1
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Tatarczuch M, Lewis KL, Gunjur A, Shaw B, Poon LM, Paul E, Ku M, Wong M, Ai S, Beekman A, Ciaccio PRD, Krigstein M, Wight J, Coombes C, Gilbertson M, Tey A, Shortt J, Nagarajan C, Talaulikar D, Hamad N, Ratnasingam S, Ho S, Cochrane T, Hawkes EA, Cheah CY, Opat S, Gregory GP. Sequential high-dose methotrexate and cytarabine administration improves outcomes in real-world patients with primary central nervous system lymphoma: A report from the Australasian Lymphoma Alliance. EJHAEM 2024; 5:709-720. [PMID: 39157596 PMCID: PMC11327773 DOI: 10.1002/jha2.951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 05/10/2024] [Indexed: 08/20/2024]
Abstract
Background Despite recent advances, optimal therapeutic approaches applicable to subpopulations with primary central nervous system (CNS) lymphoma outside of clinical trials remain to be determined. Methods We performed a retrospective study of immunocompetent, adult patients with histologically confirmed diffuse large B-cell lymphoma of the CNS (PCNSL). 190/204 (93%) patients (median age: 65) received one of five high-dose methotrexate (HD-MTX) containing chemotherapy regimens: MPV/Ara-C (HD-MTX, procarbazine, and vincristine, followed by cytarabine [Ara-C]) (n = 94, 50%), MATRix (HD-MTX, Ara-C, thiotepa, and rituximab) (n = 19, 10%), HD-MTX/Ara-C (n = 31, 16%), HD-MTX monotherapy (n = 35, 18%) and MBVP (HD-MTX, carmustine, teniposide, prednisolone) (n = 11, 6%). Results Cumulative median HD-MTX and Ara-C doses were 17 g/m2 (range: 1-64 g/m2) and 12 g/m2 (0-32 g/m2) respectively. Using 14 g/m2 as the reference dose, the median HD-MTX relative dose intensity (HD-MTX-RDI) was 1.25 (0.27-4.57) with 84% receiving > 0.75. The overall response rate (ORR) was 72% (complete response: 50%) after completing HD-MTX. At a median follow-up of 3.41 years (0.06-9.42), progression-free survival (PFS) and overall survival (OS) were different between chemotherapy cohorts, with the best outcomes achieved in the MPV/Ara-C cohort (2-year PFS 74%, 2-year OS 82%; p = 0.0001 and p = 0.0024 respectively). On multivariate analysis, MPV/Ara-C administration and HD-MTX-RDI > 0.75 were associated with longer PFS and OS. Conclusion Sequential, response-adapted approaches can improve outcomes, even in older patients who are ineligible for a high-intensity concurrent chemotherapy approach and do not undergo traditional consolidative strategies.
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Calimeri T, Anzalone N, Cangi MG, Fiore P, Gagliardi F, Miserocchi E, Ponzoni M, Ferreri AJM. Molecular diagnosis of primary CNS lymphoma in 2024 using MYD88 Leu265Pro and IL-10. Lancet Haematol 2024; 11:e540-e549. [PMID: 38937027 DOI: 10.1016/s2352-3026(24)00104-2] [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: 01/21/2024] [Revised: 04/01/2024] [Accepted: 04/09/2024] [Indexed: 06/29/2024]
Abstract
Early diagnosis is crucial for the successful treatment of primary CNS lymphoma (PCNSL), a rapidly progressing tumour. Suspicion raised on brain MRI must be confirmed by a histopathological diagnosis of a tumour specimen collected by stereotactic biopsy. In rare cases, cerebrospinal fluid (CSF) or vitreous humour might aid in providing a cytological diagnosis. Several disease-related, patient-related, and treatment-related factors affect the timing and accuracy of diagnosis and patient outcome. Some molecules detected in CSF, aqueous and vitreous humour, and peripheral blood were proposed as diagnostic biomarkers for PCNSL; however, detection methods for most of these molecules are not yet standardised, have a long turnaround time, are expensive, and have little reproducibility among labs. By contrast, the MYD88Leu265Pro somatic hotspot mutation, revealed by PCR-based assay, is currently and reliably used during the diagnosis of some lymphomas, and IL-10, measured by enzyme-linked immunosorbent assay, is routinely used to diagnose and monitor different common metabolic and immunological diseases. Several independent studies have shown that MYD88Leu265Pro and IL-10 can be easily assessed in peripheral blood, plasma, aqueous and vitreous humour, and CSF of patients with PCNSL with substantial sensitivity and specificity, especially when evaluated in combination. In this Viewpoint, evidence supporting the routine use of MYD88Leu265Pro and IL-10 in diagnosing PCNSL is considered, and some examples of the frequent difficulties found in the diagnosis of PCNSL are provided, highlighting the role and indications of these two biomarkers to improve the timely recognition of this aggressive tumour.
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Affiliation(s)
| | - Nicoletta Anzalone
- Neuroradiology Unit, IRCCS Ospedale San Raffaele, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | | | - Paolo Fiore
- Lymphoma Unit, IRCCS Ospedale San Raffaele, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Filippo Gagliardi
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS Ospedale San Raffaele, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Elisabetta Miserocchi
- Ophthalmological Unit, IRCCS Ospedale San Raffaele, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Maurilio Ponzoni
- Pathology Unit, IRCCS Ospedale San Raffaele, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Andrés J M Ferreri
- Lymphoma Unit, IRCCS Ospedale San Raffaele, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
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3
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Ferreri AJM, Illerhaus G, Doorduijn JK, Auer DP, Bromberg JEC, Calimeri T, Cwynarski K, Fox CP, Hoang‐Xuan K, Malaise D, Ponzoni M, Schorb E, Soussain C, Specht L, Zucca E, Buske C, Jerkeman M, Dreyling M. Primary central nervous system lymphomas: EHA-ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Hemasphere 2024; 8:e89. [PMID: 38836097 PMCID: PMC11148853 DOI: 10.1002/hem3.89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 05/10/2024] [Indexed: 06/06/2024] Open
Abstract
This EHA-ESMO Clinical Practice Guideline provides key recommendations for managing primary DLBCL of the CNS.The guideline covers clinical, imaging and pathological diagnosis, staging and risk assessment, treatment and follow-up.Algorithms for first-line and salvage treatments are provided.The author group encompasses a multidisciplinary group of experts from different institutions and countries in Europe.Recommendations are based on available scientific data and the authors' collective expert opinion.
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Affiliation(s)
- Andreas J. M. Ferreri
- Lymphoma Unit, IRCCS San Raffaele Scientific InstituteMilanItaly
- Università Vita e Salute San RaffaeleMilanItaly
| | - Gerald Illerhaus
- Department of HematologyOncology, Stem‐Cell Transplantation and Palliative Care, Klinikum StuttgartStuttgartGermany
| | - Jeanette K. Doorduijn
- Department of Haematology, Erasmus MC Cancer InstituteUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Dorothee P. Auer
- Mental Health & Clinical Neurosciences Unit, School of MedicineUniversity of NottinghamNottinghamUK
- NIHR Nottingham Biomedical Research CentreUniversity of NottinghamNottinghamUK
| | - Jacoline E. C. Bromberg
- Department of Neuro‐Oncology, Erasmus MC Cancer InstituteUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Teresa Calimeri
- Lymphoma Unit, IRCCS San Raffaele Scientific InstituteMilanItaly
| | - Kate Cwynarski
- Department of HaematologyUniversity College HospitalLondonUK
| | | | - Khê Hoang‐Xuan
- Department of Neurology 2 MazarinAPHP, Groupe Hospitalier Pitié‐Salpêtrière, Sorbonne Université, ICMParisFrance
| | - Denis Malaise
- Department of OphthalmologyInstitut CurieParisFrance
- LITO, INSERM U1288, Institut CuriePSL UniversityOrsayFrance
| | - Maurilio Ponzoni
- Lymphoma Unit, IRCCS San Raffaele Scientific InstituteMilanItaly
- Università Vita e Salute San RaffaeleMilanItaly
- Pathology Unit, IRCCS San Raffaele Scientific InstituteMilanItaly
| | - Elisabeth Schorb
- Department of Medicine I, Medical Center, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Carole Soussain
- Clinical Hematology Unit, Institut CurieSt CloudFrance
- INSERM U932, Institut CuriePSL Research UniversityParisFrance
| | - Lena Specht
- Department of Oncology, RigshospitaletUniversity of CopenhagenCopenhagenDenmark
| | - Emanuele Zucca
- Clinic of Medical Oncology, Oncology Institute of Southern Switzerland, Ente Ospedaliero CantonaleBellinzonaSwitzerland
- Institute of Oncology Research, Faculty of Biomedical Sciences, Università della Svizzera ItalianaBellinzonaSwitzerland
- Department of Medical OncologyBern University Hospital and University of BernBernSwitzerland
| | - Christian Buske
- Institute of Experimental Cancer Research, Comprehensive Cancer Center UlmUniversity Hospital of UlmUlmGermany
| | - Mats Jerkeman
- Department of OncologySkåne University Hospital and Lund UniversityLundSweden
| | - Martin Dreyling
- Department of Medicine IIILMU University Hospital MunichMunichGermany
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4
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Ferreri AJM, Illerhaus G, Doorduijn JK, Auer DP, Bromberg JEC, Calimeri T, Cwynarski K, Fox CP, Hoang-Xuan K, Malaise D, Ponzoni M, Schorb E, Soussain C, Specht L, Zucca E, Buske C, Jerkeman M, Dreyling M. Primary central nervous system lymphomas: EHA-ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol 2024; 35:S0923-7534(23)05074-3. [PMID: 38839484 DOI: 10.1016/j.annonc.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 06/07/2024] Open
Affiliation(s)
- A J M Ferreri
- Lymphoma Unit, IRCCS San Raffaele Scientific Institute, Milan; Università Vita e Salute San Raffaele, Milan, Italy
| | - G Illerhaus
- Department of Hematology, Oncology, Stem-Cell Transplantation and Palliative Care, Klinikum Stuttgart, Stuttgart, Germany
| | - J K Doorduijn
- Department of Haematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - D P Auer
- Mental Health & Clinical Neurosciences Unit, School of Medicine, University of Nottingham, Nottingham; NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - J E C Bromberg
- Department of Neuro-Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - T Calimeri
- Lymphoma Unit, IRCCS San Raffaele Scientific Institute, Milan
| | - K Cwynarski
- Department of Haematology, University College Hospital, London
| | - C P Fox
- School of Medicine, University of Nottingham, Nottingham, UK
| | - K Hoang-Xuan
- Department of Neurology 2 Mazarin, APHP, Groupe Hospitalier Pitié-Salpêtrière, Sorbonne Université, ICM, Paris
| | - D Malaise
- Department of Ophthalmology, Institut Curie, Paris; LITO, INSERM U1288, Institut Curie, PSL University, Orsay, France
| | - M Ponzoni
- Lymphoma Unit, IRCCS San Raffaele Scientific Institute, Milan; Università Vita e Salute San Raffaele, Milan, Italy; Pathology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - E Schorb
- Department of Medicine I, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - C Soussain
- Clinical Hematology Unit, Institut Curie, St Cloud; INSERM U932, Institut Curie, PSL Research University, Paris, France
| | - L Specht
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - E Zucca
- Clinic of Medical Oncology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona; Institute of Oncology Research, Faculty of Biomedical Sciences, Università della Svizzera Italiana, Bellinzona; Department of Medical Oncology, Bern University Hospital and University of Bern, Bern, Switzerland
| | - C Buske
- Institute of Experimental Cancer Research, Comprehensive Cancer Center Ulm, University Hospital of Ulm, Ulm, Germany
| | - M Jerkeman
- Department of Oncology, Skåne University Hospital and Lund University, Lund, Sweden
| | - M Dreyling
- Department of Medicine III, LMU University Hospital Munich, Munich, Germany
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5
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Zeremski V, Adolph L, Beer S, Berisha M, Jacobs B, Kahl C, Koenecke C, Kropf S, Panse J, Petersen J, Schmidt-Hieber M, Schneider J, Vucinic V, Walter J, Weigert O, Witte HM, Mougiakakos D. Relevance of different prognostic scores in primary CNS lymphoma in the era of intensified treatment regimens: A retrospective, multicenter analysis of 174 patients. Eur J Haematol 2024; 112:641-649. [PMID: 38164819 DOI: 10.1111/ejh.14159] [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: 11/06/2023] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES Treatment intensification (including consolidative high-dose chemotherapy with autologous stem cell transplantation [HDT-ASCT]) significantly improved outcome in primary central nervous system lymphoma (PCNSL) patients. METHODS We conducted a multicenter, retrospective analysis of newly diagnosed PCNSL patients, treated with intensified treatment regimens. The following scores were evaluated in terms of overall survival (OS) and progression-free survival (PFS): Memorial Sloan-Kettering Cancer Center (MSKCC), International Extranodal Lymphoma Study Group (IELSG), and three-factor (3F) prognostic score. Further, all scores were comparatively investigated for model quality and concordance. RESULTS Altogether, 174 PCNSL patients were included. One hundred and five patients (60.3%) underwent HDT-ASCT. Two-year OS and 2-year PFS for the entire population were 73.3% and 48.5%, respectively. The MSKCC (p = .003) and 3F score (p < .001), but not the IELSG score (p = .06), had the discriminatory power to identify different risk groups for OS. In regard to concordance, the 3F score (C-index [0.71]) outperformed both the MSKCC (C-index [0.64]) and IELSG (C-index [0.53]) score. Moreover, the superiority of the 3F score was shown for PFS, successfully stratifying patients in three risk groups, which also resulted in the highest C-index (0.66). CONCLUSION The comparative analysis of established PCNSL risk scores affirm the clinical utility of the 3F score stratifying the widest prognostic spectrum among PCNSL patients treated with intensified treatment approaches.
