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Chan CY, Ou CW, Chang H, Kuo MC, Lin TL, Hung YS, Wu JH, Shih LY, Kao HW. Primary breast diffuse large B-cell lymphoma characterized by CNS relapse and successful hematopoietic stem cell transplantation salvage therapy. J Formos Med Assoc 2024:S0929-6646(24)00053-6. [PMID: 38296697 DOI: 10.1016/j.jfma.2024.01.020] [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: 11/13/2023] [Revised: 01/02/2024] [Accepted: 01/20/2024] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Primary breast diffuse large B-cell lymphoma (PB-DLBCL) is rare, with a high incidence of central nervous system (CNS) relapse. This study aims to investigate clinical characteristics, prognostic factors, and outcomes in Taiwanese PB-DLBCL patients and review the literature on PB-DLBCL. METHODS Thirty-one PB-DLBCL patients diagnosed between 2000 and 2021 were retrospectively enrolled for analysis. RESULTS The median age was 49 (range 26-79) years. The complete remission (CR) rate was 90.3%. Nine (90%) of the ten patients who experienced relapse had CNS involvement at the time of relapse. The one-year, two-year, and five-year progression-free survival (PFS) rates were 86.6% (95% confidence interval [CI] 75.2-99.8), 75.8% (95% CI 61.6-93.2), and 45.1% (95% CI 29.5-68.9), respectively. The five-year overall survival (OS) rate was 64.1% (95 % CI 48.4-85.0). A stage-modified International Prognostic Index (mIPI) less than two (five-year PFS rate 52.5% vs. 17.1%, P = 0.02) and the achievement of CR after first-line treatment (two-year PFS rate 80.3% vs. 33.3%, P < 0.001) were significant favorable prognostic factors for PFS. Hematopoietic stem cell transplantation (HSCT) after the first relapse was associated with significantly improved post-relapse OS (five-year OS rate 85.7% vs. 20.0%, P = 0.02) and PFS (five-year PFS rate 85.7% vs. 20.0%, P = 0.02). CONCLUSION Patients with low-risk mIPI scores, CR after first-line treatment, and those who underwent HSCT after the first relapse had significantly better survival. Intrathecal chemotherapy conferred no benefit in preventing CNS relapse. Further research is needed to assess frontline HSCT's effectiveness in improving outcomes and preventing CNS relapses in PB-DLBCL patients.
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Affiliation(s)
- Chu-Yi Chan
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Che-Wei Ou
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Division of Hematology-Oncology, Department of Internal Medicine, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan
| | - Hung Chang
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Chung Kuo
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tung-Liang Lin
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Yu-Shin Hung
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Jin-Hou Wu
- Division of Hematology-Oncology, Department of Internal Medicine, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan
| | - Lee-Yung Shih
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsiao-Wen Kao
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.
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Grundström A, Harila A, Lönnerblad M. Educational and occupational outcomes in Swedish children treated for sarcomas: A nationwide registry-based study. Pediatr Blood Cancer 2024; 71:e30719. [PMID: 37837179 DOI: 10.1002/pbc.30719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/22/2023] [Accepted: 10/01/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND Many children treated for cancer experience a negative impact on their academic performance; however, most studies of children treated for sarcomas have not investigated academic performance. Our aim was to explore how Swedish children treated for sarcomas perform academically, as well as how they adjust to life afterwards. PROCEDURE We compared 167 pediatric sarcoma survivors with 776 matched, non-sibling controls without a history of cancer, in a retrospective cohort study using data from nationwide registries. Primary outcomes were grades at the end of compulsory education, high school eligibility, post-compulsory education (i.e., education after school Year 9), employment, and sickness or activity compensation. RESULTS Pediatric sarcoma survivors were more likely to be ineligible for high school (odds ratio [OR] 1.76; p = .045) and more likely to fail Swedish (OR 2.12; p = .046), mathematics (OR 2.27; p = .011), and/or physical education (OR 2.24; p = .004), compared with controls. Survivors were less likely to have been employed (OR 0.58; p = .027) and received sickness or activity compensation more often (OR 2.49; p = .008) compared with controls. CONCLUSIONS Pediatric sarcoma survivors have poorer academic performance compared to peers without cancer in multiple school subjects. Survivors seem to catch up during post-compulsory education, but might struggle to find employment.
