonstrated the feasibility and efficacy, in selected fit patients, of high-dose chemotherapy with autologous stem cell transplantation as post-induction consolidation, that will progressively replace whole brain radiotherapy associated with a much higher risk of delayed neurotoxicity. Several novel treatments have shown efficacy and overall good tolerance in PCNSL patients, such as Bruton's tyrosine kinase (BTK) inhibitors, imids, immune checkpoint inhibitors and chimeric antigen receptor T-cells (CAR-T). This opens promising therapeutic perspectives to improve the current standard treatment, especially for elderly and unfit patients who represent a growing population.
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Affiliation(s)
- A Rachdi
- Service de neurologie 2, CHU Pitié-Salpêtrière, AP-HP, Sorbonne université, 47, boulevard de l'hôpital, 75013 Paris, France; Institut Mongi Ben Hamida de neurologie de Tunis, Tunis, Tunisia
| | - H Hernandez-Tost
- Service de neurologie 2, CHU Pitié-Salpêtrière, AP-HP, Sorbonne université, 47, boulevard de l'hôpital, 75013 Paris, France
| | - D Herzi
- Service de neurologie 2, CHU Pitié-Salpêtrière, AP-HP, Sorbonne université, 47, boulevard de l'hôpital, 75013 Paris, France
| | - A Morales-Martinez
- Service de neurologie 2, CHU Pitié-Salpêtrière, AP-HP, Sorbonne université, 47, boulevard de l'hôpital, 75013 Paris, France
| | | | - C Houillier
- Service de neurologie 2, CHU Pitié-Salpêtrière, AP-HP, Sorbonne université, 47, boulevard de l'hôpital, 75013 Paris, France; LOC network, France
| | - A Alentorn
- Service de neurologie 2, CHU Pitié-Salpêtrière, AP-HP, Sorbonne université, 47, boulevard de l'hôpital, 75013 Paris, France; Brain Institute-ICM, Inserm, Sorbonne université, CNRS, Paris, France; LOC network, France
| | - K Hoang-Xuan
- Service de neurologie 2, CHU Pitié-Salpêtrière, AP-HP, Sorbonne université, 47, boulevard de l'hôpital, 75013 Paris, France; Brain Institute-ICM, Inserm, Sorbonne université, CNRS, Paris, France; LOC network, France.
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Bromberg J, Doorduijn J. Is there a future for maintenance temozolomide chemotherapy in PCNSL? Neuro Oncol 2023; 25:699-700. [PMID: 36655502 PMCID: PMC10076937 DOI: 10.1093/neuonc/noad015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Indexed: 01/20/2023] Open
Affiliation(s)
- Jacoline E C Bromberg
- Department of Neuro-Oncology, Erasmus MC University Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Jeanette K Doorduijn
- Department of Hematology, Erasmus MC University Medical Center Cancer Institute, Rotterdam, The Netherlands
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Bravetti C, Degaud M, Armand M, Sourdeau E, Mokhtari K, Maloum K, Osman J, Verrier P, Houillier C, Roos-Weil D, Soussain C, Choquet S, Hoang-Xuan K, Le Garff-Tavernier M, Denis JA, Davi F. Combining MYD88 L265P mutation detection and clonality determination on CSF cellular and cell-free DNA improves diagnosis of primary CNS lymphoma. Br J Haematol 2023. [PMID: 36941788 DOI: 10.1111/bjh.18758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/22/2023] [Accepted: 03/07/2023] [Indexed: 03/23/2023]
Abstract
Diagnosis of primary central nervous system lymphoma (PCNSL) is challenging, and although brain biopsy remains the gold standard, cerebrospinal fluid (CSF) constitutes a less invasive source of lymphomatous biomarkers. In a retrospective cohort of 54 PCNSL cases tested at diagnosis or relapse, we evaluated the contribution of immunoglobulin heavy chain (IGH) gene clonality and MYD88 L265P detection on both CSF cell pellets and supernatants, in comparison with cytology, flow cytometry, interleukin (IL)-10 and IL-6 quantification. Clonality assessment included a new assay to detect partial IGH-DJ rearrangements. Clonal IGH rearrangements and/or MYD88 L265P mutation were detected in 27 (50%) cell pellets and 24 (44%) supernatant cell-free (cf) DNA. Combining analyses on both compartments, 36 (66%) cases had at least one detectable molecular marker, present only in cfDNA for 9 (16%) of them. While cytology and flow cytometry were positive in only 7 (13.0%) and 9 (17.3%) cases respectively, high IL-10 levels were observed in 36 (66.7%) cases. Overall, taking into account molecular and cytokine results, 46/54 (85%) cases had at least one lymphomatous biomarker detectable in the CSF. These results show that this combination of biomarkers evaluated on both cell pellet and supernatant CSF fractions improves significantly the biological diagnosis of PCNSL.
