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Wilson MR, Cwynarski K, Eyre TA, Smith J, Chaganti S, Fox CP, McKay P. Central nervous system prophylaxis in large B-cell lymphoma: A British Society for Haematology Good Practice Paper. Br J Haematol 2024. [PMID: 39128894 DOI: 10.1111/bjh.19686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Accepted: 07/22/2024] [Indexed: 08/13/2024]
Abstract
This Good Practice Paper provides recommendations for the baseline investigation, risk stratification and use of prophylactic interventions for patients with large B-cell lymphoma at risk of central nervous system relapse. Recent evidence which has questioned the role of high-dose methotrexate in this clinical scenario is discussed in detail.
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Affiliation(s)
| | | | - Toby A Eyre
- Oxford University Hospitals NHS Trust, Churchill Cancer Centre, Oxford, UK
| | | | - Sridhar Chaganti
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | | | - Pamela McKay
- Beatson West of Scotland Cancer Centre, Glasgow, UK
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2
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Fox CP, Chaganti S, McIlroy G, Barrington SF, Burton C, Cwynarski K, Eyre TA, Illidge T, Kalakonda N, Kuhnl A, McKay P, Davies AJ. The management of newly diagnosed large B-cell lymphoma: A British Society for Haematology Guideline. Br J Haematol 2024; 204:1178-1192. [PMID: 38247115 DOI: 10.1111/bjh.19273] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/20/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024]
Affiliation(s)
| | - Sridhar Chaganti
- Centre for Clinical Haematology, University Hospitals Birmingham, Birmingham, UK
| | - Graham McIlroy
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Sally F Barrington
- King's College London and Guy's and St Thomas' PET Centre, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Cathy Burton
- Department of Haematology, The Leeds Teaching Hospitals, Leeds, UK
| | - Kate Cwynarski
- Department of Haematology, University College London Hospitals, London, UK
| | - Toby A Eyre
- Oxford Cancer and Haematology Centre, Oxford University Hospitals, Oxford, UK
| | - Timothy Illidge
- Division of Cancer Sciences, Manchester NIHR Biomedical Research Centre, University of Manchester, Manchester, UK
| | - Nagesh Kalakonda
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Andrea Kuhnl
- Department of Haematology, King's College Hospital, London, UK
| | - Pam McKay
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Andrew J Davies
- Cancer Sciences Division, Centre for Cancer Immunology, University of Southampton, Southampton, UK
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3
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Rinaldi I, Muthalib A, Gondhowiardjo S, Setiawan T, Gunawan A, Susanto N, Magdalena L, Winston K, Disamantiji A, Wirawan B. Relapsed isolated CNS lymphoma treated with radiotherapy and intrathecal methotrexate followed by high-dose intravenous methotrexate, rituximab, and temozolomide: A case report. Clin Case Rep 2024; 12:e8409. [PMID: 38435502 PMCID: PMC10907348 DOI: 10.1002/ccr3.8409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 12/09/2023] [Accepted: 12/18/2023] [Indexed: 03/05/2024] Open
Abstract
Key Clinical Message Optimized treatments for relapsed isolated CNS lymphoma (RI-SCNSL) remains under investigation. Temozolomide combination-based therapy, which is often used in glioblastoma may be used as potential treatment in RI-SCNSL. Abstract One of the most common types of non-Hodgkin lymphoma (NHL) is diffuse large B-cell lymphoma (DLBCL). Despite advances in treatment, relapsed isolated CNS lymphoma (RI-SCNSL) from DLBCL remains an issue. The optimal approach in RI-SCNSL remains an area of active investigation as currently there is no high level of evidence for the treatments due to lack of randomized studies. In this case report, we present a DLBCL patient with CNS recurrence treated radiotherapy and intrathecal methotrexate (MTX) followed by intravenous high-dose MTX, rituximab, and temozolomide. To the best of our knowledge, this is the first case report describing RI-SCNSL treated with the regiments above which also include temozolomide which is used for glioblastoma.
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Affiliation(s)
- Ikhwan Rinaldi
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Cipto Mangunkusumo National General Hospital, Faculty of MedicineUniversitas IndonesiaJakartaIndonesia
- Department of Internal MedicineGading Pluit HospitalJakartaIndonesia
| | - Abdul Muthalib
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Cipto Mangunkusumo National General Hospital, Faculty of MedicineUniversitas IndonesiaJakartaIndonesia
- Department of Internal MedicineGading Pluit HospitalJakartaIndonesia
| | | | - Tjondro Setiawan
- Department of Internal MedicineGading Pluit HospitalJakartaIndonesia
| | - Andhika Gunawan
- Department of Nuclear MedicineGading Pluit HospitalJakartaIndonesia
| | - Nelly Susanto
- Department of RadiologyGading Pluit HospitalJakartaIndonesia
| | | | - Kevin Winston
- Hospital MedicineBhakti Medicare HospitalCicurugIndonesia
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4
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Bibas M. Plasmablastic Lymphoma. A State-of-the-Art Review: Part 2-Focus on Therapy. Mediterr J Hematol Infect Dis 2024; 16:e2024015. [PMID: 38468838 PMCID: PMC10927196 DOI: 10.4084/mjhid.2024.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 02/14/2024] [Indexed: 03/13/2024] Open
Abstract
The objective of this two-part review is to present a current and comprehensive understanding of the diagnosis and management of plasmablastic lymphoma. The first part, which was published previously, focused on the study of epidemiology, etiology, clinicopathological characteristics, differential diagnosis, prognostic variables, and the impact of plasmablastic lymphoma on specific populations. This second part addresses the difficult topic of the treatment of plasmablastic lymphoma, specifically examining both the conventional, consolidated approach and the novel therapeutic strategy.