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Affiliation(s)
- Albin Grundström
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Arja Harila
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Department of Pediatric Oncology, Uppsala University Hospital, Uppsala, Sweden
| | - Malin Lönnerblad
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Department of Special Education, Stockholm University, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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Perkins RS, Davis A, Campagne O, Owens TS, Stewart CF. CNS penetration of methotrexate and its metabolite 7-hydroxymethotrexate in mice bearing orthotopic Group 3 medulloblastoma tumors and model-based simulations for children. Drug Metab Pharmacokinet 2023; 48:100471. [PMID: 36669926 DOI: 10.1016/j.dmpk.2022.100471] [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: 03/15/2022] [Revised: 07/28/2022] [Accepted: 08/06/2022] [Indexed: 01/22/2023]
Abstract
The brain penetration of methotrexate (MTX) and its metabolite 7-hydroxymethotrexate (7OHMTX) was characterized in non-tumor bearing mice and mice bearing orthotopic Group 3 medulloblastoma. Plasma pharmacokinetic studies and cerebral and ventricular microdialysis studies were performed in animals dosed with 200 or 1000 mg/kg MTX by IV bolus. Plasma, brain/tumor extracellular fluid (ECF) and lateral ventricle cerebrospinal fluid (CSF) MTX and 7OHMTX concentration-time data were analyzed by validated LC-MS/MS methods and modeled using a population-based pharmacokinetic approach and a hybrid physiologically-based model structure for the brain compartments. Brain penetration was similar for MTX and 7OHMTX and was not significantly different between non-tumor and tumor bearing mice. Overall, mean (±SD) model-derived unbound plasma to ECF partition coefficient Kp,uu were 0.17 (0.09) and 0.17 (0.12) for MTX and 7OHMTX, respectively. Unbound plasma to CSF Kp,uu were 0.11 (0.06) and 0.18 (0.09) for MTX and 7OHMTX, respectively. The plasma and brain model were scaled to children using allometric principles and pediatric physiological parameters. Model-based simulations were adequately overlaid with digitized plasma and CSF lumbar data collected in children receiving different MTX systemic infusions. This model can be used to further explore and optimize methotrexate dosing regimens in children with brain tumors.
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Affiliation(s)
- Rachel S Perkins
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN, 38105, USA
| | - Abigail Davis
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN, 38105, USA
| | - Olivia Campagne
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN, 38105, USA
| | - Thandranese S Owens
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN, 38105, USA
| | - Clinton F Stewart
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN, 38105, USA.
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Optimum Methotrexate Exposure in Patients With Suspected or Confirmed CNS Invasive Hematological Malignancies: A Systematic Critical Review. Ther Drug Monit 2023; 45:287-292. [PMID: 35971672 DOI: 10.1097/ftd.0000000000001022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 06/13/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND METHODS The present review aims to evaluate the current state-of-the-art dosing regimens of high-dose (HD) and intrathecal methotrexate (MTX) using therapeutic drug monitoring (TDM) to optimize its therapeutic response and minimize associated toxicity, particularly in the central nervous system (CNS). RESULTS MTX is administered systemically in a HD regimen (>1 g/m 2 ) for the treatment of various hematological neoplasms. HD-MTX treatment becomes complicated by marked interindividual drug elimination variability. TDM is specified to manage this high variability. Approximately 3%-7% of adults with acute lymphoblastic leukemia are diagnosed with CNS involvement, and the incidence of CNS relapse in patients, despite receiving prophylaxis, ranges from 5% to 10%. HD-MTX penetrates the blood-brain barrier and can be administered intrathecally, making this drug an important component of chemotherapy regimens for patients with hematologic malignancies involving the CNS or those at high risk of CNS relapse. CONCLUSIONS The major evidence found was that an MTX area under the curve target between 1000 and 1100 μmol hour -1 L is associated with better clinical outcomes. However, there seems to be a clinical gap in the prospective validation of HD and IT MTX management to optimize clinical outcomes and minimize toxicity, using the relationship between exposure level (area under the curve MTX) and optimal response to MTX, at systemic and CNS exposure.