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Affiliation(s)
- Vanja Zeremski
- Department of Hematology and Oncology, Medical Faculty, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Louisa Adolph
- Department of Internal Medicine III, Ludwig-Maximilians-University Hospital, Munich, Germany
| | - Sina Beer
- Department of Hematology and Oncology, University Hospital Tuebingen, Tuebingen, Germany
| | - Mirjeta Berisha
- Department of Hematology and Oncology, Medical Faculty, Otto von Guericke University Magdeburg, Magdeburg, Germany
- Department of Internal Medicine 5, Hematology and Clinical Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany
| | - Benedikt Jacobs
- Department of Internal Medicine 5, Hematology and Clinical Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany
| | - Christoph Kahl
- Department of Hematology, Oncology and Palliative Care, Klinikum Magdeburg, Magdeburg, Germany
- Department of Hematology, Oncology, and Palliative Care, University Medical Center, University of Rostock, Rostock, Germany
| | - Christian Koenecke
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Siegfried Kropf
- Department of Biometry and Medical Informatics, Medical Faculty, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Jens Panse
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Center for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf (ABCD), Aachen, Germany
| | - Judith Petersen
- Department of Hematology, Cell Therapy, Hemostaseology and Infectious Diseases, Leipzig University Medical Center, Leipzig, Germany
| | - Martin Schmidt-Hieber
- Clinic of Hematology, Oncology, Pneumology and Nephrology, Carl-Thiem-Hospital Cottbus, Cottbus, Germany
| | - Jessica Schneider
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Vladan Vucinic
- Department of Hematology, Cell Therapy, Hemostaseology and Infectious Diseases, Leipzig University Medical Center, Leipzig, Germany
| | - Jeanette Walter
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Center for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf (ABCD), Aachen, Germany
| | - Oliver Weigert
- Department of Internal Medicine III, Ludwig-Maximilians-University Hospital, Munich, Germany
| | - Hanno M Witte
- Department of Hematology and Oncology, Federal Armed Hospital Ulm, Ulm, Germany
| | - Dimitrios Mougiakakos
- Department of Hematology and Oncology, Medical Faculty, Otto von Guericke University Magdeburg, Magdeburg, Germany
- Department of Internal Medicine 5, Hematology and Clinical Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany
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6
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D'Angelo CR. Diagnostic, Pathologic, and Therapeutic Considerations for Primary CNS Lymphoma. JCO Oncol Pract 2024; 20:195-202. [PMID: 37967301 DOI: 10.1200/op.23.00294] [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: 05/12/2023] [Revised: 09/27/2023] [Accepted: 10/12/2023] [Indexed: 11/17/2023] Open
Abstract
Primary CNS lymphoma (PCNSL) is a rare lymphoma representing 3% of CNS malignancies. The diagnosis is complicated by the unique risks associated with brain biopsy, and the treatment is similarly complicated by the restriction of effective therapeutics able to cross the blood-brain barrier. Currently, the majority of individuals diagnosed with this disease are immunocompetent although immune deficiency related to HIV or immunosuppressive therapy remains an important risk factor. Improvements in both frontline therapy and consolidation options, including the use of hematopoietic stem-cell transplantation, have translated to improved survival. Unfortunately, patients experiencing relapsed or refractory disease often fare poorly. Here, we review key clinical, pathologic, and therapeutic aspects of PCNSL and highlight challenging clinical scenarios that may be encountered by the treating oncologist.
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7
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Chuang CH, Kuo MC, Chang H, Wu JH, Hung YS, Ou CW, Lin TL, Su YJ, Ong YC, Shih LY, Kao HW. Different patterns of failure in two treatment regimens for primary central nervous system lymphoma, a retrospective analysis of 124 cases in Taiwan. Clin Exp Med 2023; 23:5327-5336. [PMID: 37679606 PMCID: PMC10725386 DOI: 10.1007/s10238-023-01182-2] [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: 06/18/2023] [Accepted: 08/28/2023] [Indexed: 09/09/2023]
Abstract
To explore prognostic factors and outcomes of primary central nervous system lymphoma (PCNSL) of diffuse large B-cell lymphoma (DLBCL) in Taiwan, 124 PCNSL-DLBCL patients (from 1995 to 2021) were retrospectively analyzed. Mainly, two treatment modalities including sandwich chemoradiotherapy and modified MATRix regimen were employed in these patients. Overall survival (OS) was determined by log-rank test and time-dependent Cox analysis. Median OS of all patients was 27.1 months. 47 (37.9%) patients who underwent sandwich chemoradiotherapy had a complete remission (CR) rate of 87.2%, median OS of 53.9 months, and progression free survival (PFS) of 42.9 months. 11 (8.9%) patients who underwent modified MATRix regimen had CR rate of 72.7%, median OS of 18.9, and PFS of 11.2 months. There are no significant OS differences between treatment groups or addition of Rituximab. Patients treated with the modified MATRix regimen experienced a higher early mortality rate followed by a survival plateau. IELSG low-risk group had significantly improved OS and PFS than IELSG intermediate- or high-risk group. In multivariant analysis, age > 60 years old and bilateral cerebral lesions are associated with significantly inferior OS. Sandwich chemoradiotherapy demonstrated better early survival and reduced treatment-related toxicity for PCNSL patients compared to the modified MATRix regimen. However, the long-term follow-up revealed a higher rate of treatment failure events in the sandwich chemoradiotherapy group. IELSG and MSKCC scores served as reliable risk assessment models. Incorporating bilateral cerebral lesions as a risk factor further improved risk evaluation.
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Affiliation(s)
- Chin-Hsuan Chuang
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, No. 5, Fuxing Street, Guishan Dist., Taoyuan City, 333423, Taiwan, ROC
| | - Ming-Chung Kuo
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, No. 5, Fuxing Street, Guishan Dist., Taoyuan City, 333423, Taiwan, ROC
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hung Chang
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, No. 5, Fuxing Street, Guishan Dist., Taoyuan City, 333423, Taiwan, ROC
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jin-Hou Wu
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, No. 5, Fuxing Street, Guishan Dist., Taoyuan City, 333423, Taiwan, ROC
| | - Yu-Shin Hung
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, No. 5, Fuxing Street, Guishan Dist., Taoyuan City, 333423, Taiwan, ROC
| | - Che-Wei Ou
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, No. 5, Fuxing Street, Guishan Dist., Taoyuan City, 333423, Taiwan, ROC
| | - Tung-Liang Lin
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, No. 5, Fuxing Street, Guishan Dist., Taoyuan City, 333423, Taiwan, ROC
| | - Yi-Jiun Su
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, No. 5, Fuxing Street, Guishan Dist., Taoyuan City, 333423, Taiwan, ROC
| | - Yuen-Chin Ong
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, No. 5, Fuxing Street, Guishan Dist., Taoyuan City, 333423, Taiwan, ROC
| | - Lee-Yung Shih
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, No. 5, Fuxing Street, Guishan Dist., Taoyuan City, 333423, Taiwan, ROC
- 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, No. 5, Fuxing Street, Guishan Dist., Taoyuan City, 333423, Taiwan, ROC.
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8
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Alderuccio JP, Nayak L, Cwynarski K. How I treat secondary CNS involvement by aggressive lymphomas. Blood 2023; 142:1771-1783. [PMID: 37702537 PMCID: PMC10862244 DOI: 10.1182/blood.2023020168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/14/2023] [Accepted: 08/17/2023] [Indexed: 09/14/2023] Open
Abstract
Secondary central nervous system (CNS) lymphoma (SCNSL) is a rare but clinically challenging scenario with historically disappointing outcomes. SCNSL refers to lymphoma that has spread into the CNS concurrently with systemic disease or CNS relapse during or after frontline immunochemotherapy, presenting with or without systemic lymphoma. Diffuse large B-cell lymphoma (DLBCL) denotes the most common entity, but an increased incidence is observed in other histologies, such as Burkitt lymphoma and mantle-cell lymphoma. The incidence, timing in disease course, location, evidence supporting the use of CNS prophylaxis, and treatment pathways vary according to histology. No randomized data exist to delineate the best treatment approaches with current recommendations based on retrospective and single-arm studies. However, a regimen comprising immunochemotherapy, incorporating agents that cross the blood-brain barrier, followed by thiotepa-containing conditioning and autologous stem-cell transplant outlined in the international MARIETTA study demonstrated improvement in outcomes, representing a major accomplishment in the care of patients with DLBCL with SCNSL. Anti-CD19 chimeric antigen receptor T cell denotes a paradigm shift in the treatment of patients with systemic aggressive lymphomas, with emerging data also demonstrating efficacy without higher neurotoxicity in those with SCNSL. In this manuscript we discuss 5 clinical scenarios and review the evidence supporting our recommendations.
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Affiliation(s)
- Juan Pablo Alderuccio
- Division of Hematology, Department of Medicine, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL
| | - Lakshmi Nayak
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Kate Cwynarski
- Department of Haematology, University College London Hospital, London, United Kingdom
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9
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Khwaja J, Nayak L, Cwynarski K. Evidence-based management of primary and secondary CNS lymphoma. Semin Hematol 2023; 60:313-321. [PMID: 38135609 DOI: 10.1053/j.seminhematol.2023.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 11/15/2023] [Accepted: 11/20/2023] [Indexed: 12/24/2023]
Abstract
Central nervous system (CNS) lymphoma has traditionally had very poor outcomes however advances in management have resulted in dramatic improvements and long-term survival of patients. We describe the evidence for treatment strategies for these aggressive disorders. In primary CNS lymphoma there are randomized trial data to inform treatment decisions but these are lacking to guide management in secondary CNS lymphoma. Dynamic assessment of patient fitness and frailty is key throughout treatment, alongside delivery of CNS-bioavailable therapy and enrolment in clinical trials, at each stage of the disease. Intensive high-dose methotrexate-containing induction followed by consolidation with autologous stem cell transplantation with thiotepa-based conditioning is recommended for patients who are fit. Less intensive chemoimmunotherapy, novel agents (including Bruton tyrosine kinase inhibitors, cereblon targeting immunomodulatory agents, and checkpoint inhibitors in the context of clinical trials), and whole brain radiotherapy may be reserved for less fit patients or disease which is chemoresistant. Data regarding the efficacy of chimeric antigen receptor T-cells therapy is emerging, and concerns regarding greater toxicity have not been realized. Future areas of prospective studies include the identification of those at high risk of developing CNS lymphoma, management in elderly or frail patients as well as incorporating novel agents into regimens, particularly for those with chemoresistant disease.