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Affiliation(s)
- Clotilde Bravetti
- Department of Biological Hematology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) and Sorbonne Université, Paris, France
| | - Michaël Degaud
- Department of Biological Hematology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) and Sorbonne Université, Paris, France
| | - Marine Armand
- Department of Biological Hematology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) and Sorbonne Université, Paris, France
| | - Elise Sourdeau
- Department of Biological Hematology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) and Sorbonne Université, Paris, France
| | - Karima Mokhtari
- Department of Neuropathology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Karim Maloum
- Department of Biological Hematology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) and Sorbonne Université, Paris, France
| | - Jennifer Osman
- Department of Biological Hematology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) and Sorbonne Université, Paris, France
| | - Patricia Verrier
- Department of Biological Hematology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) and Sorbonne Université, Paris, France
| | - Caroline Houillier
- Department of Neurology-2, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), IHU, ICM, Sorbonne Université, Paris, France
| | - Damien Roos-Weil
- Department of Clinical Hematology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) and Sorbonne Université, Paris, France
| | - Carole Soussain
- Division of Hematology, Institut Curie, Site Saint-Cloud, and INSERM U932, PSL Research University, Paris, France
| | - Sylvain Choquet
- Department of Clinical Hematology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) and Sorbonne Université, Paris, France
| | - Khe Hoang-Xuan
- Department of Neurology-2, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), IHU, ICM, Sorbonne Université, Paris, France
| | - Magali Le Garff-Tavernier
- Department of Biological Hematology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) and Sorbonne Université, Paris, France
| | - Jérôme Alexandre Denis
- Department of Endocrine and Oncological Biochemistry, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) and Sorbonne Université, Centre de recherche Saint-Antoine (UMR_S 938), Biologie et thérapeutiques du cancer, Paris, France
| | - Frédéric Davi
- Department of Biological Hematology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) and Sorbonne Université, Paris, France
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Long term outcomes in older patients with primary central nervous system lymphoma: an analysis of the Texas Cancer Registry. Ann Hematol 2023; 102:1111-1120. [PMID: 36922432 DOI: 10.1007/s00277-023-05140-6] [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: 12/16/2022] [Accepted: 02/15/2023] [Indexed: 03/18/2023]
Abstract
Primary central nervous system lymphoma (PCNSL) is an aggressive subtype of non-Hodgkin lymphoma that carries a poor prognosis in the elderly. The aim of this study is to investigate treatment patterns and survival trends in patients ≥ 65 years with PCNSL through data provided by the Texas Cancer Registry. Adults ≥ 65 years diagnosed with PCNSL and followed between 1995-2017 were identified and separated into three eras: 1995-2003, 2004-2012, and 2013-2017. Baseline covariates compared included patient demographics and treatments administered. Pearson's chi-squared test and Cox proportional hazard models compared covariates; overall survival (OS) and disease-specific survival (DSS) were assessed via Kaplan-Meier methodology. There were 375 patients; 104 (27.7%) in 1995-2003, 146 (38.9%) in 2004-2012, and 125 (33.3%) in 2013-2017. There were 50 (48.1%), 55 (37.7%), and 31 (24.8%) in 1995-2003, 2004-2012, and 2013-2017, respectively, that did not receive treatment. At last follow up, 101 (97.1%), 130 (89.0%), and 94 (75.2%) in each era died, of which 89 (85.6%), 112 (76.7%), and 70 (56.0%) were attributed to PCNSL. Median OS per era was eight (95% confidence interval [CI] 5.06-10.93), six (95% CI, 2.30-9.69), and five months (95% CI, 2.26-7.73) (p = 0.638). DSS per era was nine (95% CI: 0.00, 26.53), 10 (95% CI: 5.14, 14.86), and 19 (95% CI, 0.00-45.49) (p = 0.931) months. Spinal cord as primary disease site (HR: 0.668 [95% CI, 0.45-0.99], p = 0.049), and chemotherapy (HR 0.532 [95% CI, 0.42-0.673], p = < 0.001) or chemotherapy + radiation (HR, 0.233 [95% CI, 0.11-0.48] p < 0.001) had better outcomes compared to no therapy or radiation therapy alone. Survival in older patients ≥ 65 with PCNSL has not improved per our analysis of the TCR from 1995-2017 despite increasing trends of treatment utilization. Strategies to augment recruitment of older individuals in trials are needed in order to determine who would derive treatment benefit and minimize treatment toxicities.
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Seidel S, Kowalski T, Nilius-Eliliwi V, Schroers R, Schlegel U. Survival, prognostic factors, hospitalization time and clinical performance status after first cerebral relapse or progression in 54 patients with primary CNS lymphoma not eligible for high dose chemotherapy: a retrospective analysis. Neurol Res Pract 2023; 5:8. [PMID: 36814351 PMCID: PMC9948364 DOI: 10.1186/s42466-023-00234-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 02/08/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Treatment of relapsed or refractory primary CNS lymphoma (r/r PCNSL) is difficult, particularly in patients not eligible for high dose chemotherapy with autologous stem cell transplantation (HDC-ASCT). No standard treatment has been defined for these patients yet. METHODS We retrospectively analyzed survival, prognostic factors, hospitalization time and Karnofsky performance score (KPS) before and after treatment in 54 r/r PCNSL patients with isolated cerebral relapse or progression (n = 23 refractory, n = 31 relapsed) not eligible for HDC-ASCT, who received heterogenous salvage treatments. RESULTS Treatments were temozolomide (+ rituximab) (n = 21), high dose methotrexate (HD-MTX)-based therapy (n = 11), whole brain radiotherapy (WBRT)/focal radiotherapy (n = 11), other systemic treatments (n = 2) and best supportive care (BSC, n = 9). Median progression free survival (PFS) and overall survival (OS) were 2.6 months (95% CI 1.0-4.2 months) and 4.8 months (95% CI 3.3-6.3 months), respectively. Eight patients survived for ≥ 3 years (13.1%, n = 3 received temozolomide, n = 3 WBRT, n = 2 HD-MTX-based treatment). Application of any salvage treatment (vs. BSC), younger age at relapse and asymptomatic (vs. symptomatic) relapse were positive prognostic factors. No significant differences in OS were found for the different salvage treatments. Median hospitalization time for treatment was 15/13 days for temozolomide (+ rituximab)/radiotherapy compared to 55 days for HD-MTX-based therapy. Median KPS in assessable patients (n = 41) was 60 (range 30-100) before treatment and 50 (range 20-90) after treatment. In patients with response to treatment (n = 16) KPS improved from 60 (range 40-90) before treatment to 70 (range 50-90) after treatment, while patients with PD (n = 25) deteriorated from 60 (range 30-100) to 40 (range 20-70). CONCLUSION Survival for this cohort of r/r PCNSL patients with isolated cerebral relapse or progression was poor. Considering long hospital stays associated with HD-MTX-based chemotherapy and neurotoxicity associated with WBRT, temozolomide might be worth considering with a chance of prolonged survival and avoidance of long hospitalization. Novel therapeutic agents are urgently needed to improve survival in r/r PCNSL patients.