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Smita P, Narayan PA, J K, Gaurav P. Therapeutic drug monitoring for cytotoxic anticancer drugs: Principles and evidence-based practices. Front Oncol 2022; 12:1015200. [PMID: 36568145 PMCID: PMC9773989 DOI: 10.3389/fonc.2022.1015200] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/24/2022] [Indexed: 12/13/2022] Open
Abstract
Cytotoxic drugs are highly efficacious and also have low therapeutic index. A great degree of caution needs to be exercised in their usage. To optimize the efficacy these drugs need to be given at maximum tolerated dose which leads to significant amount of toxicity to the patient. The fine balance between efficacy and safety is the key to the success of cytotoxic chemotherapeutics. However, it is possibly more rewarding to obtain that balance for this class drugs as the frequency of drug related toxicities are higher compared to the other therapeutic class and are potentially life threatening and may cause prolonged morbidity. Significant efforts have been invested in last three to four decades in therapeutic drug monitoring (TDM) research to understand the relationship between the drug concentration and the response achieved for therapeutic efficacy as well as drug toxicity for cytotoxic drugs. TDM evolved over this period and the evidence gathered favored its routine use for certain drugs. Since, TDM is an expensive endeavor both from economic and logistic point of view, to justify its use it is necessary to demonstrate that the implementation leads to perceivable improvement in the patient outcomes. It is indeed challenging to prove the utility of TDM in randomized controlled trials and at times may be nearly impossible to generate such data in view of the obvious findings and concern of compromising patient safety. Therefore, good quality data from well-designed observational study do add immense value to the scientific knowledge base, when they are examined in totality, despite the heterogeneity amongst them. This article compiles the summary of the evidence and the best practices for TDM for the three cytotoxic drug, busulfan, 5-FU and methotrexate. Traditional use of TDM or drug concentration data for dose modification has been witnessing a sea change and model informed precision dosing is the future of cytotoxic drug therapeutic management.
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Affiliation(s)
- Pattanaik Smita
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India,*Correspondence: Pattanaik Smita,
| | - Patil Amol Narayan
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kumaravel J
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Prakash Gaurav
- Department of Clinical Hematology and Medical Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Naung H, Cohen KJ. An intrathecal limited postoperative chemotherapy regimen for the treatment of young children with nodular/desmoplastic medulloblastoma and medulloblastoma with extensive nodularity. J Neurooncol 2021; 152:567-572. [PMID: 33689104 DOI: 10.1007/s11060-021-03727-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 02/24/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Therapy for medulloblastoma in patients < 4 years old omits radiotherapy due to anticipated neurocognitive deficits. The German Pediatric Brain Tumor Study Group described a chemotherapy regimen (HIT-SKK' 92 and HIT-SKK 2000) without radiation which yielded a 5-year progression-free survival (PFS) rate of 85% in children with nodular/desmoplastic medulloblastoma (NDMB) and medulloblastoma with extensive nodularity (MBEN). We modified the HIT-SKK regimen to reduce the total number of intrathecal methotrexate (IT MTX) doses from 12 to 2 doses/cycle and obviate Ommaya reservoir implantation through the use of lumbar administration. We report the outcomes of five patients treated with our approach. METHODS IT MTX was eliminated altogether on weeks when high-dose intravenous methotrexate was administered. On weeks when no systemic methotrexate was administered, a single dose of lumbar-administered IT MTX was substituted in place of multiple intra-Ommaya doses. Cumulative dosing of MTX was 16-24 mg/cycle (age-based) compared to 24 mg/cycle in the HIT-SKK regimen. Following chemotherapy, patients were monitored with interval imaging, observation for acute and late effects, and survival. RESULTS Four children remained in remission 3, 5, 9, and 10 years post-treatment respectively, without observed learning difficulties. One child had recurrent tumor and metastasis 6 months post-treatment. She failed the attempted salvage regimen and continued to deteriorate, dying of disease at 3 years old. CONCLUSIONS Review of existing literature supported our modifications well. While this report is limited by the small number of children treated, we believe there is encouraging evidence that our approach warrants further evaluation in a larger population of young children with NDMB and MBEN.
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Affiliation(s)
- Harrison Naung
- The Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD, 21205, USA
| | - Kenneth J Cohen
- The Sidney Kimmel Comprehensive Cancer Center, Bloomberg 11379, 1800 Orleans St., Baltimore, MD, 21231, USA.