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Affiliation(s)
- Jahanzaib Khwaja
- Department of Haematology, University College London Hospital, London, United Kingdom.
| | - Lakshmi Nayak
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Kate Cwynarski
- Department of Haematology, University College London Hospital, London, United Kingdom
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10
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Mehta N, Scholle T, Chevez-Barrios P, Schefler AC, Weng CY. PRIMARY CENTRAL NERVOUS SYSTEM AND VITREORETINAL LYMPHOMA MIMICKING VIRAL RETINITIS IN A YOUNG PATIENT. Retin Cases Brief Rep 2023; 17:567-571. [PMID: 37643044 DOI: 10.1097/icb.0000000000001255] [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: 08/31/2023]
Abstract
BACKGROUND/PURPOSE The purpose of this study was to report a young immunocompetent patient with primary central nervous system and vitreoretinal lymphoma initially presenting with peripheral retinitis. METHODS This study is a case report. RESULTS A 31-year-old woman presented with 20/60 vision in her left eye, vitreous haze, and peripheral retinal whitening. Intravitreal and oral antivirals were initiated for presumed acute retinal necrosis. Anterior chamber paracentesis was negative for viral nucleotide. Subretinal infiltrates developed, and vitreous biopsy was performed and interpreted as "negative except for rare yeast." Antifungal therapy was initiated. She developed multiple unilateral cranial neuropathies with multifocal areas of enhancement on neuroimaging. Lumbar puncture cytology was negative for neoplastic cells. After further worsening, aforementioned specimens were sent to a specialized ophthalmic pathology laboratory and the diagnosis revised to lymphoma of the diffuse B-cell type. Initial disease regression was seen after combined systemic and intraocular chemotherapy; unfortunately, the patient suffered a central nervous system recurrence and died from systemic complications 1 year later. CONCLUSION There has been an increased incidence of primary central nervous system and vitreoretinal lymphoma in young patients. Although vitreous biopsy is the diagnostic gold standard for vitreoretinal lymphoma, a risk of false negative interpretation exists. A high index of suspicion and expert interpretation of pathology may be necessary to secure the correct diagnosis.
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Affiliation(s)
- Nitish Mehta
- Department of Ophthalmology-Cullen Eye Institute, Baylor College of Medicine, Houston, Texas
- Department of Ophthalmology, Ben Taub General Hospital, Houston, Texas
| | - Tahira Scholle
- Department of Ophthalmology-Cullen Eye Institute, Baylor College of Medicine, Houston, Texas
- Department of Ophthalmology, Ben Taub General Hospital, Houston, Texas
| | - Patricia Chevez-Barrios
- Department of Ophthalmology-Cullen Eye Institute, Baylor College of Medicine, Houston, Texas
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Houston, Texas; and
| | - Amy C Schefler
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Houston, Texas; and
- Retina Consultants of Texas and Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas
| | - Christina Y Weng
- Department of Ophthalmology-Cullen Eye Institute, Baylor College of Medicine, Houston, Texas
- Department of Ophthalmology, Ben Taub General Hospital, Houston, Texas
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11
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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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12
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Isbell LK, Uibeleisen R, Friedl A, Burger E, Dopatka T, Scherer F, Orban A, Lauer E, Malenica N, Semenova I, Vreden A, Valk E, Wendler J, Neumaier S, Fricker H, El Rabih AAH, Gloggengießer C, Hilbig D, Bleul S, Weis J, Gmehlin D, Backenstrass M, Wirtz S, Ihorst G, Finke J, Illerhaus G, Schorb E. Age-adjusted high-dose chemotherapy followed by autologous stem cell transplantation or conventional chemotherapy with R-MP as first-line treatment in elderly primary CNS lymphoma patients - the randomized phase III PRIMA-CNS trial. BMC Cancer 2023; 23:767. [PMID: 37596517 PMCID: PMC10436648 DOI: 10.1186/s12885-023-11193-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/19/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Older primary central nervous system lymphoma (PCNSL) patients have an inferior prognosis compared to younger patients because available evidence on best treatment is scarce and treatment delivery is challenging due to comorbidities and reduced performance status. High-dose chemotherapy and autologous stem cell transplantation (HCT-ASCT) after high-dose methotrexate (MTX)-based immuno-chemotherapy has become an increasingly used treatment approach in eligible elderly PCNSL patients with promising feasibility and efficacy, but has not been compared with conventional chemotherapy approaches. In addition, eligibility for HCT-ASCT in elderly PCNSL is not well defined. Geriatric assessment (GA) may be helpful in selecting patients for the best individual treatment choice, but no standardized GA exists to date. A randomized controlled trial, incorporating a GA and comparing age-adapted HCT-ASCT treatment with conventional chemotherapy is needed. METHODS This open-label, multicenter, randomized phase III trial with two parallel arms will recruit 310 patients with newly diagnosed PCNSL > 65 years of age in 40 centers in Germany and Austria. The primary objective is to demonstrate that intensified chemotherapy followed by consolidating HCT-ASCT is superior to conventional chemotherapy with rituximab, MTX, procarbazine (R-MP) followed by maintenance with procarbazine in terms of progression free survival (PFS). Secondary endpoints include overall survival (OS), event free survival (EFS), (neuro-)toxicity and quality of life (QoL). GA will be conducted at specific time points during the course of the study. All patients will be treated with a pre-phase rituximab-MTX (R-MTX) cycle followed by re-assessment of transplant eligibility. Patients judged transplant eligible will be randomized (1:1). Patients in arm A will be treated with 3 cycles of R-MP followed by maintenance therapy with procarbazine for 6 months. Patients in arm B will be treated with 2 cycles of MARTA (R-MTX/AraC) followed by busulfan- and thiotepa-based HCT-ASCT. DISCUSSION The best treatment strategy for elderly PCNSL patients remains unknown. Treatments range from palliative to curative but more toxic therapies, and there is no standardized measure to select patients for the right treatment. This randomized controlled trial will create evidence for the best treatment strategy with the focus on developing a standardized GA to help define eligibility for an intensive treatment approach. TRIAL REGISTRATION German clinical trials registry DRKS00024085 registered March 29, 2023.
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Affiliation(s)
- Lisa K Isbell
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Roswitha Uibeleisen
- Clinic of Hematology, Oncology and Palliative Care, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Alexander Friedl
- Department of Endocrinology, Diabetology and Geriatrics, Klinikum Stuttgart, Prießnitzweg 24, 70374, Bad Cannstatt, Germany
| | - Elvira Burger
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Tatja Dopatka
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Florian Scherer
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Andras Orban
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Eliza Lauer
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Natalie Malenica
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Inna Semenova
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Annika Vreden
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Elke Valk
- Stuttgart Cancer Center - Tumorzentrum Eva Mayer-Stihl, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Julia Wendler
- Clinic of Hematology, Oncology and Palliative Care, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Simone Neumaier
- Clinic of Hematology, Oncology and Palliative Care, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Heidi Fricker
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Abed Al Hadi El Rabih
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Cora Gloggengießer
- Stuttgart Cancer Center - Tumorzentrum Eva Mayer-Stihl, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Daniela Hilbig
- Stuttgart Cancer Center - Tumorzentrum Eva Mayer-Stihl, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Sabine Bleul
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Joachim Weis
- Endowed Professorship Self-Help Research, Comprehensive Cancer Center, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Dennis Gmehlin
- Institute for Clinical Psychology, Klinikum Stuttgart, Prießnitzweg 24, 70374, Bad Cannstatt, Germany
| | - Matthias Backenstrass
- Institute for Clinical Psychology, Klinikum Stuttgart, Prießnitzweg 24, 70374, Bad Cannstatt, Germany
| | - Sebastian Wirtz
- Clinical Trials Unit, Faculty of Medicine and Medical Center, University of Freiburg, Elsässer Straße 2, 79110, Freiburg, Germany
| | - Gabriele Ihorst
- Clinical Trials Unit, Faculty of Medicine and Medical Center, University of Freiburg, Elsässer Straße 2, 79110, Freiburg, Germany
| | - Jürgen Finke
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Gerald Illerhaus
- Clinic of Hematology, Oncology and Palliative Care, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Elisabeth Schorb
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany.
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13
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Cornell I, Al Busaidi A, Wastling S, Anjari M, Cwynarski K, Fox CP, Martinez-Calle N, Poynton E, Maynard J, Thust SC. Early MRI Predictors of Relapse in Primary Central Nervous System Lymphoma Treated with MATRix Immunochemotherapy. J Pers Med 2023; 13:1182. [PMID: 37511795 PMCID: PMC10381964 DOI: 10.3390/jpm13071182] [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: 04/15/2023] [Revised: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023] Open
Abstract
Primary Central Nervous System Lymphoma (PCNSL) is a highly malignant brain tumour. We investigated dynamic changes in tumour volume and apparent diffusion coefficient (ADC) measurements for predicting outcome following treatment with MATRix chemotherapy in PCNSL. Patients treated with MATRix (n = 38) underwent T1 contrast-enhanced (T1CE) and diffusion-weighted imaging (DWI) before treatment, after two cycles and after four cycles of chemotherapy. Response was assessed using the International PCNSL Collaborative Group (IPCG) imaging criteria. ADC histogram parameters and T1CE tumour volumes were compared among response groups, using one-way ANOVA testing. Logistic regression was performed to examine those imaging parameters predictive of response. Response after two cycles of chemotherapy differed from response after four cycles; of the six patients with progressive disease (PD) after four cycles of treatment, two (33%) had demonstrated a partial response (PR) or complete response (CR) after two cycles. ADCmean at baseline, T1CE at baseline and T1CE percentage volume change differed between response groups (0.005 < p < 0.038) and were predictive of MATRix treatment response (area under the curve: 0.672-0.854). Baseline ADC and T1CE metrics are potential biomarkers for risk stratification of PCNSL patients early during remission induction therapy with MATRix. Standard interim response assessment (after two cycles) according to IPCG imaging criteria does not reliably predict early disease progression in the context of a conventional treatment approach.
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Affiliation(s)
- Isabel Cornell
- UCL Institute of Neurology, Department of Brain Rehabilitation and Repair, Queen Square, London WC1N 3BG, UK
| | - Ayisha Al Busaidi
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London WC1N 3BG, UK
- Neuroradiology Department, Kings College Hospital NHS Foundation Trust, London SE5 9RS, UK
| | - Stephen Wastling
- UCL Institute of Neurology, Department of Brain Rehabilitation and Repair, Queen Square, London WC1N 3BG, UK
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London WC1N 3BG, UK
| | - Mustafa Anjari
- UCL Institute of Neurology, Department of Brain Rehabilitation and Repair, Queen Square, London WC1N 3BG, UK
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London WC1N 3BG, UK
- Radiology Department, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Kate Cwynarski
- Haematology Department, University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK
| | - Christopher P Fox
- School of Medicine, University of Nottingham, Nottingham NG7 2UH, UK
| | | | - Edward Poynton
- Haematology Department, University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK
| | - John Maynard
- UCL Institute of Neurology, Department of Brain Rehabilitation and Repair, Queen Square, London WC1N 3BG, UK
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London WC1N 3BG, UK
| | - Steffi C Thust
- UCL Institute of Neurology, Department of Brain Rehabilitation and Repair, Queen Square, London WC1N 3BG, UK
- Precision Imaging Beacon, School of Medicine, University of Nottingham, Nottingham NG7 2UH, UK
- Neuroradiology Department, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
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14
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Ferreri AJM, Calimeri T, Cwynarski K, Dietrich J, Grommes C, Hoang-Xuan K, Hu LS, Illerhaus G, Nayak L, Ponzoni M, Batchelor TT. Primary central nervous system lymphoma. Nat Rev Dis Primers 2023; 9:29. [PMID: 37322012 PMCID: PMC10637780 DOI: 10.1038/s41572-023-00439-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2023] [Indexed: 06/17/2023]
Abstract
Primary central nervous system lymphoma (PCNSL) is a diffuse large B cell lymphoma in which the brain, spinal cord, leptomeninges and/or eyes are exclusive sites of disease. Pathophysiology is incompletely understood, although a central role seems to comprise immunoglobulins binding to self-proteins expressed in the central nervous system (CNS) and alterations of genes involved in B cell receptor, Toll-like receptor and NF-κB signalling. Other factors such as T cells, macrophages or microglia, endothelial cells, chemokines, and interleukins, probably also have important roles. Clinical presentation varies depending on the involved regions of the CNS. Standard of care includes methotrexate-based polychemotherapy followed by age-tailored thiotepa-based conditioned autologous stem cell transplantation and, in patients unsuitable for such treatment, consolidation with whole-brain radiotherapy or single-drug maintenance. Personalized treatment, primary radiotherapy and only supportive care should be considered in unfit, frail patients. Despite available treatments, 15-25% of patients do not respond to chemotherapy and 25-50% relapse after initial response. Relapse rates are higher in older patients, although the prognosis of patients experiencing relapse is poor independent of age. Further research is needed to identify diagnostic biomarkers, treatments with higher efficacy and less neurotoxicity, strategies to improve the penetration of drugs into the CNS, and roles of other therapies such as immunotherapies and adoptive cell therapies.