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Affiliation(s)
- Sabine Seidel
- Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23-25, 44892, Bochum, Germany.
| | - Thomas Kowalski
- grid.5570.70000 0004 0490 981XDepartment of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23-25, 44892 Bochum, Germany
| | - Verena Nilius-Eliliwi
- grid.5570.70000 0004 0490 981XDepartment of Hematology and Oncology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23-25, 44892 Bochum, Germany
| | - Roland Schroers
- grid.5570.70000 0004 0490 981XDepartment of Hematology and Oncology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23-25, 44892 Bochum, Germany
| | - Uwe Schlegel
- grid.5570.70000 0004 0490 981XDepartment of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23-25, 44892 Bochum, Germany
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Abstract
Importance Malignant primary brain tumors cause more than 15 000 deaths per year in the United States. The annual incidence of primary malignant brain tumors is approximately 7 per 100 000 individuals and increases with age. Five-year survival is approximately 36%. Observations Approximately 49% of malignant brain tumors are glioblastomas, and 30% are diffusely infiltrating lower-grade gliomas. Other malignant brain tumors include primary central nervous system (CNS) lymphoma (7%) and malignant forms of ependymomas (3%) and meningiomas (2%). Symptoms of malignant brain tumors include headache (50%), seizures (20%-50%), neurocognitive impairment (30%-40%), and focal neurologic deficits (10%-40%). Magnetic resonance imaging before and after a gadolinium-based contrast agent is the preferred imaging modality for evaluating brain tumors. Diagnosis requires tumor biopsy with consideration of histopathological and molecular characteristics. Treatment varies by tumor type and often includes a combination of surgery, chemotherapy, and radiation. For patients with glioblastoma, the combination of temozolomide with radiotherapy improved survival when compared with radiotherapy alone (2-year survival, 27.2% vs 10.9%; 5-year survival, 9.8% vs 1.9%; hazard ratio [HR], 0.6 [95% CI, 0.5-0.7]; P < .001). In patients with anaplastic oligodendroglial tumors with 1p/19q codeletion, probable 20-year overall survival following radiotherapy without vs with the combination of procarbazine, lomustine, and vincristine was 13.6% vs 37.1% (80 patients; HR, 0.60 [95% CI, 0.35-1.03]; P = .06) in the EORTC 26951 trial and 14.9% vs 37% in the RTOG 9402 trial (125 patients; HR, 0.61 [95% CI, 0.40-0.94]; P = .02). Treatment of primary CNS lymphoma includes high-dose methotrexate-containing regimens, followed by consolidation therapy with myeloablative chemotherapy and autologous stem cell rescue, nonmyeloablative chemotherapy regimens, or whole brain radiation. Conclusions and Relevance The incidence of primary malignant brain tumors is approximately 7 per 100 000 individuals, and approximately 49% of primary malignant brain tumors are glioblastomas. Most patients die from progressive disease. First-line therapy for glioblastoma is surgery followed by radiation and the alkylating chemotherapeutic agent temozolomide.
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Affiliation(s)
- Lauren R Schaff
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Ingo K Mellinghoff
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Neurology, Weill Cornell Medicine, New York, New York
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Pharmacology, Weill Cornell Medicine, New York, New York
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Kuitunen HK, Rönkä ALK, Sonkajärvi EM, Isokangas JM, Pyörälä M, Palosaari KAA, Jokimäki AS, Partanen AE, Littow HJ, Vakkala MA, Jantunen EJ, Huttunen ME, Marin KJ, Aromaa-Häyhä AMK, Auvinen PK, Selander T, Puhakka IK, Kuittinen OM. Blood-Brain Barrier Disruption (BBBD)-Based Immunochemotherapy for Primary Central Nervous System Lymphoma (PCNSL), Early Results of a Phase II Study. Cancers (Basel) 2023; 15:cancers15041341. [PMID: 36831682 PMCID: PMC9953868 DOI: 10.3390/cancers15041341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 02/07/2023] [Accepted: 02/17/2023] [Indexed: 02/22/2023] Open
Abstract
Primary central nervous system lymphoma is a rare but aggressive brain malignancy. It is associated with poor prognosis even with the current standard of care. The aim of this study was to evaluate the effect and tolerability of blood-brain barrier disruption treatment combined with high-dose treatment with autologous stem cell transplantation as consolidation on primary central nervous system lymphoma patients. We performed a prospective phase II study for 25 patients with previously untreated primary central nervous system lymphoma. The blood-brain barrier disruption treatment was initiated 3-4 weeks after the MATRix regimen using the previously optimized therapy protocol. Briefly, each chemotherapy cycle included two subsequent intra-arterial blood-brain barrier disruption treatments on days 1 and 2 via either one of the internal carotid arteries or vertebral arteries. Patients received the therapy in 3-week intervals. The treatment was continued for two more courses after achieving a maximal radiological response to the maximum of six courses. The complete treatment response was observed in 88.0% of the patients. At the median follow-up time of 30 months, median progression-free and overall survivals were not reached. The 2-year overall and progression-free survival rates were 67.1% and 70.3%, respectively. Blood-brain barrier disruption treatment is a promising option for primary central nervous system lymphoma with an acceptable toxicity profile.