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Outcomes of Local Radiation and Intensified Combined Intrathecal Methotrexate and High-dose Chemotherapy for Intracranial Germ Cell Tumors. J Pediatr Hematol Oncol 2020; 42:e551-e557. [PMID: 32398600 DOI: 10.1097/mph.0000000000001820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Many attempts to reduce radiation fields for intracranial germ cell tumors (iGCTs) remain unsuccessful. To assess the possibility of reduction, we analyzed registry data of 57 patients who mostly underwent local irradiation for iGCTs between 1997 and 2006. The recommended treatment for pure germinomas (PGNs) included 3 courses of cisplatin and etoposide followed by 24 Gy local irradiation. Intensified chemotherapy using a combination of cyclophosphamide and intrathecal methotrexate was recommended for human chorionic gonadotropin-producing germinomas (hCG-GNs) and nongerminomatous germ cell tumors (NGGCTs); both received 50.4 Gy local irradiation. High-dose chemotherapy was only administered for residual NGGCTs after chemoradiotherapy. Craniospinal irradiation was recommended only in metastatic cases. During the median follow-up of 114.8 months, 8 of 9 relapses from 24 PGNs occurred outside irradiation fields, with a 5-year progression-free survival (5-year PFS) of 75%±8.8%. Conversely, no recurrences occurred from 11 hCG-GNs, with a 5-year PFS of 100%. Eleven of 22 patients with NGGCTs received high-dose chemotherapy; the 5-year PFS was 81.3%±8.4%; 2 of 3 relapses occurred in the spinal cord. Thus, local irradiation for PGNs was insufficient without treatment intensification. The introduction of intensified chemotherapy improved outcomes of both patients with hCG-GNs and NGGCTs. However, the contributions of either modality remained unclear.
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Panetta JC, Roberts JK, Huang J, Lin T, Daryani VM, Harstead KE, Patel YT, Onar-Thomas A, Campagne O, Ward DA, Broniscer A, Robinson G, Gajjar A, Stewart CF. Pharmacokinetic basis for dosing high-dose methotrexate in infants and young children with malignant brain tumours. Br J Clin Pharmacol 2020; 86:362-371. [PMID: 31657864 DOI: 10.1111/bcp.14160] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 10/03/2019] [Accepted: 10/15/2019] [Indexed: 01/17/2023] Open
Abstract
AIMS No population pharmacokinetic studies of high-dose methotrexate (HDMTX) have been conducted in infants with brain tumours, which are a vulnerable population. The aim of this study was to evaluate HDMTX disposition in these children to provide a rational basis for MTX dosing. METHODS Patients received 4 monthly courses of HDMTX (5 g/m2 or 2.5 g/m2 for infants aged ≤31 days) as a 24-h infusion. Serial samples were analysed for MTX by an enzyme immunoassay method. Pharmacokinetic parameters were estimated using nonlinear mixed effects population modelling. Demographics, concomitant medications and genetic polymorphisms were considered as pharmacokinetic covariates while MTX exposure and patient age were considered as covariates for Grade 3 and 4 toxicities. RESULTS The population pharmacokinetics of HDMTX were estimated in 178 patients (age range 0.02-4.7 years) in 648 courses. The population clearance and volume were 90 mL/min/m2 and 14.4 L/m2 , respectively. Significant covariates on body surface area adjusted MTX clearance included estimated glomerular filtration rate and co-treatment with dexamethasone or vancomycin. No significant association was observed between MTX toxicity and MTX exposure, patient age, leucovorin dosage or duration. MTX clearance in infants ≤31 days at enrolment was 44% lower than in older infants, but their incidence of toxicity was not higher since they also received a lower MTX dosage. CONCLUSIONS By aggressively following institutional clinical guidelines, HDMTX-related toxicities were low, and using covariates from the population pharmacokinetic model enabled the calculation of a rational dosage for this patient population for future clinical trials.
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Affiliation(s)
- John C Panetta
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jessica K Roberts
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jie Huang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Tong Lin
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Vinay M Daryani
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - K Elaine Harstead
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Yogesh T Patel
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Arzu Onar-Thomas
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Olivia Campagne
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Deborah A Ward
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Alberto Broniscer
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Giles Robinson
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Amar Gajjar
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Clinton F Stewart
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
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Qualls D, Abramson JS. Advances in risk assessment and prophylaxis for central nervous system relapse in diffuse large B-cell lymphoma. Haematologica 2018; 104:25-34. [PMID: 30573511 PMCID: PMC6312016 DOI: 10.3324/haematol.2018.195834] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 11/15/2018] [Indexed: 12/13/2022] Open
Abstract
Central nervous sytem recurrence of diffuse large B-cell lymphoma is an uncommon but devastating event, making identification of patients at high risk for relapse within the central nervous system essential for clinicians. Modern risk stratification includes both clinical and biological features. A validated clinical risk model employing the five traditional International Prognostic Index risk factors plus renal or adrenal involvement can identify a high-risk patient population with a central nervous system recurrence risk of greater than 10%. Lymphoma involvement of certain discrete extranodal sites such as the testis also confers increased risk, even in stage I disease. Adverse biological risk factors for central nervous system relapse include presence of translocations of MYC, BCL2 and/or BCL6, in so-called double- or triple-hit lymphoma. Immunohistochemically detectable co-expression of MYC and BCL2 in the absence of translocations also portends an increased risk of relapse within the central nervous system, particularly in the setting of the activated B-cell-like subtype of diffuse large B-cell lymphoma. The role, method, and timing of prophylactic therapy remain controversial based on the available data. We review both intrathecal and systemic strategies for prophylaxis in high-risk patients. Our preference is for systemic methotrexate in concert with standard chemoimmunotherapy in the majority of cases. Several novel agents have also demonstrated clinical activity in primary and secondary central nervous system lymphoma and warrant future investigation in the prophylactic setting.