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Affiliation(s)
| | - Teresa Calimeri
- Lymphoma Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Kate Cwynarski
- Department of Haematology, University College Hospital, London, UK
| | - Jorg Dietrich
- Cancer and Neurotoxicity Clinic and Brain Repair Research Program, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Christian Grommes
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Khê Hoang-Xuan
- APHP, Groupe Hospitalier Salpêtrière, Sorbonne Université, IHU, ICM, Service de Neurologie 2, Paris, France
| | - Leland S Hu
- Department of Radiology, Neuroradiology Division, Mayo Clinic, Phoenix, AZ, USA
| | - Gerald Illerhaus
- Clinic of Hematology, Oncology and Palliative Care, Klinikum Stuttgart, Stuttgart, Germany
| | - Lakshmi Nayak
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Maurilio Ponzoni
- Pathology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Ateneo Vita-Salute San Raffaele, Milan, Italy
| | - Tracy T Batchelor
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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15
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Liu N, Jiang C, Yao X, Fang M, Qiao X, Zhu L, Yang Z, Gao X, Ji Y, Niu C, Cheng C, Qu K, Lin J. Single-cell landscape of primary central nervous system diffuse large B-cell lymphoma. Cell Discov 2023; 9:55. [PMID: 37308475 DOI: 10.1038/s41421-023-00559-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 04/29/2023] [Indexed: 06/14/2023] Open
Abstract
Understanding tumor heterogeneity and immune infiltrates within the tumor-immune microenvironment (TIME) is essential for the innovation of immunotherapies. Here, combining single-cell transcriptomics and chromatin accessibility sequencing, we profile the intratumor heterogeneity of malignant cells and immune properties of the TIME in primary central nervous system diffuse large B-cell lymphoma (PCNS DLBCL) patients. We demonstrate diverse malignant programs related to tumor-promoting pathways, cell cycle and B-cell immune response. By integrating data from independent systemic DLBCL and follicular lymphoma cohorts, we reveal a prosurvival program with aberrantly elevated RNA splicing activity that is uniquely associated with PCNS DLBCL. Moreover, a plasmablast-like program that recurs across PCNS/activated B-cell DLBCL predicts a worse prognosis. In addition, clonally expanded CD8 T cells in PCNS DLBCL undergo a transition from a pre-exhaustion-like state to exhaustion, and exhibit higher exhaustion signature scores than systemic DLBCL. Thus, our study sheds light on potential reasons for the poor prognosis of PCNS DLBCL patients, which will facilitate the development of targeted therapy.
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Affiliation(s)
- Nianping Liu
- Department of Neurosurgery, The First Affiliated Hospital of USTC, School of Basic Medical Sciences, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Chen Jiang
- Department of Neurosurgery, The First Affiliated Hospital of USTC, School of Basic Medical Sciences, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
- Institute of Artificial Intelligence, Hefei Comprehensive National Science Center, Hefei, Anhui, China
| | - Xinfeng Yao
- Department of Neurosurgery, The First Affiliated Hospital of USTC, School of Basic Medical Sciences, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Minghao Fang
- Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Xiaolong Qiao
- Anhui University of Science and Technology, Huainan, Anhui, China
| | - Lin Zhu
- Department of Neurosurgery, The First Affiliated Hospital of USTC, School of Basic Medical Sciences, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Zongcheng Yang
- Department of Stomatology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Xuyuan Gao
- Department of Neurosurgery, The First Affiliated Hospital of USTC, School of Basic Medical Sciences, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Ying Ji
- Department of Neurosurgery, The First Affiliated Hospital of USTC, School of Basic Medical Sciences, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Chaoshi Niu
- Department of Neurosurgery, The First Affiliated Hospital of USTC, School of Basic Medical Sciences, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Chuandong Cheng
- Department of Neurosurgery, The First Affiliated Hospital of USTC, School of Basic Medical Sciences, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China.
| | - Kun Qu
- Department of Neurosurgery, The First Affiliated Hospital of USTC, School of Basic Medical Sciences, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China.
- Institute of Artificial Intelligence, Hefei Comprehensive National Science Center, Hefei, Anhui, China.
- CAS Center for Excellence in Molecular Cell Sciences, The CAS Key Laboratory of Innate Immunity and Chronic Disease, University of Science and Technology of China, Hefei, Anhui, China.
| | - Jun Lin
- Department of Neurosurgery, The First Affiliated Hospital of USTC, School of Basic Medical Sciences, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China.
- Institute of Artificial Intelligence, Hefei Comprehensive National Science Center, Hefei, Anhui, China.
- CAS Center for Excellence in Molecular Cell Sciences, The CAS Key Laboratory of Innate Immunity and Chronic Disease, University of Science and Technology of China, Hefei, Anhui, China.
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16
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Khwaja J, Cwynarski K. Management of primary and secondary CNS lymphoma. Hematol Oncol 2023; 41 Suppl 1:25-35. [PMID: 37294958 DOI: 10.1002/hon.3148] [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] [Received: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 06/11/2023]
Abstract
Central nervous system (CNS) lymphoma has traditionally had very poor outcomes however advances in management have seen dramatic improvements and long-term survival of patients. In primary CNS lymphoma there are now randomised trial data to inform practice, however secondary CNS lymphoma has a lack of randomised trial data and CNS prophylaxis remains a contentious area. We describe treatment strategies in these aggressive disorders. Dynamic assessment of patient fitness and frailty is key throughout treatment alongside delivery of CNS-bioavailable therapy and enrolment in clinical trials. Intensive high-dose methotrexate-containing induction followed by autologous stem cell transplantation is preferred for patients who are fit. Less intensive chemoimmunotherapy, whole brain radiotherapy and novel therapies may be reserved for patients unfit or chemoresistant. It is essential to better define patients at increased risk of CNS relapse, as well as effective prophylactic strategies to prevent it. Future prospective studies incorporating novel agents are key.
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Affiliation(s)
- Jahanzaib Khwaja
- Department of Haematology, University College London Hospitals, London, England
| | - Kate Cwynarski
- Department of Haematology, University College London Hospitals, London, England
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17
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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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18
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Bobillo S, Khwaja J, Ferreri AJM, Cwynarski K. Prevention and management of secondary central nervous system lymphoma. Haematologica 2023; 108:673-689. [PMID: 36384246 PMCID: PMC9973486 DOI: 10.3324/haematol.2022.281457] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Indexed: 11/18/2022] Open
Abstract
Secondary central nervous system (CNS) lymphoma (SCNSL) is defined by the involvement of the CNS, either at the time of initial diagnosis of systemic lymphoma or in the setting of relapse, and can be either isolated or with synchronous systemic disease. The risk of CNS involvement in patients with diffuse large B-cell lymphoma is approximately 5%; however, certain clinical and biological features have been associated with a risk of up to 15%. There has been growing interest in improving the definition of patients at increased risk of CNS relapse, as well as identifying effective prophylactic strategies to prevent it. SCNSL often occurs within months of the initial diagnosis of lymphoma, suggesting the presence of occult disease at diagnosis in many cases. The differing presentations of SCNSL create the therapeutic challenge of controlling both the systemic disease and the CNS disease, which uniquely requires agents that penetrate the blood-brain barrier. Outcomes are generally poor with a median overall survival of approximately 6 months in retrospective series, particularly in those patients presenting with SCNSL after prior therapy. Prospective studies of intensive chemotherapy regimens containing high-dose methotrexate, followed by hematopoietic stem cell transplantation have shown the most favorable outcomes, especially for patients receiving thiotepa-based conditioning regimens. However, a proportion of patients will not respond to induction therapies or will subsequently relapse, indicating the need for more effective treatment strategies. In this review we focus on the identification of high-risk patients, prophylactic strategies and recent treatment approaches for SCNSL. The incorporation of novel agents in immunochemotherapy deserves further study in prospective trials.
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Affiliation(s)
- Sabela Bobillo
- Department of Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron University Hospital, Barcelona
| | - Jahanzaib Khwaja
- Department of Haematology, University College London Hospitals, London
| | - Andrés J M Ferreri
- Lymphoma Unit, Department of Onco-Haematology, IRCCS San Raffaele Scientific Institute, Milan
| | - Kate Cwynarski
- Department of Haematology, University College London Hospitals, London
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19
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Ostrowska B, Domanska-Czyz K, Romejko-Jarosinska J, Osowiecki M, Targonski L, Poplawska L, Konecki R, Kotarska M, Szymanski M, Borawska A, Swierkowska M, Dabrowska-Iwanicka A, Druzd-Sitek A, Paszkiewicz-Kozik E, Mroz-Zycinska E, Tajer J, Wojciechowska-Lampka E, Osiadacz W, Rymkiewicz G, Lapinska G, Wojewodzka-Mirocha M, Michalski W, Walewski J. Safety and efficacy of induction immunochemotherapy with rituximab, methotrexate, ifosfamide, and vincristine (R-MIV) in patients with primary CNS lymphoma including recent COVID-19 pandemic experience. Br J Haematol 2023; 201:663-672. [PMID: 36762710 DOI: 10.1111/bjh.18687] [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: 11/16/2022] [Revised: 01/23/2023] [Accepted: 01/27/2023] [Indexed: 02/11/2023]
Abstract
Clinical data on primary central nervous system (CNS) lymphoma (PCNSL) patients is mostly generated from prospective studies, and many frail real-world patients are not included. Recently,the diagnosis and treatment of PCNSL patients was confounded by the COVID-19 pandemic. In particular, treatment with high-dose cytarabine was linked to increased risk of pneumonia and virus persistence. We report on outcome of the induction regimen R-MIV (rituximab, methotrexate, ifosfamide, and vincristine) involving intensive administration of high-dose methotrexate (3.5 g/m2 ) with ifosfamide, every 2 weeks and rituximab once per week for six doses. The median age and performance status (PS) for 64 patients was 58 years and 2 (PS 3; 22%) respectively. The overall response rate by magnetic resonance imaging/computed tomography (MRI/CT) was 73% (n = 46/63), with an additional 17.5% (n = 11/63) patients without measurable disease at baseline. Grade 3-4 haematological toxicity was low for R-MIV (neutropenia: 25% and thrombocytopenia: 1%). Three patients (4.7%) died from treatment-related toxicity. Co-existence of SARS-CoV-2 infection with cytomegalovirus reactivation and the varicella-zoster virus in two patients was fatal. Fifty patients (78%) were eligible for consolidation. Median progression-free and overall survival were not reached (median follow-up: 44 months). In conclusion, the R-MIV regimen is feasible in routine practice, effective and safe, even during the COVID-19 pandemic.