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Affiliation(s)
- Hanne K. Kuitunen
- Cancer Center, Oulu University Hospital, 90220 Oulu, Finland
- Correspondence: ; Tel.: +358-503561799
| | - Aino L. K. Rönkä
- Department of Oncology and Radiotherapy, Kuopio University Hospital, 70210 Kuopio, Finland
| | - Eila M. Sonkajärvi
- Surgery and Anaesthesia Center, Oulu University Hospital, 90220 Oulu, Finland
| | - Juha-Matti Isokangas
- Service for Medical Care, Oulu University Hospital Diagnostics, 90220 Oulu, Finland
| | - Marja Pyörälä
- Department of Medicine, Kuopio University Hospital, 70210 Kuopio, Finland
| | - Kari A. A. Palosaari
- Service for Medical Care, Oulu University Hospital Diagnostics, 90220 Oulu, Finland
| | | | - Anu E. Partanen
- Department of Medicine, Kuopio University Hospital, 70210 Kuopio, Finland
| | - Harri J. Littow
- Service for Medical Care, Oulu University Hospital Diagnostics, 90220 Oulu, Finland
| | - Merja A. Vakkala
- Surgery and Anaesthesia Center, Oulu University Hospital, 90220 Oulu, Finland
- Medical Research Center Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, 90220 Oulu, Finland
| | - Esa J. Jantunen
- Department of Medicine, Kuopio University Hospital, 70210 Kuopio, Finland
- Institute of Clinical Medicine, University of Eastern Finland and Department of Medicine, 70210 Kuopio, Finland
- Hospital District of North Carelia, Joensuu Central Hospital, 80210 Joensuu, Finland
| | - Mirja E. Huttunen
- Surgery and Anaesthesia Center, Oulu University Hospital, 90220 Oulu, Finland
| | - Katja J. Marin
- Department of Oncology and Radiotherapy, Kuopio University Hospital, 70210 Kuopio, Finland
| | | | - Päivi K. Auvinen
- Department of Oncology and Radiotherapy, Kuopio University Hospital, 70210 Kuopio, Finland
| | - Tuomas Selander
- Science Service Center, Kuopio University Hospital, 70210 Kuopio, Finland
| | - Inka K. Puhakka
- Department of Neurology, Kuopio University Hospital, 70210 Kuopio, Finland
| | - Outi M. Kuittinen
- Department of Oncology and Radiotherapy, Kuopio University Hospital, 70210 Kuopio, Finland
- School of Medicine, Institute of Clinical Medicine, Oncology, Faculty of Medicine, University of Eastern Finland, 70210 Kuopio, Finland
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Kamepalli H, Kalaparti V, Kesavadas C. Imaging Recommendations for the Diagnosis, Staging, and Management of Adult Brain Tumors. Indian J Med Paediatr Oncol 2023. [DOI: 10.1055/s-0042-1759712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
AbstractNeuroimaging plays a pivotal role in the clinical practice of brain tumors aiding in the diagnosis, genotype prediction, preoperative planning, and prognostication. The brain tumors most commonly seen in adults are extra-axial lesions like meningioma, intra-axial lesions like gliomas and lesions of the pituitary gland. Clinical features may be localizing like partial seizures, weakness, and sensory disturbances or nonspecific like a headache. On clinical suspicion of a brain tumor, the primary investigative workup should focus on imaging. Other investigations like fundoscopy and electroencephalography may be performed depending on the clinical presentation. Obtaining a tissue sample after identifying a brain tumor on imaging is crucial for confirming the diagnosis and planning further treatment. Tissue sample may be obtained by techniques such as stereotactic biopsy or upfront surgery. The magnetic resonance (MR) imaging protocol needs to be standardized and includes conventional sequences like T1-weighted (T1W) imaging with and without contrast, T2w imaging, fluid-attenuated axial inversion recovery, diffusion-weighted imaging (DWI), susceptibility-weighted imaging, and advanced imaging sequences like MR perfusion and MR spectroscopy. Various tumor characteristics in each of these sequences can help us narrow down the differential diagnosis and also predict the grade of the tumor. Multidisciplinary co-ordination is needed for proper management and care of brain tumor patients. Treatment protocols need to be adapted and individualized for each patient depending on the age, general condition of the patient, histopathological characteristics, and genotype of the tumor. Treatment options include surgery, radiotherapy, and chemotherapy. Imaging also plays a vital role in post-treatment follow-up. Sequences like DWI, MR perfusion, and MR spectroscopy are useful to distinguish post-treatment effects like radiation necrosis and pseudoprogression from true recurrence. Radiological reporting of brain tumor images should follow a structured format to include all the elements that could have an impact on the treatment decisions in patients.
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Affiliation(s)
- HariKishore Kamepalli
- Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Viswanadh Kalaparti
- Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Chandrasekharan Kesavadas
- Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, Kerala, India
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Delphine L, Pierre-Edouard D, Bruno R, Bérengère G, Magalie J, Patrick V, Jean-Pierre M, Pierre M. Thiotepa, Busulfan, Cyclophosphamide: Effective but Toxic Conditioning Regimen Prior to Autologous Hematopoietic Stem Cell Transplantation in Central Nervous System Lymphoma. Med Sci (Basel) 2023; 11:medsci11010014. [PMID: 36810481 PMCID: PMC9944873 DOI: 10.3390/medsci11010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/16/2023] [Accepted: 01/22/2023] [Indexed: 02/03/2023] Open
Abstract
In primary central nervous system lymphoma, two-year progression-free survival rates of up to 63 percent have been reported for first-line autologous stem cell transplantation after conditioning with the thiotepa busulfan cyclophosphamide regimen. However, 11 percent of the patients died due to toxicity. Besides conventional survival, progression-free survival and treatment related mortality analyses, a competing-risk analysis was applied to our cohort of twenty-four consecutive patients with primary or secondary central nervous system lymphoma who underwent autologous stem cell transplantation after thiotepa busulfan cyclophosphamide conditioning. The two-year overall survival and progression-free survival rates were 78 percent and 65 percent, respectively. The treatment-related mortality rate was 21 percent. The competing risks analysis demonstrate that age 60 or over and the infusion of less than 4.6 × 106/kg CD34+ stem cells were significant adverse prognostic factors for overall survival. Autologous stem cell transplantation with thiotepa busulfan cyclophosphamide conditioning was associated with sustained remission and survival. Nevertheless, the intensive thiotepa busulfan cyclophosphamide conditioning regimen was highly toxic, especially in older patients. Thus, our results suggest that future studies should aim at identifying the subgroup of patients who will really benefit of the procedure and/or to reduce the toxicity of future conditioning regimen.