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Affiliation(s)
- David Qualls
- Center for Lymphoma, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Jeremy S Abramson
- Center for Lymphoma, Massachusetts General Hospital Cancer Center, Boston, MA, USA
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Tiwari P, Ganesan P, Radhakrishnan V, Arivazhagan R, Ganesan TS, Dhanushkodi M, Totadri S, Sagar TG. Prospective evaluation of the toxicity profile, and predictors of toxicity of high dose methotrexate in patients of acute lymphoblastic leukemia/lymphoma. PEDIATRIC HEMATOLOGY ONCOLOGY JOURNAL 2018. [DOI: 10.1016/j.phoj.2018.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Forster VJ, McDonnell A, Theobald R, McKay JA. Effect of methotrexate/vitamin B 12 on DNA methylation as a potential factor in leukemia treatment-related neurotoxicity. Epigenomics 2017; 9:1205-1218. [PMID: 28809129 PMCID: PMC5638018 DOI: 10.2217/epi-2016-0165] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Methotrexate (MTX) is administered to treat childhood acute lymphoblastic leukemia (ALL). It acts by inhibiting dihydrofolate reductase which reduces methyltetrahydrofolate, a key component in one carbon metabolism, thus reducing cell proliferation. Further perturbations to one carbon metabolism, such as reduced vitamin B12 levels via the use of nitrous oxide for sedation during childhood ALL treatment, may increase neurotoxicity risk. With B12 as an enzymatic cofactor, methyltetrahydrofolate is essential to produce methionine, which is critical for DNA methylation. We investigated global and gene specific DNA methylation in neuronal cell lines in response to MTX treatment and vitamin B12 concentration individually, and in combination. Results: MTX treatment alone significantly increased LINE-1 methylation in SH-SY5Y (p = 0.040) and DAOY (p < 0.001), and increased FKBP5 methylation in MO3.13 cells (p = 0.009). Conclusion: We conclude that altered DNA methylation of brain/central nervous system cells could be one mechanism involved in MTX treatment-related neurotoxicities and neurocognitive late effects in ALL survivors.
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Affiliation(s)
- Victoria J Forster
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Alex McDonnell
- Institute of Health & Society, Human Nutrition Research Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Rachel Theobald
- Institute of Health & Society, Human Nutrition Research Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Jill A McKay
- Institute of Health & Society, Human Nutrition Research Centre, Newcastle University, Newcastle upon Tyne, UK
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Factors Affecting the Upper Limit of the Methotrexate (MTX) CSF Levels Achievable in Children With Brain Tumors Treated With High-dose Intravenous MTX. J Pediatr Hematol Oncol 2016; 38:544-8. [PMID: 27403773 DOI: 10.1097/mph.0000000000000635] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Little has been published in the medical literature on serum and cerebrospinal fluid (CSF) methotrexate (MTX) levels in children with brain tumors. METHODS Matched 24-hour serum and CSF MTX levels were studied after 113 treatments in 35 brain tumors patients. RESULTS A correlation between the 24-hour serum levels of MTX and MTX dosage was observed after 113 treatments in all 35 patients (r=0.39, P<0.001) but no statistical difference was found between CSF MTX levels in the irradiated and nonirradiated groups (P=0.12). Nonirradiated children received a lower dose of MTX (12.3±4.8 cf 14.8±3.7) (P=0.002). The 24-hour MTX CSF levels of these 2 groups were also found to be different (the nonirradiated group 7.6±9.8 cf 12.5±0.15.3). Using the Levene test for variances we found that these variances were not equal and therefore we used the Welch test which resulted in a P-value of 0.04. However, when an analysis of covariance was performed looking at evidence of CSF disease and MTX dose the radiation difference was no longer significant (P=0.15). The 24-hour CSF MTX levels in children without evidence of active CSF disease were consistently lower than those with active disease using a mixed-model analysis (P=0.002). Although a 24-hour CSF MTX level of at least 1 μM was observed after infusions of >5 g/m MTX in previously irradiated children and after infusion of ≥10 g/m in nonirradiated children this difference did not reach statistical significance. CSF MTX levels plateau at doses of MTX 15 g/m putting in doubt the value of administering even higher doses of MTX. CONCLUSIONS The 24-hour MTX CSF levels are higher in patients with active CSF disease. Doses of <10 gm/m in children with brain tumors may not achieve a guaranteed 24-hour MTX CSF level of 1 μM. There may be little value in a given dose of >15 g/m MTX as CSF levels plateau at this dose.