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Affiliation(s)
- Beata Ostrowska
- Department of Lymphoid Malignancies, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Katarzyna Domanska-Czyz
- Department of Lymphoid Malignancies, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Joanna Romejko-Jarosinska
- Department of Lymphoid Malignancies, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Michal Osowiecki
- Department of Lymphoid Malignancies, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Lukasz Targonski
- Department of Lymphoid Malignancies, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Lidia Poplawska
- Department of Lymphoid Malignancies, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Robert Konecki
- Department of Lymphoid Malignancies, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Martyna Kotarska
- Department of Lymphoid Malignancies, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Marcin Szymanski
- Department of Lymphoid Malignancies, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Anna Borawska
- Department of Lymphoid Malignancies, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Monika Swierkowska
- Department of Lymphoid Malignancies, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Anna Dabrowska-Iwanicka
- Department of Lymphoid Malignancies, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Agnieszka Druzd-Sitek
- Department of Lymphoid Malignancies, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Ewa Paszkiewicz-Kozik
- Department of Lymphoid Malignancies, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Ewa Mroz-Zycinska
- Department of Lymphoid Malignancies, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Joanna Tajer
- Department of Lymphoid Malignancies, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | | | - Wlodzimierz Osiadacz
- Department of Lymphoid Malignancies, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Grzegorz Rymkiewicz
- Flow Cytometry Laboratory, Department of Cancer Pathomorphology, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Grazyna Lapinska
- Department of Oncological Endocrinology and Nuclear Medicine, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Marta Wojewodzka-Mirocha
- Department of Oncological Endocrinology and Nuclear Medicine, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Wojciech Michalski
- Biostatistics Unit, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Jan Walewski
- Department of Lymphoid Malignancies, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
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20
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Steffanoni S, Calimeri T, Marktel S, Nitti R, Foppoli M, Ferreri AJM. Diagnosis and Treatment Using Autologous Stem-Cell Transplantation in Primary Central Nervous System Lymphoma: A Systematic Review. Cancers (Basel) 2023; 15:cancers15020526. [PMID: 36672475 PMCID: PMC9856418 DOI: 10.3390/cancers15020526] [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: 12/23/2022] [Revised: 01/08/2023] [Accepted: 01/10/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Consolidation therapy has improved the outcome of newly diagnosed PCNSL patients. Whole-brain radiotherapy (WBRT) was the first consolidation strategy used and represented the gold standard for many years, but at the expense of a high risk of neurotoxicity. Thus, alternative strategies are being investigated in order to improve disease outcomes and to spare the neurocognitive side effects due to WBRT. METHODS We reviewed published studies on PCNSL patients treated with HDC/ASCT, focusing on the efficacy and safety of the conditioning regimens. Prospective and retrospective studies, published in the English language from 1992 to 2022, in high-quality international journals were identified in PubMed. RESULTS Consolidation with HDC containing highly CNS-penetrating agents (thiotepa, busulfan or BCNU) followed by ASCT provided long-term disease control and survival in PCNSL patients. Two prospective randomized studies, comparing HDC/ASCT versus WBRT, reported similar progression-free survival (PFS) and similar results on the decline in neurocognitive functions in a substantial proportion of patients after WBRT but not after HDC-ASCT. A recent randomized study comparing HDC/ASCT versus non-myeloablative consolidation reported a longer PFS in transplanted patients. CONCLUSION ASCT conditioned with regimens, including highly CNS-penetrating agents, represents, to date, the best choice among the available consolidation strategies for fit newly diagnosed PCNSL patients.
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Affiliation(s)
- Sara Steffanoni
- Department of Medicine, Division of Hematology, Valduce Hospital, 22100 Como, Italy
- Correspondence:
| | - Teresa Calimeri
- Lymphoma Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Sarah Marktel
- Hematology and BMT Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Rosamaria Nitti
- Hematology and BMT Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Marco Foppoli
- Lymphoma Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
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21
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Cwynarski K, Cummin T, Osborne W, Lewis J, Chaganti S, Smith J, Linton K, Greaves P, McKay P, Fox CP. Management of secondary central nervous system lymphoma. Br J Haematol 2023; 200:160-169. [PMID: 36408800 DOI: 10.1111/bjh.18539] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 10/07/2022] [Accepted: 10/17/2022] [Indexed: 11/22/2022]
Affiliation(s)
- Kate Cwynarski
- Department of Haematology, University College London Hospitals NHS Trust, London, UK
| | - Thomas Cummin
- Department of Haematology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Wendy Osborne
- Department of Haematology, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| | - Joanne Lewis
- Department of Haematology, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| | - Sridhar Chaganti
- Department of Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jeff Smith
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool University Hospitals NHS Trust, Liverpool, UK
| | - Kim Linton
- Haematology and Transplant Unit, The Christie NHS Foundation Trust, Manchester, UK
| | - Paul Greaves
- Department of Haematology, Barking Havering and Redbridge University Hospital NHS Trust, Romford, UK
| | - Pam McKay
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Christopher P Fox
- Department of Clinical Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
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22
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Wilson MR, Bobillo S, Cwynarski K. CNS prophylaxis in aggressive B-cell lymphoma. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:138-145. [PMID: 36485105 PMCID: PMC9820554 DOI: 10.1182/hematology.2022000331] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
The prevention of central nervous system (CNS) relapse in diffuse large B-cell lymphoma (DLBCL) continues to be one of the most contentious areas of lymphoma management. Outcomes for patients with secondary CNS lymphoma (SCNSL) have historically been very poor. However, in recent years improved responses have been reported with intensive immunochemotherapy approaches, and there is a growing interest in potential novel/cellular therapies. Traditional methods for selecting patients for CNS prophylaxis, including the CNS International Prognostic Index, are hampered by a lack of specificity, and there is accumulating evidence to question the efficacy of widely employed prophylactic interventions, including intrathecal and high-dose methotrexate (HD-MTX). Given the potential toxicity of HD-MTX in particular and the ongoing need to prioritize systemic disease control in high-risk patients, there is an urgent need to develop more robust methods for identifying patients at highest risk of CNS relapse, as well as investigating prophylactic interventions with greater efficacy. Here we review new evidence in this field from the last 5 years, focusing on the potential use of molecular diagnostics to improve the identification of high-risk patients, recent large data sets questioning the efficacy of HD-MTX, and the current approach to management of patients with SCNSL. We provide a suggested algorithm for approaching this very challenging clinical scenario.
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Affiliation(s)
- Matthew R. Wilson
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
| | - Sabela Bobillo
- Department of Haematology, Vall d’Hebron Institute of Oncology, University Hospital Vall d’Hebron, Barcelona, Spain
| | - Kate Cwynarski
- Department of Haematology, University College London Hospital, London, United Kingdom
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23
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Wendler J, Fox CP, Valk E, Steinheber C, Fricker H, Isbell LK, Neumaier S, Okosun J, Scherer F, Ihorst G, Cwynarski K, Schorb E, Illerhaus G. Optimizing MATRix as remission induction in PCNSL: de-escalated induction treatment in newly diagnosed primary CNS lymphoma. BMC Cancer 2022; 22:971. [PMID: 36088292 PMCID: PMC9464101 DOI: 10.1186/s12885-022-09723-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/31/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Primary diffuse large B-cell lymphoma (DLBCL) of the central nervous system (PCNSL) is a rare disorder with an increasing incidence over the past decades. High-level evidence has been reported for the MATRix regimen (high-dose methotrexate (HD-MTX), high-dose AraC (HD-AraC), thiotepa and rituximab) followed by high-dose chemotherapy and autologous stem cell transplantation (HCT-ASCT) supporting this approach to be considered a standard therapy in newly diagnosed PCNSL patients ≤ 70 years. However, early treatment-related toxicities (predominantly infectious complications), occurring in up to 28% per MATRix cycle, diminish its therapeutic success. Furthermore, sensitivity to first-line treatment is an independent prognostic factor for improved overall survival (OS) in PCNSL. Thus, patients achieving early partial remission (PR) after 2 cycles of MATRix might be over-treated with 4 cycles, in the context of consolidation HCT-ASCT. METHODS This is an open-label, multicentre, randomized phase III trial with two parallel arms. 326 immunocompetent patients with newly diagnosed PCNSL will be recruited from 37 German, 1 Austrian and 12 UK sites. Additional IELSG (International Extranodal Lymphoma Study Group) sites are planned. The objective is to demonstrate superiority of a de-escalated and optimised remission induction treatment strategy, followed by HCT-ASCT. Randomization (1:1) will be performed after completion of all screening procedures. Patients in Arm A (control treatment) will receive 4 cycles of MATRix. Patients in Arm B (experimental treatment) will receive a pre-phase (R/HD-MTX), followed by 2 cycles of MATRix. Patients in both arms achieving PR or better will proceed to HCT-ASCT (BCNU, thiotepa). The primary endpoint of the study is event-free-survival (EFS), defined as time from randomization to premature end of treatment due to any reason, lymphoma progression or death whichever occurs first. Secondary endpoints include OS, progression free survival (PFS), toxicity, neurocognitive impairment and quality of life. Minimal follow-up is 24 months. DISCUSSION Current treatment options for PCNSL in patients ≤ 70 years have improved remarkably over recent years. However, the potential efficacy benefits are offset by an increased incidence of short-term toxicities which can impact on treatment delivery and hence on survival outcomes. In patients ≤ 70 years with newly diagnosed PCNSL addressing the need to reduce treatment-related toxicity by de-escalating and optimising the induction phase of treatment, is a potentially attractive treatment strategy. TRIAL REGISTRATION German clinical trials registry DRKS00022768 registered June 10th, 2021.
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Affiliation(s)
- Julia Wendler
- Clinic of Hematology, Oncology and Palliative Care, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Christopher P Fox
- Russell Centre for Clinical Haematology, Nottingham University Hospitals NHS Trust, City Campus, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Elke Valk
- Stuttgart Cancer Center - Tumorzentrum Eva Mayer-Stihl, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Cora Steinheber
- Stuttgart Cancer Center - Tumorzentrum Eva Mayer-Stihl, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Heidi Fricker
- Department Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Lisa K Isbell
- Department Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Simone Neumaier
- Stuttgart Cancer Center - Tumorzentrum Eva Mayer-Stihl, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Jessica Okosun
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Florian Scherer
- Department Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Gabriele Ihorst
- Clinical Trials Unit, Faculty of Medicine and Medical Center, University of Freiburg, Elsässer Straße 2, 79110, Freiburg, Germany
| | - Kate Cwynarski
- Department of Haematology, University College of London Hospitals, NHS Foundation Trust, London, UK
| | - Elisabeth Schorb
- Department Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Gerald Illerhaus
- Clinic of Hematology, Oncology and Palliative Care, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany.
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24
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Ferreri AJM, Cwynarski K, Pulczynski E, Fox CP, Schorb E, Celico C, Falautano M, Nonis A, La Rosée P, Binder M, Fabbri A, Ilariucci F, Krampera M, Roth A, Hemmaway C, Johnson PW, Linton KM, Pukrop T, Gørløv JS, Balzarotti M, Hess G, Keller U, Stilgenbauer S, Panse J, Tucci A, Orsucci L, Pisani F, Zanni M, Krause SW, Schmoll HJ, Hertenstein B, Rummel M, Smith J, Thurner L, Cabras G, Pennese E, Ponzoni M, Deckert M, Politi LS, Finke J, Ferranti A, Cozens K, Burger E, Ielmini N, Cavalli F, Zucca E, Illerhaus G. Long-term efficacy, safety and neurotolerability of MATRix regimen followed by autologous transplant in primary CNS lymphoma: 7-year results of the IELSG32 randomized trial. Leukemia 2022; 36:1870-1878. [PMID: 35562406 DOI: 10.1038/s41375-022-01582-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/16/2022] [Accepted: 04/20/2022] [Indexed: 11/09/2022]
Abstract
219 HIV-negative adults ≤70 years with primary CNS lymphoma (PCNSL) were enrolled in the randomized IELSG32 trial. Enrolled patients were randomly assigned to receive methotrexate-cytarabine (arm A), or methotrexate-cytarabine-rituximab (B), or methotrexate-cytarabine-thiotepa-rituximab (MATRix; arm C). A second randomization allocated patients with responsive/stable disease to whole-brain irradiation (WBRT) or carmustine-thiotepa-conditioned autologous transplantation (ASCT). First results, after a median follow-up of 30 months, showed that MATRix significantly improves outcome, with both WBRT and ASCT being similarly effective. However, sound assessment of overall survival (OS), efficacy of salvage therapy, late complications, secondary tumors, and cognitive impairment requires longer follow-up. Herein, we report the results of this trial at a median follow-up of 88 months. As main findings, MATRix was associated with excellent long-lasting outcome, with a 7-year OS of 21%, 37%, and 56% respectively for arms A, B, and C. Notably, patients treated with MATRix and consolidation had a 7-year OS of 70%. The superiority of arm B on arm A suggests a benefit from the addition of rituximab. Comparable efficacy of WBRT and ASCT was confirmed. Salvage therapy was ineffective; benefit was recorded only in patients with late relapse re-treated with methotrexate. Eight (4%) patients developed a second cancer. Importantly, MATRix and ASCT did not result in higher non-relapse mortality or second tumors incidence. Patients who received WBRT experienced impairment in attentiveness and executive functions, whereas patients undergoing ASCT experienced improvement in these functions as well as in memory and quality of life.