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Affiliation(s)
- Lebon Delphine
- Hématologie Clinique et Thérapie Cellulaire, Centre Hospitalier Universitaire Amiens-Picardie, 80000 Amiens, France
- Correspondence: (L.D.); (D.P.-E.)
| | - Debureaux Pierre-Edouard
- Hématologie Clinique, Hôpital Saint-Louis, Assistance Publique—Hôpitaux de Paris, 75014 Paris, France
- Correspondence: (L.D.); (D.P.-E.)
| | - Royer Bruno
- Hématologie Clinique, Hôpital Saint-Louis, Assistance Publique—Hôpitaux de Paris, 75014 Paris, France
| | - Gruson Bérengère
- Hématologie Clinique et Thérapie Cellulaire, Centre Hospitalier Universitaire Amiens-Picardie, 80000 Amiens, France
| | - Joris Magalie
- Hématologie Clinique et Thérapie Cellulaire, Centre Hospitalier Universitaire Amiens-Picardie, 80000 Amiens, France
| | - Votte Patrick
- Hématologie Clinique et Thérapie Cellulaire, Centre Hospitalier Universitaire Amiens-Picardie, 80000 Amiens, France
| | - Marolleau Jean-Pierre
- Hématologie Clinique et Thérapie Cellulaire, Centre Hospitalier Universitaire Amiens-Picardie, 80000 Amiens, France
| | - Morel Pierre
- Hématologie Clinique et Thérapie Cellulaire, Centre Hospitalier Universitaire Amiens-Picardie, 80000 Amiens, France
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36
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Renovanz M, Kurz SC, Rieger J, Walter B, Becker H, Hille H, Bombach P, Rieger D, Grosse L, Häusser L, Skardelly M, Merk DJ, Paulsen F, Hoffmann E, Gani C, Neumann M, Beschorner R, Rieß O, Roggia C, Schroeder C, Ossowski S, Armeanu-Ebinger S, Gschwind A, Biskup S, Schulze M, Fend F, Singer S, Zender L, Lengerke C, Brucker SY, Engler T, Forschner A, Stenzl A, Kohlbacher O, Nahnsen S, Gabernet G, Fillinger S, Bender B, Ernemann U, Öner Ö, Beha J, Malek HS, Möller Y, Ruhm K, Tatagiba M, Schittenhelm J, Bitzer M, Malek N, Zips D, Tabatabai G. Clinical outcome of biomarker-guided therapies in adult patients with tumors of the nervous system. Neurooncol Adv 2023; 5:vdad012. [PMID: 36915613 PMCID: PMC10007909 DOI: 10.1093/noajnl/vdad012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
Background The clinical utility of molecular profiling and targeted therapies for neuro-oncology patients outside of clinical trials is not established. We aimed at investigating feasibility and clinical utility of molecular profiling and targeted therapy in adult patients with advanced tumors in the nervous system within a prospective observational study. Methods molecular tumor board (MTB)@ZPM (NCT03503149) is a prospective observational precision medicine study for patients with advanced tumors. After inclusion of patients, we performed comprehensive molecular profiling, formulated ranked biomarker-guided therapy recommendations based on consensus by the MTB, and collected prospective clinical outcome data. Results Here, we present initial data of 661 adult patients with tumors of the nervous system enrolled by December 31, 2021. Of these, 408 patients were presented at the MTB. Molecular-instructed therapy recommendations could be made in 380/408 (93.1%) cases and were prioritized by evidence levels. Therapies were initiated in 86/380 (22.6%) cases until data cutoff. We observed a progression-free survival ratio >1.3 in 31.3% of patients. Conclusions Our study supports the clinical utility of biomarker-guided therapies for neuro-oncology patients and indicates clinical benefit in a subset of patients. Our data might inform future clinical trials, translational studies, and even clinical care.
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Affiliation(s)
- Mirjam Renovanz
- Department of Neurology and Interdisciplinary Neuro-Oncology, Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Germany.,Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Germany.,Department of Neurosurgery, Eberhard Karls University Tübingen, Germany
| | - Sylvia C Kurz
- Department of Neurology and Interdisciplinary Neuro-Oncology, Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Germany.,Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Germany
| | - Johannes Rieger
- Department of Neurology and Interdisciplinary Neuro-Oncology, Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Germany.,Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Germany
| | - Bianca Walter
- Department of Neurology and Interdisciplinary Neuro-Oncology, Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Germany
| | - Hannes Becker
- Department of Neurology and Interdisciplinary Neuro-Oncology, Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Germany.,Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Germany.,Department of Neurosurgery, Eberhard Karls University Tübingen, Germany
| | - Hanni Hille
- Department of Neurology and Interdisciplinary Neuro-Oncology, Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Germany
| | - Paula Bombach
- Department of Neurology and Interdisciplinary Neuro-Oncology, Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Germany.,Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Germany.,Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany
| | - David Rieger
- Department of Neurology and Interdisciplinary Neuro-Oncology, Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Germany.,Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Germany
| | - Lucia Grosse
- Department of Neurology and Interdisciplinary Neuro-Oncology, Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Germany.,Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Germany
| | - Lara Häusser
- Department of Neurology and Interdisciplinary Neuro-Oncology, Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Germany.,German Cancer Consortium (DKTK), DKFZ partner site Tübingen, Eberhard Karls University of Tübingen, Germany
| | - Marco Skardelly
- Department of Neurology and Interdisciplinary Neuro-Oncology, Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Germany.,Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Germany
| | - Daniel J Merk
- Department of Neurology and Interdisciplinary Neuro-Oncology, Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Germany
| | - Frank Paulsen
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Germany.,Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany.,Department of Radiation Oncology, Eberhard Karls University Tübingen, Germany
| | - Elgin Hoffmann
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Germany.,Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany.,Department of Radiation Oncology, Eberhard Karls University Tübingen, Germany
| | - Cihan Gani