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Prediction of methotrexate CNS distribution in different species - influence of disease conditions. Eur J Pharm Sci 2014; 57:11-24. [PMID: 24462766 DOI: 10.1016/j.ejps.2013.12.020] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 12/30/2013] [Accepted: 12/31/2013] [Indexed: 01/05/2023]
Abstract
Children and adults with malignant diseases have a high risk of prevalence of the tumor in the central nervous system (CNS). As prophylaxis treatment methotrexate is often given. In order to monitor methotrexate exposure in the CNS, cerebrospinal fluid (CSF) concentrations are often measured. However, the question is in how far we can rely on CSF concentrations of methotrexate as appropriate surrogate for brain target site concentrations, especially under disease conditions. In this study, we have investigated the spatial distribution of unbound methotrexate in healthy rat brain by parallel microdialysis, with or without inhibition of Mrp/Oat/Oatp-mediated active transport processes by a co-administration of probenecid. Specifically, we have focused on the relationship between brain extracellular fluid (brainECF) and CSF concentrations. The data were used to develop a systems-based pharmacokinetic (SBPK) brain distribution model for methotrexate. This model was subsequently applied on literature data on methotrexate brain distribution in other healthy and diseased rats (brainECF), healthy dogs (CSF) and diseased children (CSF) and adults (brainECF and CSF). Important differences between brainECF and CSF kinetics were found, but we have found that inhibition of Mrp/Oat/Oatp-mediated active transport processes does not significantly influence the relationship between brainECF and CSF fluid methotrexate concentrations. It is concluded that in parallel obtained data on unbound brainECF, CSF and plasma concentrations, under dynamic conditions, combined with advanced mathematical modeling is a most valid approach to develop SBPK models that allow for revealing the mechanisms underlying the relationship between brainECF and CSF concentrations in health and disease.
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Kapoor G, Sinha R, Abedin S. Experience with high dose methotrexate therapy in childhood acute lymphoblastic leukemia in a tertiary care cancer centre of a developing country. Pediatr Blood Cancer 2012; 59:448-53. [PMID: 22271707 DOI: 10.1002/pbc.24081] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 12/27/2011] [Indexed: 11/07/2022]
Abstract
BACKGROUND Intensification of systemic chemotherapy with inclusion of high dose methotrexate (HDMTX) has helped omit cranial irradiation from standard risk acute lymphoblastic leukemia (ALL) protocols, thereby eliminating the adverse side effects associated with its use. Administration of HDMTX needs meticulous monitoring. Limitations in the availability of trained staff and adequate infrastructure often pose problems in the developing world. The aim of this study was (1) to treat childhood ALL with a protocol that would have reduced use of cranial irradiation and containing infusions of high-dose methotrexate HDMTX (5 g/m(2)) without compromising on survival, and (2) evaluate the experience with HDMTX in a tertiary care cancer centre in a developing country. METHODS A retrospective chart review was done of 41 consecutive children with a confirmed diagnosis of ALL who had received at least one cycle of HDMTX as part of their consolidation treatment with regard to the patient demographic profile, details of HDMTX infusion and leucovorin rescue, toxicity, additional hospitalization, delay in next cycle of chemotherapy and survival. RESULTS The clinically most significant toxicities observed were mucositis 39% (58/149) and fever 28% (42/149) together leading to additional hospital stay in 7% (11/149) cycles and neutropenia grade 3 or more in 24.8% (34/137) contributing to delay in next cycle of chemotherapy in 15% (23/149) cycles. CONCLUSION With this strategy, it was possible to omit or reduce the dose of cranial irradiation while maintaining survival outcomes. The administration of HDMTX therapy was found to be feasible and safe with the precautions described.
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Affiliation(s)
- Gauri Kapoor
- Department of Pediatric Hematology and Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India.
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