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Affiliation(s)
- Andrés J M Ferreri
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milano, Italy.
| | | | | | | | | | | | | | - Alessandro Nonis
- Ateneo Vita-Salute San Raffaele University, Pathology Unit, Milano, Italy
| | - Paul La Rosée
- Schwarzwald-Baar-Klinikum, Villingen-Schwenningen, Germany
| | - Mascia Binder
- Universitätsklinikum Hamburg- Eppendorf, Hamburg, Germany
| | | | - Fiorella Ilariucci
- Azienda Ospedaliera Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy
| | - Mauro Krampera
- Dipartimento di Medicina, Sezione di Ematologia, Università di Verona, Verona, Italy
| | | | | | - Peter W Johnson
- Medical Oncology Unit, Southampton General Hospital, Southampton, UK
| | - Kim M Linton
- The Christie Hospital NHS Foundation Trust, Manchester, UK
| | | | | | | | - Georg Hess
- J. Gutenberg Universität, Mainz, Germany
| | | | | | - Jense Panse
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital Aachen, Aachen, Germany
| | | | - Lorella Orsucci
- AOU Città Della Salute e Della Scienza di Torino, Turin, Italy
| | - Francesco Pisani
- Hematology and Stem Cell Transplantation Unit, IRCCS Istituto Nazionale dei Tumori Regina Elena, Roma, Italy
| | - Manuela Zanni
- A.O. Santi Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | | | | | | | - Mathias Rummel
- Klinikum Der Justus-Liebig-Universität, Giessen, Germany
| | | | | | | | | | - Maurilio Ponzoni
- Ateneo Vita-Salute San Raffaele University, Pathology Unit, Milano, Italy
| | - Martina Deckert
- Institute of Neuropathology, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Letterio S Politi
- Istituto Clinico Humanitas, Milano Rozzano, Italy
- Unit of Neuroradiology, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | | | | | - Kelly Cozens
- Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Elvira Burger
- Zentrum Klinische Studien, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Nicoletta Ielmini
- International Extranodal Lymphoma Study Group, Foundation for the Institute of Oncology Research, Bellinzona, Switzerland
| | - Franco Cavalli
- International Extranodal Lymphoma Study Group, Foundation for the Institute of Oncology Research, Bellinzona, Switzerland
- Istituto Oncologico della Svizzera Italiana, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Emanuele Zucca
- International Extranodal Lymphoma Study Group, Foundation for the Institute of Oncology Research, Bellinzona, Switzerland
- Istituto Oncologico della Svizzera Italiana, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
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25
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Lebel E, Goldschmidt N, Siegal T, Lossos A, Rosenberg S, Makranz C, Linetski E, Gatt ME, Gural A, Saban R, Lavie D, Vainstein V, Zimran E, Avni B, Grisaro S, Shaulov A, Nachmias B. Rituximab, methotrexate, procarbazine and lomustine (R-MPL) for the treatment of primary Central nervous system lymphoma. Leuk Lymphoma 2022; 63:2102-2108. [DOI: 10.1080/10428194.2022.2064996] [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]
Affiliation(s)
- Eyal Lebel
- Faculty of Medicine, The Hebrew University of Jerusalem, Israel
- Hematology department, Hadassah Medical Center, Jerusalem, Israel
| | - Neta Goldschmidt
- Faculty of Medicine, The Hebrew University of Jerusalem, Israel
- Hematology department, Hadassah Medical Center, Jerusalem, Israel
| | - Tali Siegal
- Center of Neuro-Oncology, Davidoff Institute of Oncology, Rabin Medical Center, Campus Beilinson, Petach Tikva, Israel
| | - Alexander Lossos
- Faculty of Medicine, The Hebrew University of Jerusalem, Israel
- Gaffin Center of Neuro-Oncology, Hadassah Medical Center, Jerusalem, Israel
| | - Shai Rosenberg
- Faculty of Medicine, The Hebrew University of Jerusalem, Israel
- Gaffin Center of Neuro-Oncology, Hadassah Medical Center, Jerusalem, Israel
| | - Chen Makranz
- Faculty of Medicine, The Hebrew University of Jerusalem, Israel
- Gaffin Center of Neuro-Oncology, Hadassah Medical Center, Jerusalem, Israel
| | - Eduard Linetski
- Faculty of Medicine, The Hebrew University of Jerusalem, Israel
- Gaffin Center of Neuro-Oncology, Hadassah Medical Center, Jerusalem, Israel
| | - Moshe E. Gatt
- Faculty of Medicine, The Hebrew University of Jerusalem, Israel
- Hematology department, Hadassah Medical Center, Jerusalem, Israel
| | - Alexander Gural
- Faculty of Medicine, The Hebrew University of Jerusalem, Israel
- Hematology department, Hadassah Medical Center, Jerusalem, Israel
| | - Revital Saban
- Faculty of Medicine, The Hebrew University of Jerusalem, Israel
- Hematology department, Hadassah Medical Center, Jerusalem, Israel
| | - David Lavie
- Faculty of Medicine, The Hebrew University of Jerusalem, Israel
- Hematology department, Hadassah Medical Center, Jerusalem, Israel
| | - Vladimir Vainstein
- Faculty of Medicine, The Hebrew University of Jerusalem, Israel
- Hematology department, Hadassah Medical Center, Jerusalem, Israel
| | - Eran Zimran
- Faculty of Medicine, The Hebrew University of Jerusalem, Israel
- Bone-marrow transplant department, Hadassah medical center, Jerusalem, Israel
| | - Batia Avni
- Faculty of Medicine, The Hebrew University of Jerusalem, Israel
- Bone-marrow transplant department, Hadassah medical center, Jerusalem, Israel
| | - Sigal Grisaro
- Faculty of Medicine, The Hebrew University of Jerusalem, Israel
- Bone-marrow transplant department, Hadassah medical center, Jerusalem, Israel
| | - Adir Shaulov
- Faculty of Medicine, The Hebrew University of Jerusalem, Israel
- Hematology department, Hadassah Medical Center, Jerusalem, Israel
| | - Boaz Nachmias
- Faculty of Medicine, The Hebrew University of Jerusalem, Israel
- Hematology department, Hadassah Medical Center, Jerusalem, Israel
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26
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Wismann J, Sommer-Sørensen RH, Kofoed MS, Halle B, Pedersen CB, Schulz MK, Grønhøj MH, Larsen TS, Møller MB, Poulsen FR. Diagnosis, treatment, and outcome of primary CNS lymphoma-a single-center experience. Acta Neurochir (Wien) 2022; 164:1365-1373. [PMID: 35257217 DOI: 10.1007/s00701-022-05170-5] [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: 12/06/2021] [Accepted: 02/20/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Primary CNS lymphoma (PCNSL) is a highly aggressive non-Hodgkin lymphoma (NHL) that occurs in the CNS (e.g. brain, meninges, spinal cord, cerebrospinal fluid, or intraocular involvement) in the absence of systemic NHL. Tumor resection does not improve survival, and neurosurgical intervention is generally limited to stereotactic biopsy to provide a histopathological diagnosis. OBJECTIVE The objective of this single-center study was to evaluate the management and outcome of PCNSL patients diagnosed by biopsy, using overall survival and progression-free survival as endpoints. METHODS At our department of neurosurgery, 140 patients were diagnosed with PCNSL by biopsy between January 1, 2009, and December 31, 2018. Of these, 37 patients were included in the study and were divided into three groups according to their postoperative therapy. RESULTS Median OS was 35.7 months for the intensive treatment group, 29.5 months for the moderate treatment group, and 8.6 months for the palliative treatment group. The intensive and moderate treatment groups had similar progression-free survival, while the palliative treatment group had poor overall and progression-free survival. Six patients were long-term survivors (> 80 months). Age under 65 years was the main significant parameter affecting overall survival. CONCLUSION In this cohort, patients with PCNSL had an overall fair prognosis if they (1) were under 65 years old, (2) had a performance score < 2 at the time of diagnosis, and (3) received either intensive or moderate chemotherapeutic treatment. Biopsy is still the primary diagnostic tool; other methods have been investigated but are not yet recommended.
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Affiliation(s)
- Joakim Wismann
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark.
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
- BRIDGE - Brain Research Inter-Disciplinary Guided Excellence, Odense, Denmark.
| | - Rune Hørlykke Sommer-Sørensen
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- BRIDGE - Brain Research Inter-Disciplinary Guided Excellence, Odense, Denmark
| | - Mikkel Seremet Kofoed
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- BRIDGE - Brain Research Inter-Disciplinary Guided Excellence, Odense, Denmark
| | - Bo Halle
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- BRIDGE - Brain Research Inter-Disciplinary Guided Excellence, Odense, Denmark
| | - Christian Bonde Pedersen
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- BRIDGE - Brain Research Inter-Disciplinary Guided Excellence, Odense, Denmark
| | - Mette Katrine Schulz
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- BRIDGE - Brain Research Inter-Disciplinary Guided Excellence, Odense, Denmark
| | - Mads Hjortdal Grønhøj
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- BRIDGE - Brain Research Inter-Disciplinary Guided Excellence, Odense, Denmark
| | - Thomas Stauffer Larsen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Hematology, Odense University Hospital, Odense, Denmark
| | - Michael Boe Møller
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Clinical Pathology, Odense University Hospital, Odense, Denmark
| | - Frantz Rom Poulsen
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- BRIDGE - Brain Research Inter-Disciplinary Guided Excellence, Odense, Denmark
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27
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Zhou J, Zuo M, Li L, Li F, Ke P, Zhou Y, Xu Y, Gao X, Guan Y, Xia X, Yi X, Zhang X, Huang Y. PIM1 and CD79B Mutation Status Impacts the Outcome of Primary Diffuse Large B-Cell Lymphoma of the CNS. Front Oncol 2022; 12:824632. [PMID: 35223507 PMCID: PMC8864287 DOI: 10.3389/fonc.2022.824632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/17/2022] [Indexed: 12/13/2022] Open
Abstract
Primary diffuse large B cell lymphoma of the central nervous system (CNS DLBCL) is a rare malignancy with a distinct genetic profile. The clinicopathological significance of the mutation patterns remains unknown. Forty cases of primary CNS DLBCL were subjected to targeted exome sequencing covering 413 genes, including MYD88, CD79B and PIM1. Mutational analysis recognized two groups. The CDP (including CD79B and/or PIM1mutations) group was identified in 27 cases (67.5%), and the non-CDP (without CD79B and PIM1 mutations) group was identified in 13 cases 32.5%). The CDP group tended to occur in older patients (median age 57.0 vs. 48.4 years, p=0.015). Patients in the CDP group had a significantly longer 2-year overall survival (OS) (76% and 40%, p=0.0372) than those in the non-CDP group. Multivariate analysis revealed that age less than 60 years, no MYC and BCL2 double expression, and CDP group were three independent risk factors indicating favorable OS. PyClone analysis revealed the subcloning heterogeneity between the groups. In addition, transcriptional sequencing was successfully performed in 8 cases. A total of 131 genes were significantly differentially expressed between these two groups. The major categories of biological processes that were significantly altered between these two groups related to intracellular metabolism mechanisms. We developed a new molecular classification to divide CNS DLBCL into CDP and non-CDP groups based on CD79B and PIM1 mutational status. Patients with PIM1 and/or CD79B mutations had favorable long-term survival after high-dose methotrexate-based polychemotherapy.