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Germany.,Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany.,Department of Radiation Oncology, Eberhard Karls University Tübingen, Germany.,German Cancer Consortium (DKTK), DKFZ partner site Tübingen, Eberhard Karls University of Tübingen, Germany
| | - Manuela Neumann
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Germany.,Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany.,Institute of Pathology and Neuropathology, Department of Neuropathology, Eberhard Karls University Tübingen, Germany.,German Cancer Consortium (DKTK), DKFZ partner site Tübingen, Eberhard Karls University of Tübingen, Germany
| | - Rudi Beschorner
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Germany.,Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany.,Institute of Pathology and Neuropathology, Department of Neuropathology, Eberhard Karls University Tübingen, Germany.,German Cancer Consortium (DKTK), DKFZ partner site Tübingen, Eberhard Karls University of Tübingen, Germany
| | - Olaf Rieß
- Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany.,Institute of Medical Genetics and Applied Genomics, Eberhard Karls University Tübingen, Germany.,Cluster of Excellence (EXC 2180) "Image Guided and Functionally Instructed Tumor Therapies", Eberhard Karls University of Tübingen, Germany.,German Cancer Consortium (DKTK), DKFZ partner site Tübingen, Eberhard Karls University of Tübingen, Germany
| | - Cristiana Roggia
- Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany.,Institute of Medical Genetics and Applied Genomics, Eberhard Karls University Tübingen, Germany
| | - Christopher Schroeder
- Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany.,Institute of Medical Genetics and Applied Genomics, Eberhard Karls University Tübingen, Germany
| | - Stephan Ossowski
- Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany.,Institute of Medical Genetics and Applied Genomics, Eberhard Karls University Tübingen, Germany
| | - Sorin Armeanu-Ebinger
- Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany.,Institute of Medical Genetics and Applied Genomics, Eberhard Karls University Tübingen, Germany
| | - Axel Gschwind
- Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany.,Institute of Medical Genetics and Applied Genomics, Eberhard Karls University Tübingen, Germany
| | - Saskia Biskup
- Center for Genomics and Transcriptomics (CeGaT) & Center for Human Genetics Tübingen, Germany.,Cluster of Excellence (EXC 2180) "Image Guided and Functionally Instructed Tumor Therapies", Eberhard Karls University of Tübingen, Germany
| | - Martin Schulze
- Center for Genomics and Transcriptomics (CeGaT) & Center for Human Genetics Tübingen, Germany
| | - Falko Fend
- Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany.,Department of Pathology and Neuropathology, Institute of Pathology and Molecular Pathology, Eberhard Karls University Tübingen, Germany.,Cluster of Excellence (EXC 2180) "Image Guided and Functionally Instructed Tumor Therapies", Eberhard Karls University of Tübingen, Germany.,German Cancer Consortium (DKTK), DKFZ partner site Tübingen, Eberhard Karls University of Tübingen, Germany
| | - Stephan Singer
- Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany.,Department of Pathology and Neuropathology, Institute of Pathology and Molecular Pathology, Eberhard Karls University Tübingen, Germany.,Cluster of Excellence (EXC 2180) "Image Guided and Functionally Instructed Tumor Therapies", Eberhard Karls University of Tübingen, Germany.,German Cancer Consortium (DKTK), DKFZ partner site Tübingen, Eberhard Karls University of Tübingen, Germany
| | - Lars Zender
- Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany.,Department of Medical Oncology and Pneumology (Internal Medicine VIII), Eberhard Karls University Tübingen, Germany.,Cluster of Excellence (EXC 2180) "Image Guided and Functionally Instructed Tumor Therapies", Eberhard Karls University of Tübingen, Germany.,German Cancer Consortium (DKTK), DKFZ partner site Tübingen, Eberhard Karls University of Tübingen, Germany
| | - Claudia Lengerke
- Department of Internal Medicine II, Eberhard Karls University Tübingen, Germany.,German Cancer Consortium (DKTK), DKFZ partner site Tübingen, Eberhard Karls University of Tübingen, Germany
| | - Sara Yvonne Brucker
- Department of Gynecology and Obstetrics, Eberhard Karls University Tübingen, Germany.,German Cancer Consortium (DKTK), DKFZ partner site Tübingen, Eberhard Karls University of Tübingen, Germany
| | - Tobias Engler
- Department of Gynecology and Obstetrics, Eberhard Karls University Tübingen, Germany.,German Cancer Consortium (DKTK), DKFZ partner site Tübingen, Eberhard Karls University of Tübingen, Germany
| | - Andrea Forschner
- Department of Dermatology and Center for Dermato-Oncology, Eberhard Karls University Tübingen, Germany.,German Cancer Consortium (DKTK), DKFZ partner site Tübingen, Eberhard Karls University of Tübingen, Germany
| | - Arnulf Stenzl
- Department of Urology, Eberhard Karls University Tübingen, Germany.,German Cancer Consortium (DKTK), DKFZ partner site Tübingen, Eberhard Karls University of Tübingen, Germany
| | - Oliver Kohlbacher
- Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany.,Institute for Translational Bioinformatics, Eberhard Karls University Tübingen, Germany.,German Cancer Consortium (DKTK), DKFZ partner site Tübingen, Eberhard Karls University of Tübingen, Germany
| | - Sven Nahnsen
- Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany.,Quantitative Biology Center (QBiC), Eberhard Karls University Tübingen, Germany.,Department of Medical Oncology and Pneumology (Internal Medicine VIII), Eberhard Karls University Tübingen, Germany.,Cluster of Excellence (EXC 2180) "Image Guided and Functionally Instructed Tumor Therapies", Eberhard Karls University of Tübingen, Germany.,German Cancer Consortium (DKTK), DKFZ partner site Tübingen, Eberhard Karls University of Tübingen, Germany
| | - Gisela Gabernet
- Quantitative Biology Center (QBiC), Eberhard Karls University Tübingen, Germany
| | - Sven Fillinger
- Quantitative Biology Center (QBiC), Eberhard Karls University Tübingen, Germany
| | - Benjamin Bender
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Germany.,Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany.,Department of Diagnostic and Interventional Neuroradiology, Department of Radiology, Eberhard Karls University Tübingen, Germany
| | - Ulrike Ernemann
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Germany.,Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany.,Department of Diagnostic and Interventional Neuroradiology, Department of Radiology, Eberhard Karls University Tübingen, Germany
| | - Öznur Öner
- Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany
| | - Janina Beha
- Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany
| | - Holly Sundberg Malek
- Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany
| | - Yvonne Möller
- Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany
| | - Kristina Ruhm
- Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany
| | - Marcos Tatagiba
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Germany.,Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany.,Department of Neurosurgery, Eberhard Karls University Tübingen, Germany
| | - Jens Schittenhelm
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Germany.,Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany.,Institute of Pathology and Neuropathology, Department of Neuropathology, Eberhard Karls University Tübingen, Germany.,German Cancer Consortium (DKTK), DKFZ partner site Tübingen, Eberhard Karls University of Tübingen, Germany
| | - Michael Bitzer
- Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany.,Department of Internal Medicine I, Eberhard Karls University Tübingen, Germany.,Cluster of Excellence (EXC 2180) "Image Guided and Functionally Instructed Tumor Therapies", Eberhard Karls University of Tübingen, Germany.,German Cancer Consortium (DKTK), DKFZ partner site Tübingen, Eberhard Karls University of Tübingen, Germany
| | - Nisar Malek
- Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany.,Department of Internal Medicine I, Eberhard Karls University Tübingen, Germany.,Cluster of Excellence (EXC 2180) "Image Guided and Functionally Instructed Tumor Therapies", Eberhard Karls University of Tübingen, Germany.,German Cancer Consortium (DKTK), DKFZ partner site Tübingen, Eberhard Karls University of Tübingen, Germany
| | - Daniel Zips
- Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Germany.,Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany.,Department of Radiation Oncology, Eberhard Karls University Tübingen, Germany.,German Cancer Consortium (DKTK), DKFZ partner site Tübingen, Eberhard Karls University of Tübingen, Germany
| | - Ghazaleh Tabatabai
- Department of Neurology and Interdisciplinary Neuro-Oncology, Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Germany.,Center for Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Germany.,Center for Personalized Medicine Tübingen, Eberhard Karls University Tübingen, Germany.,Cluster of Excellence (EXC 2180) "Image Guided and Functionally Instructed Tumor Therapies", Eberhard Karls University of Tübingen, Germany.,German Cancer Consortium (DKTK), DKFZ partner site Tübingen, Eberhard Karls University of Tübingen, Germany
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Manickam Gurusamy V, Raveendran Divakar S, Halsnad Chandramouli S, Kunheri B, Hussain Al-Abdulla H, Shaikh G, Chaudary Apsani R, Riyaz Poolakundan M, Caparrotti P, Wafiq Hammoud R, Al-Hammadi N. The role of radiotherapy in newly diagnosed primary CNS lymphoma: A descriptive review and a pragmatic approach to clinical practice. Clin Transl Radiat Oncol 2022; 39:100559. [PMID: 36590826 PMCID: PMC9800264 DOI: 10.1016/j.ctro.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 12/06/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022] Open
Abstract
Earlier, prior to the development of effective systemic therapy, monotherapy with whole-brain radiotherapy (WBRT) was widely used to treat primary central nervous system lymphoma (PCNSL). Recently, chemotherapy, especially with high dose methotrexate (HDMTX), has largely replaced WBRT as upfront treatment, and the most accepted standard of care is induction with a combination drug therapy followed by consolidation therapy with either autologous stem-cell transplantation (ASCT) or radiation. Whilst WBRT is an effective component of treatment, it is occasionally associated with risk of permanent, irreversible neurotoxicity when doses of more than 30 Gy are used. Hence, there has been a strong focus on the optimization of radiotherapy (RT) which includes dose reduction in the consolidation phase. In this comprehensive review, we have summarized the progress on clinical results and evidence considering the role and use of radiation including combined treatment modalities, low-dose radiotherapy, and neurotoxicity. Finally, we present a practical approach to low-dose WBRT and boosting higher doses to the gross tumor that can be integrated into clinical practice.
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38
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Chojak R, Koźba-Gosztyła M, Polańska K, Rojek M, Chojko A, Bogacz R, Skorupa N, Więcław J, Czapiga B. Surgical resection versus biopsy in the treatment of primary central nervous system lymphoma: a systematic review and meta-analysis. J Neurooncol 2022; 160:753-761. [PMID: 36449256 PMCID: PMC9758097 DOI: 10.1007/s11060-022-04200-7] [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: 10/18/2022] [Accepted: 11/16/2022] [Indexed: 12/03/2022]
Abstract
PURPOSE Despite the improvement in treatment and prognosis of primary central nervous system lymphoma (PCNSL) over the last decades, the 5-year survival rate is approximately 30%; thus, new therapeutic approaches are needed to improve patient survival. The study's aim was to evaluate the role of surgical resection of PCNSL. METHODS Primary outcomes were the overall survival (OS) and progression-free survival (PFS) of patients with PCNSL who underwent surgical resection versus biopsy alone. The meta-analysis was conducted to calculate pooled hazard ratios (HRs) under a random-effects model for the time-to-event variables. The odds ratios (ORs) were calculated for binary, secondary outcome parameters. RESULTS Seven studies (n = 1046) were included. We found that surgical resection was associated with significantly better OS (HR 0.63 [95% CI 0.51-0.77]) when compared with biopsy. PFS was also significantly improved (HR 0.64 [95% CI 0.49-0.85]) in patients who underwent resection compared with those who underwent biopsy. The heterogeneity for OS and PFS was low (I2 = 7% and 24%, respectively). We also found that patients who underwent biopsy more often had multiple (OR 0.38 [95% CI 0.19-0.79]) or deep-seated (OR 0.20 [95% CI 0.12-0.34]) lesions compared with those who underwent surgical resection. There were no significant differences in chemotherapy or radiotherapy use or the occurrence of postoperative complications between the two groups. CONCLUSION In selected patients, surgical resection of PCNSL is associated with significantly better overall survival and progression-free survival compared with biopsy alone.
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Affiliation(s)
- Rafał Chojak
- Faculty of Medicine, Wroclaw Medical University, Ludwika Pasteura 1, 50-367, Wrocław, Poland.