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Affiliation(s)
- Jihao Zhou
- Department of Hematology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Min Zuo
- Department of Pathology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Lifeng Li
- Medical Center, Geneplus-Beijing, Beijing, China
| | - Fang Li
- Geneplus-Beijing Institute, Beijing, China
| | - Peng Ke
- Department of Hematology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Yangying Zhou
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Yaping Xu
- Medical Center, Geneplus-Beijing, Beijing, China
| | - Xuan Gao
- Medical Center, Geneplus-Beijing, Beijing, China
| | - Yanfang Guan
- Medical Center, Geneplus-Beijing, Beijing, China
| | - Xuefeng Xia
- Medical Center, Geneplus-Beijing, Beijing, China
| | - Xin Yi
- Medical Center, Geneplus-Beijing, Beijing, China
| | - Xinyou Zhang
- Department of Hematology, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Yuhua Huang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Pathology, Sun Yat-sen University Cancer Center, Guangzhou, China
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Wang A, Cirrone F, De Los Reyes FA, Papadopoulos J, Saint Fleur-Lominy S, Xiang E. High-dose methotrexate dosing strategy in primary central nervous system lymphoma. Leuk Lymphoma 2022; 63:1348-1355. [PMID: 35120432 DOI: 10.1080/10428194.2021.2024818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The backbone induction therapy for primary central nervous system lymphoma (PCNSL) is high dose methotrexate (HD-MTX) and rituximab, which can be combined with other chemotherapeutic agents. The optimal dose of HD-MTX remains unclear, as doses between 3 and 8 g/m2 have been shown to be effective. In this retrospective study, HD-MTX dosed at 3-5 g/m2 demonstrated an overall response of 81.8%, with 11 (50%) complete responses. The median overall survival was not met at 29 months and median progression free survival was 12.5 months.There were two discontinuations due to nephrotoxicity. The most common adverse event was hepatotoxicity (18.5%), with no treatment-related mortality events observed.Overall, HD-MTX dosed at 3-5 g/m2 demonstrated similar efficacy and lower toxicity compared to higher doses in PCNSL patients. Reducing the initial HD-MTX dose may help ensure tolerability and completion of induction therapy, especially in patients with co-morbidities or older age who have poorer outcomes.
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Affiliation(s)
- Alexander Wang
- Department of Pharmacy, NYU Langone Health, New York, NY, USA
| | - Frank Cirrone
- Department of Pharmacy, NYU Langone Health, New York, NY, USA
| | | | - John Papadopoulos
- Department of Pharmacy, NYU Langone Health, New York, NY, USA.,Department of Medicine, NYU Langone Health, New York, NY, USA
| | | | - Elaine Xiang
- Department of Pharmacy, NYU Langone Health, New York, NY, USA
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29
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A phase 1/2 study of thiotepa-based immunochemotherapy in relapsed/refractory primary CNS lymphoma: the TIER trial. Blood Adv 2021; 5:4073-4082. [PMID: 34464973 PMCID: PMC8945638 DOI: 10.1182/bloodadvances.2021004779] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/07/2021] [Indexed: 11/25/2022] Open
Abstract
Thiotepa at 50 mg/m2 was safely incorporated into TIER immunochemotherapy. Despite a clinically meaningful treatment response rate, long-term survival was seen only with ASCT consolidation.
Relapsed or refractory primary central nervous system lymphoma (rrPCNSL) confers a poor prognosis with no accepted standard of care. Very few prospective studies have been conducted in this patient group. This study was a multicenter phase 1/2 study that investigated thiotepa in combination with ifosfamide, etoposide, and rituximab (TIER) for the treatment of PCNSL relapsed or refractory to high-dose methotrexate-based chemotherapy. A 3 + 3 design investigated the recommended phase 2 dose of thiotepa for a single-stage phase 2 cohort by assessing the activity of 2 cycles of TIER against rrPCNSL. The primary outcome was overall response rate. The dose-finding study demonstrated that 50 mg/m2 of thiotepa could be safely delivered within the TIER regimen. No dose-limiting toxicities were encountered in phase 1, and TIER was well-tolerated by the 27 patients treated in phase 2. The most common grade 3 to 4 toxicities were neutropenia (56% of patients) and thrombocytopenia (39%). An overall response was confirmed in 14 patients (52%), which met the prespecified threshold for clinically relevant activity. The median progression-free survival was 3 months (95% confidence interval [CI], 2 to 6 months) and overall survival 5 months (95% CI, 3 to 9 months). Exploratory analyses suggest a greater benefit for thiotepa-naïve patients. Six patients successfully completed autologous stem cell transplantation (ASCT) consolidation, with 4 experiencing durable remissions after a median follow-up of 50 months. The TIER regimen can be delivered safely and is active against rrPCNSL. When it is followed by ASCT, it can provide durable remission and long-term survival. However, for the majority of patients, prognosis remains poor, and novel treatment strategies are urgently needed. This trial was registered at https://www.clinicaltrialsregister.eu/ctr-search/search as EudraCT 2014-000227-24 and ISRCTN 12857473.
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30
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Martinez-Calle N, Isbell LK, Cwynarski K, Schorb E. Advances in treatment of elderly primary central nervous system lymphoma. Br J Haematol 2021; 196:473-487. [PMID: 34448202 DOI: 10.1111/bjh.17799] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The management of older individuals (≥60 years) with primary central nervous system lymphoma remains a clinical challenge. Identification of optimal therapy and delivering adequate dose intensity are two of the major issues in treating elderly patients. Premorbid performance status and comorbidities influence individualised treatment approaches and geriatric assessment tools are increasingly utilised. Optimal induction treatment remains high-dose methotrexate-based immunochemotherapy, delivery is feasible in the majority of patients and the goal of treatment remains achieving complete remission. Consolidation strategies are also relevant in the elderly, aiming to maximise duration of response and quality of life (QoL). Potential options include high-dose therapy with haematopoietic stem cell consolidation, non-myeloablative chemotherapy and whole-brain radiotherapy. Efficacy of novel agents, such as Bruton tyrosine kinase inhibitors and lenalidomide, have been reported; these represent an alternative for elderly patients unfit for chemotherapy. Prognosis remains poor, improvement of outcomes in this age group is urgently needed.
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Affiliation(s)
- Nicolas Martinez-Calle
- Clinical Haematology Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Lisa K Isbell
- Department of Haematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kate Cwynarski
- Department of Haematology, University College Hospital, London, UK
| | - Elisabeth Schorb
- Department of Haematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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31
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Schorb E, Isbell LK, Illerhaus G, Ihorst G, Meerpohl JJ, Grummich K, Nagavci B, Schmucker C. Treatment Regimens for Immunocompetent Elderly Patients with Primary Central Nervous System Lymphoma: A Scoping Review. Cancers (Basel) 2021; 13:cancers13174268. [PMID: 34503078 PMCID: PMC8428349 DOI: 10.3390/cancers13174268] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/13/2021] [Accepted: 08/20/2021] [Indexed: 01/17/2023] Open
Abstract
Simple Summary Most patients diagnosed with primary central nervous system lymphoma (PCNSL) are 60 years or older and tend to have a poor prognosis. Evidence to guide and optimize treatment choices for these vulnerable patients is limited. We performed a scoping review to identify and describe all relevant clinical studies investigating chemotherapies and combinations of chemotherapies (including high-dose chemotherapy followed by autologous stem cell transplantation (HCT-ASCT)) in elderly PCNSL patients. In total, we identified six randomized controlled trials, 26 prospective and 24 retrospective studies (with/without control group). While most studies investigated protocols based on ‘conventional’ chemotherapy treatment, data evaluating HCT-ASCT in the elderly were scarce, and the generalizability of the only RCT published is questionable. Considering the poor prognosis of these patients and their need for more effective treatment options, a thoroughly planned randomized controlled trial comparing HCT-ASCT with ‘conventional’ chemoimmunotherapy is urgently needed to evaluate the efficacy of HCT-ASCT. Abstract Background: Most patients diagnosed with primary central nervous system lymphoma (PCNSL) are older than 60 years. Despite promising treatment options for younger patients, prognosis for the elderly remains poor and efficacy of available treatment options is limited. Materials and Methods: We conducted a scoping review to identify and summarize the current study pool available evaluating different types and combinations of (immuno) chemotherapy with a special focus on HCT-ASCT in elderly PCNSL. Relevant studies were identified through systematic searches in the bibliographic databases Medline, Web of Science, Cochrane Library and ScienceDirect (last search conducted in September 2020). For ongoing studies, we searched ClinicalTrials.gov, the German study register and the WHO registry. Results: In total, we identified six randomized controlled trials (RCT) with 1.346 patients, 26 prospective (with 1.366 patients) and 24 retrospective studies (with 2.629 patients). Of these, only six studies (one completed and one ongoing RCT (with 447 patients), one completed and one ongoing prospective single arm study (with 65 patients), and two retrospective single arm studies (with 122 patients)) evaluated HCT-ASCT. Patient relevant outcomes such as progression-free and overall survival and (neuro-)toxicity were adequately considered across almost all studies. The current study pool is, however, not conclusive in terms of the most effective treatment options for elderly. Main limitations were (very) small sample sizes and heterogeneous patient populations in terms of age ranges (particularly in RCTs) limiting the applicability of the results to the target population (elderly). Conclusions: Although it has been shown that HCT-ASCT is probably a feasible and effective treatment option, this approach has never been investigated within a RCT including a wide range of elderly patients. A RCT comparing conventional (immuno) chemotherapy with HCT-ASCT is crucial to evaluate benefit and harms in an un-biased manner to eventually provide older PCNSL patients with the most effective treatment.
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Affiliation(s)
- Elisabeth Schorb
- Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (L.K.I.); (G.I.)
- Correspondence: ; Tel.: +49-(0)761-270-35360
| | - Lisa Kristina Isbell
- Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (L.K.I.); (G.I.)
| | - Gerald Illerhaus
- Department of Hematology, Oncology and Palliative Care, Klinikum Stuttgart, 70174 Stuttgart, Germany;
| | - Gabriele Ihorst
- Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (L.K.I.); (G.I.)
- Clinical Trials Unit, Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany
| | - Joerg J. Meerpohl
- Institute for Evidence in Medicine, Medical Center & Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany; (J.J.M.); (K.G.); (B.N.); (C.S.)
- Cochrane Germany, Cochrane Germany Foundation, 79110 Freiburg, Germany
| | - Kathrin Grummich
- Institute for Evidence in Medicine, Medical Center & Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany; (J.J.M.); (K.G.); (B.N.); (C.S.)
- Cochrane Germany, Cochrane Germany Foundation, 79110 Freiburg, Germany
| | - Blin Nagavci
- Institute for Evidence in Medicine, Medical Center & Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany; (J.J.M.); (K.G.); (B.N.); (C.S.)
| | - Christine Schmucker
- Institute for Evidence in Medicine, Medical Center & Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany; (J.J.M.); (K.G.); (B.N.); (C.S.)
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32
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Sieg N, Naendrup JH, Gödel P, Balke-Want H, Simon F, Deckert M, Gillessen S, Kreissl S, Bröckelmann PJ, Borchmann P, von Tresckow B, Heger JM. Treatment patterns and disease course of previously untreated Primary Central Nervous System Lymphoma: Feasibility of MTX-based regimens in clinical routine. Eur J Haematol 2021; 107:202-210. [PMID: 33960535 DOI: 10.1111/ejh.13639] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Primary central nervous system lymphoma (PCNSL) is a rare type of aggressive lymphoma of the central nervous system. Treatment strategies improved significantly over the past decades differ regionally but mainly consist of rituximab and high-dosed methotrexate (MTX)-based therapies. METHODS We assessed clinical outcomes of 100 patients with newly diagnosed PCNSL between 2010-2020 at the University Hospital of Cologne, Germany. RESULTS Patients were 23-88 years of age and either treated with MTX-based regimens (PRIMAIN, MARTA, MATRix), individual regimens, or best supportive care, respectively. Overall response rates were generally high (66,7-83,8%), but different organ toxicities required dose adjustments in most groups. Two-year overall survival rates were 57,9% (PRIMAIN), 63,6% (MARTA), 65,4% (MATRix), and 37,5% (Other), respectively. Out of 9 patients suffering from relapse >12 months from primary diagnosis, 7 patients (77,8%) received methotrexate-based salvage therapy with 2-year overall survival of 4/6 patients (66,7%). CONCLUSION Although a relevant proportion of patients are not eligible for clinical trials due to age, performance status, or comorbidities, these results prove feasibility of different MTX-based treatment strategies in clinical routine. Even elderly patients displayed surprisingly favorable outcomes. However, with compromising organ toxicities, reduction of intensity should be part of strategies in future clinical trials.