- Department of Neurosurgery, 4th Military Hospital in Wroclaw, Wrocław, Poland.
| | | | - Karolina Polańska
- Faculty of Medicine, Wroclaw Medical University, Ludwika Pasteura 1, 50-367, Wrocław, Poland
| | - Marta Rojek
- Faculty of Medicine, Wroclaw Medical University, Ludwika Pasteura 1, 50-367, Wrocław, Poland
| | - Aleksandra Chojko
- Faculty of Medicine, Wroclaw Medical University, Ludwika Pasteura 1, 50-367, Wrocław, Poland
| | - Rafał Bogacz
- Faculty of Medicine, Wroclaw Medical University, Ludwika Pasteura 1, 50-367, Wrocław, Poland
| | - Natalia Skorupa
- Faculty of Medicine, Wroclaw Medical University, Ludwika Pasteura 1, 50-367, Wrocław, Poland
| | - Jakub Więcław
- Faculty of Medicine, Wroclaw Medical University, Ludwika Pasteura 1, 50-367, Wrocław, Poland
| | - Bogdan Czapiga
- Department of Neurosurgery, 4th Military Hospital in Wroclaw, Wrocław, Poland
- Department of Nervous System Diseases, Faculty of Health Sciences, Wroclaw Medical University, Wrocław, Poland
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39
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Mishima K, Nishikawa R, Narita Y, Mizusawa J, Sumi M, Koga T, Sasaki N, Kinoshita M, Nagane M, Arakawa Y, Yoshimoto K, Shibahara I, Shinojima N, Asano K, Tsurubuchi T, Sasaki H, Asai A, Sasayama T, Momii Y, Sasaki A, Nakamura S, Kojima M, Tamaru J, Tsuchiya K, Gomyo M, Abe K, Natsumeda M, Yamasaki F, Katayama H, Fukuda H. Randomized phase III study of high-dose methotrexate and whole-brain radiotherapy with/without temozolomide for newly diagnosed primary CNS lymphoma: JCOG1114C. Neuro Oncol 2022; 25:687-698. [PMID: 36334050 PMCID: PMC10076938 DOI: 10.1093/neuonc/noac246] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The goal was to determine whether the addition of temozolomide (TMZ) to the standard treatment of high-dose methotrexate (HD-MTX) and whole-brain radiotherapy (WBRT) for primary central nervous system lymphoma (PCNSL) improves survival. METHODS An open-label, randomized, phase III trial was conducted in Japan, enrolling immunocompetent patients aged 20-70 years with histologically confirmed, newly diagnosed PCNSL. After administration of HD-MTX, patients were randomly assigned to receive WBRT (30 Gy) ± 10 Gy boost (arm A) or WBRT ± boost with concomitant and maintenance TMZ for two years (arm B). The primary endpoint was overall survival (OS). RESULTS Between September 29, 2014 and October 15, 2018, 134 patients were enrolled, of whom 122 were randomly assigned and analyzed. At the planned interim analysis, two-year OS was 86.8% (95% confidence interval [CI]: 72.5-94.0%) in arm A and 71.4% (56.0-82.2%) in arm B. The hazard ratio was 2.18 (95% CI: 0.95 to 4.98), with the predicted probability of showing the superiority of arm B at the final analysis estimated to be 1.3%. The study was terminated early due to futility. O 6-methylguanine-DNA methyltransferase (MGMT) promoter methylation status was measured in 115 tumors, and it was neither prognostic nor predictive of TMZ response. CONCLUSIONS This study failed to demonstrate the benefit of concomitant and maintenance TMZ in newly diagnosed PCNSL.
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Affiliation(s)
- Kazuhiko Mishima
- Department of Neuro-Oncology/Neurosurgery, Saitama Medical University International Medical Center
| | - Ryo Nishikawa
- Department of Neuro-Oncology/Neurosurgery, Saitama Medical University International Medical Center
| | - Yoshitaka Narita
- Department of Neurosurgery and Neuro-Oncology, National Cancer Center Hospital
| | - Junki Mizusawa
- Japan Clinical Oncology Group Data Center/Operations Office, National Cancer Center Hospital
| | - Minako Sumi
- Radiation Oncology Department, Cancer Institute Hospital
| | - Tomoyuki Koga
- Department of Neuro-Oncology/Neurosurgery, Saitama Medical University International Medical Center.,Department of Neurosurgery, Faculty of Medicine, The University of Tokyo
| | - Nobuyoshi Sasaki
- Department of Neurosurgery, Kyorin University Faculty of Medicine
| | - Manabu Kinoshita
- Department of Neurosurgery, Osaka International Cancer Institute
| | - Motoo Nagane
- Department of Neurosurgery, Kyorin University Faculty of Medicine
| | - Yoshiki Arakawa
- Department of Neurosurgery, Kyoto University Graduate School of Medicine
| | - Koji Yoshimoto
- Department of Neurosurgery, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Ichiyo Shibahara
- Department of Neurosurgery, Kitasato University School of Medicine
| | - Naoki Shinojima
- Department of Neurosurgery, Kumamoto University Graduate School of Medicine
| | - Kenichiro Asano
- Department of Neurosurgery, Hirosaki University Graduate School of Medicine
| | - Takao Tsurubuchi
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba
| | - Hikaru Sasaki
- Department of Neurosurgery, Keio University School of Medicine
| | - Akio Asai
- Department of Neurosurgery, Kansai Medical University
| | - Takashi Sasayama
- Department of Neurosurgery, Kobe University Graduate School of Medicine
| | - Yasutomo Momii
- Department of Neurosurgery, Oita University Faculty of Medicine
| | | | - Shigeo Nakamura
- Department of Pathology and Laboratory Medicine, Nagoya University Hospital
| | - Masaru Kojima
- Department of Anatomical and Surgical Pathology, Dokkyo University School of Medicine
| | - Junichi Tamaru
- Department of Pathology, Saitama Medical Center, Saitama Medical University
| | - Kazuhiro Tsuchiya
- Department of Radiology, Saitama Medical Center, Saitama Medical University
| | - Miho Gomyo
- Department of Radiology, Kyorin University Faculty of Medicine
| | - Kayoko Abe
- Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University
| | - Manabu Natsumeda
- Department of Neurosurgery, Brain Research Institute, University of Niigata
| | - Fumiyuki Yamasaki
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University
| | - Hiroshi Katayama
- Japan Clinical Oncology Group Data Center/Operations Office, National Cancer Center Hospital
| | - Haruhiko Fukuda
- Japan Clinical Oncology Group Data Center/Operations Office, National Cancer Center Hospital
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