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Affiliation(s)
- Noëlle Sieg
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany.,Cologne Lymphoma Working Group, Cologne, Germany.,Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, California, USA
| | - Jan-Hendrik Naendrup
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany.,Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, California, USA
| | - Philipp Gödel
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany.,Cologne Lymphoma Working Group, Cologne, Germany.,Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, California, USA
| | - Hyatt Balke-Want
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany.,Cologne Lymphoma Working Group, Cologne, Germany.,Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, California, USA.,Institute of Neuropathology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Florian Simon
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany.,Cologne Lymphoma Working Group, Cologne, Germany.,Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, California, USA
| | - Martina Deckert
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, California, USA.,Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Sarah Gillessen
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany.,Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, California, USA
| | - Stefanie Kreissl
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany.,Cologne Lymphoma Working Group, Cologne, Germany.,Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, California, USA
| | - Paul J Bröckelmann
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany.,Cologne Lymphoma Working Group, Cologne, Germany.,Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, California, USA
| | - Peter Borchmann
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany.,Cologne Lymphoma Working Group, Cologne, Germany.,Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, California, USA
| | - Bastian von Tresckow
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, California, USA.,Cancer Center Cologne Essen (CCCE), Cologne and Essen, Germany
| | - Jan-Michel Heger
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany.,Cologne Lymphoma Working Group, Cologne, Germany.,Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, California, USA
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Khan SR, Nasir S, Tariq M, Siddiqui ZA, Moosajee M. Primary Central Nervous System T-cell Lymphoma Associated With Hepatitis B and D Virus Coinfection. Cureus 2021; 13:e14394. [PMID: 34079647 PMCID: PMC8159298 DOI: 10.7759/cureus.14394] [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] [Indexed: 11/05/2022] Open
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare type of non-Hodgkin's lymphoma. It is defined as lymphoma of the central nervous system without any systemic disease elsewhere at the time of diagnosis. Based on the phenotypical features, it is divided into two categories, B-cell and T-cell, with the latter being less common. Viruses, such as human immunodeficiency virus (HIV) and human T-lymphotropic virus type 1 (HTLV-1), are linked to the T-cell variant; however, there is a lack of evidence suggesting associating hepatitis B and D virus coinfection with it. We report a case of a 34-year-old male who presented with T-cell PCNSL and was later diagnosed with a hepatitis B and D virus coinfection.
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Affiliation(s)
- Saqib R Khan
- Medical Oncology, Aga Khan University Hospital, Karachi, PAK
| | - Saad Nasir
- Internal Medicine, Aga Khan University Hospital, Karachi, PAK
| | - Muhammad Tariq
- Medical Oncology, Aga Khan University Hospital, Karachi, PAK
| | - Zoya A Siddiqui
- Internal Medicine, Aga Khan University Hospital, Karachi, PAK
| | - Munira Moosajee
- Medical Oncology, Aga Khan University Hospital, Karachi, PAK
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35
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Ferreri AJM, Doorduijn JK, Re A, Cabras MG, Smith J, Ilariucci F, Luppi M, Calimeri T, Cattaneo C, Khwaja J, Botto B, Cellini C, Nassi L, Linton K, McKay P, Olivieri J, Patti C, Re F, Fanni A, Singh V, Bromberg JEC, Cozens K, Gastaldi E, Bernardi M, Cascavilla N, Davies A, Fox CP, Frezzato M, Osborne W, Liberati AM, Novak U, Zambello R, Zucca E, Cwynarski K. MATRix-RICE therapy and autologous haematopoietic stem-cell transplantation in diffuse large B-cell lymphoma with secondary CNS involvement (MARIETTA): an international, single-arm, phase 2 trial. Lancet Haematol 2021; 8:e110-e121. [PMID: 33513372 PMCID: PMC7844712 DOI: 10.1016/s2352-3026(20)30366-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 10/30/2020] [Accepted: 11/03/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Secondary CNS lymphoma is a rare but potentially lethal event in patients with diffuse large B-cell lymphoma. We aimed to assess the activity and safety of an intensive, CNS-directed chemoimmunotherapy consolidated by autologous haematopoietic stem-cell transplantation (HSCT) in patients with secondary CNS lymphoma. METHODS This international, single-arm, phase 2 trial was done in 24 hospitals in Italy, the UK, the Netherlands, and Switzerland. Adults (aged 18-70 years) with histologically diagnosed diffuse large B-cell lymphoma and CNS involvement at the time of primary diagnosis or at relapse and Eastern Cooperative Oncology Group Performance Status of 3 or less were enrolled and received three courses of MATRix (rituximab 375 mg/m2, intravenous infusion, day 0; methotrexate 3·5 g/m2, the first 0·5 g/m2 in 15 min followed by 3 g/m2 in a 3 h intravenous infusion, day 1; cytarabine 2 g/m2 every 12 h, in 1 h intravenous infusions, days 2 and 3; thiotepa 30 mg/m2, 30 min intravenous infusion, day 4) followed by three courses of RICE (rituximab 375 mg/m2, day 1; etoposide 100 mg/m2 per day in 500-1000 mL over a 60 min intravenous infusion, days 1, 2, and 3; ifosfamide 5 g/m2 in 1000 mL in a 24 h intravenous infusion with mesna support, day 2; carboplatin area under the curve of 5 in 500 mL in a 1 h intravenous infusion, day 2) and carmustine-thiotepa and autologous HSCT (carmustine 400 mg/m2 in 500 mL glucose 5% solution in a 1-2 h infusion, day -6; thiotepa 5 mg/kg in saline solution in a 2 h infusion every 12 h, days -5 and -4). The primary endpoint was progression-free survival at 1 year. Overall and complete response rates before autologous HSCT, duration of response, overall survival, and safety were the secondary endpoints. Analyses were in the modified intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT02329080. The trial ended after accrual completion; the database lock was Dec 31, 2019. FINDINGS Between March 30, 2015, and Aug 3, 2018, 79 patients were enrolled. 75 patients were assessable. 319 (71%) of the 450 planned courses were delivered. At 1 year from enrolment the primary endpoint was met, 42 patients were progression free (progression-free survival 58%; 95% CI 55-61). 49 patients (65%; 95% CI 54-76) had an objective response after MATRix-RICE, 29 (39%) of whom had a complete response. 37 patients who responded had autologous HSCT. At the end of the programme, 46 patients (61%; 95% CI 51-71) had an objective response, with a median duration of objective response of 26 months (IQR 16-37). At a median follow-up of 29 months (IQR 20-40), 35 patients were progression-free and 33 were alive, with a 2-year overall survival of 46% (95% CI 39-53). Grade 3-4 toxicity was most commonly haematological: neutropenia in 46 (61%) of 75 patients, thrombocytopenia in 45 (60%), and anaemia in 26 (35%). 79 serious adverse events were recorded in 42 (56%) patients; four (5%) of those 79 were lethal due to sepsis caused by Gram-negative bacteria (treatment-related mortality 5%; 95% CI 0·07-9·93). INTERPRETATION MATRix-RICE plus autologous HSCT was active in this population of patients with very poor prognosis, and had an acceptable toxicity profile. FUNDING Stand Up To Cancer Campaign for Cancer Research UK, the Swiss Cancer Research foundation, and the Swiss Cancer League.
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Affiliation(s)
- Andrés J M Ferreri
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | | | | | | | - Jeffery Smith
- Department of Haematology, Aintree Hospital, Liverpool, UK
| | - Fiorella Ilariucci
- Division of Hematology, Azienda USL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Mario Luppi
- Azienda Ospedaliera Universitaria, UNIMORE, Modena, Italy
| | - Teresa Calimeri
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Jahanzaib Khwaja
- Department of Haematology, University College Hospital, London, UK
| | - Barbara Botto
- AOU Città della salute e della Scienza, Turin, Italy
| | | | - Luca Nassi
- Division of Hematology, Department of Translational Medicine, University of Eastern Piedmont and AOU Maggiore della Carità, Novara, Italy
| | - Kim Linton
- Department of Haemato-Oncology, The Christie Hospital, Manchester, UK
| | | | | | - Caterina Patti
- Division of Hematology, Azienda Villa Sofia-Cervello, Palermo, Italy
| | | | | | - Vikram Singh
- Department of Haematology, Aintree Hospital, Liverpool, UK
| | | | - Kelly Cozens
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Elisabetta Gastaldi
- International Extranodal Lymphoma Study Group Coordinating Center, Institute of Oncology Research, Università della Svizzera Italiana, Bellinzona, Switzerland
| | - Massimo Bernardi
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicola Cascavilla
- Casa Sollievo della Sofferenza Hospital, IRCCS, San Giovanni Rotondo, Italy
| | - Andrew Davies
- Cancer Research UK Centre, University of Southampton, Southampton, UK
| | - Christopher P Fox
- Department of Clinical Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Wendy Osborne
- Department of Haematology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | | | - Urban Novak
- Department of Medical Oncology, Inselspital, Bern University Hospital, Bern, Switzerland; Swiss Group for Clinical Cancer Research, Bern, Switzerland
| | | | - Emanuele Zucca
- International Extranodal Lymphoma Study Group Coordinating Center, Institute of Oncology Research, Università della Svizzera Italiana, Bellinzona, Switzerland; Department of Medical Oncology, Inselspital, Bern University Hospital, Bern, Switzerland; Medical Oncology Clinic, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland; Swiss Group for Clinical Cancer Research, Bern, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Kate Cwynarski
- Department of Haematology, University College Hospital, London, UK
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Franca RA, Travaglino A, Varricchio S, Russo D, Picardi M, Pane F, Pace M, Del Basso De Caro M, Mascolo M. HIV prevalence in primary central nervous system lymphoma: A systematic review and meta-analysis. Pathol Res Pract 2020; 216:153192. [PMID: 32956921 DOI: 10.1016/j.prp.2020.153192] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 08/22/2020] [Accepted: 08/25/2020] [Indexed: 12/30/2022]
Abstract
HIV infection is considered a major risk factor for primary central nervous system lymphoma (PCNSL). However, the percentage of PCNSL that occurs in HIV + patients is not well defined. We aimed to assess the prevalence of HIV infection in patients with PCNSL through a systematic review and meta-analysis. Electronic databases were searched for studies assessing the presence of HIV infection in series of patients with PCNSL. Pooled prevalence of HIV infection in PCNSL was calculated, with a subgroup analysis based on the geographic area. Twenty-seven studies with 6422 patients were included. Overall, pooled prevalence of HIV infection among PCNSL patients was 6.1 % with high heterogeneity. In the subgroup analysis, pooled prevalence was 3.6 % in India with low heterogeneity, 30.2 % (overall) and 16.5 % (after 2000) in the USA with high heterogeneity, 5.7 % in Europe with high heterogeneity, 2.2 % in East Asia with null heterogeneity, 7.3 % in South America with moderate heterogeneity. In conclusion, only a minor part of PCNSL occurs in patients with HIV. The results stratified by geographic area reflect the different prevalence of HIV infection in the general population, except for India, probably due to the shorter life expectancy of HIV + patients.
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Affiliation(s)
- Raduan Ahmed Franca
- Department of Advanced Biomedical Sciences, Pathology Section, Federico II University of Naples, Naples, Italy
| | - Antonio Travaglino
- Department of Advanced Biomedical Sciences, Pathology Section, Federico II University of Naples, Naples, Italy
| | - Silvia Varricchio
- Department of Advanced Biomedical Sciences, Pathology Section, Federico II University of Naples, Naples, Italy
| | - Daniela Russo
- Department of Advanced Biomedical Sciences, Pathology Section, Federico II University of Naples, Naples, Italy
| | - Marco Picardi
- Department of Clinical Medicine and Surgery, Hematology Section, Federico II University of Naples, Naples, Italy
| | - Fabrizio Pane
- Department of Clinical Medicine and Surgery, Hematology Section, Federico II University of Naples, Naples, Italy
| | - Mirella Pace
- Department of Advanced Biomedical Sciences, Pathology Section, Federico II University of Naples, Naples, Italy
| | | | - Massimo Mascolo
- Department of Advanced Biomedical Sciences, Pathology Section, Federico II University of Naples, Naples, Italy.
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