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Affiliation(s)
- Michele Bibas
- Department of Clinical Research, Hematology. National Institute for Infectious Diseases "Lazzaro Spallanzani" I.R.C.S.S. Via Portuense 292 00148 Rome Italy
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5
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Wilson MR, Kirkwood AA, Wong Doo N, Soussain C, Choquet S, Lees C, Fox C, Preston G, Ahearne M, Strüßmann T, Clavert A, Rusconi C, Ku M, Khwaja J, Narkhede M, Lewis K, Durot E, Smith J, Renaud L, Ferreri AJM, El-Galaly T, Cwynarski K, McKay P, Eyre TA. Dosage of high-dose methotrexate as CNS prophylaxis in DLBCL: A detailed analysis of toxicity and impact on CNS relapse. Am J Hematol 2024; 99:E46-E50. [PMID: 38037530 DOI: 10.1002/ajh.27167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/27/2023] [Accepted: 11/06/2023] [Indexed: 12/02/2023]
Affiliation(s)
| | - Amy A Kirkwood
- Cancer Research UK and UCL Cancer Trials Centre, UCL Cancer Institute, London, UK
| | - Nicole Wong Doo
- Concord Clinical School, Concord Hospital University of Sydney, Sydney, Australia
| | | | - Sylvain Choquet
- La Pitie Salpetriere Hospital, APHP-Sorbonne Universite, Paris, France
| | - Charlotte Lees
- Oxford University Hospitals NHS Trust, Churchill Cancer Center, Oxford, UK
| | | | | | | | - Tim Strüßmann
- University Medical Center Freiburg, Freiburg, Germany
| | - Aline Clavert
- Service des Maladies du Sang, CHU Angers, Angers, France
| | - Chiara Rusconi
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Matthew Ku
- St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Jahanzaib Khwaja
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Katharine Lewis
- Linear Clinical Research and Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Eric Durot
- Hôpital Robert Debré CHU de Reims, Reims, France
| | - Jeffery Smith
- Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | - Loic Renaud
- Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | | | - Kate Cwynarski
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Pam McKay
- Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Toby A Eyre
- Oxford University Hospitals NHS Trust, Churchill Cancer Center, Oxford, UK
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6
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Akimoto M, Miyazaki T, Takahashi H, Saigusa Y, Takeda T, Hibino Y, Tokunaga M, Ohashi T, Matsumura A, Teshigawara H, Suzuki T, Teranaka H, Nakajima Y, Matsumoto K, Hashimoto C, Fujimaki K, Fujita H, Sakai R, Fujisawa S, Nakajima H. Comparison of standardized prophylactic high-dose and intrathecal methotrexate for DLBCL with a high risk of CNS relapse. Int J Hematol 2024; 119:164-172. [PMID: 38233702 DOI: 10.1007/s12185-023-03700-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 12/25/2023] [Accepted: 12/27/2023] [Indexed: 01/19/2024]
Abstract
The efficacy of high-dose methotrexate (HD-MTX) for central nervous system (CNS) relapse prophylaxis in patients with high-risk diffuse large B-cell lymphoma (DLBCL) is controversial. We compared the prophylactic effects of HD-MTX and intrathecal methotrexate (IT-MTX) on CNS relapse in high-risk DLBCL, in a multicenter retrospective study. A total of 132 patients with DLBCL at high risk of CNS relapse who received frontline chemotherapy and IT-MTX from 2003 to 2013 (n = 34) or HD-MTX from 2014 to 2020 (n = 98) were included. After a median follow-up of 52 months (range: 9-174), 11 patients had isolated CNS relapse: six (6.1%) in the HD-MTX group and five (14.7%) in the IT-MTX group. The median time until CNS relapse was 38 months (range: 11-122), and the cumulative incidence of CNS relapse at 3 years was 3.9% in the HD-MTX group and 6.1% in the IT-MTX group (P = 0.93). Similar results were obtained after adjusting for background factors using propensity score-matched analysis (4.5% HD-MTX vs. 7.6% IT-MTX, P = 0.84). The CNS relapse rate in HD-MTX-treated patients was equivalent to that in IT-MTX patients, demonstrating that HD-MTX was not superior to IT-MTX in preventing CNS relapse.
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Affiliation(s)
- Masahiro Akimoto
- Department of Hematology, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Takuya Miyazaki
- Department of Hematology, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, Kanagawa, 232-0024, Japan.
| | - Hiroyuki Takahashi
- Department of Hematology and Medical Oncology, Kanagawa Cancer Center, Yokohama, Japan
| | - Yusuke Saigusa
- Department of Biostatistics, Yokohama City University School of Medicine, Yokohama, Japan
| | - Takaaki Takeda
- Department of Hematology and Medical Oncology, Kanagawa Cancer Center, Yokohama, Japan
| | - Yuto Hibino
- Department of Hematology and Medical Oncology, Kanagawa Cancer Center, Yokohama, Japan
| | - Mayumi Tokunaga
- Department of Hematology and Medical Oncology, Kanagawa Cancer Center, Yokohama, Japan
| | - Takuma Ohashi
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Ayako Matsumura
- Department of Hematology, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Haruka Teshigawara
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Taisei Suzuki
- Department of Hematology, Fujisawa City Hospital, Fujisawa, Japan
| | - Hiroshi Teranaka
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Yuki Nakajima
- Department of Hematology, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Kenji Matsumoto
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Chizuko Hashimoto
- Department of Hematology/Oncology, Yamato Municipal Hospital, Yamato, Japan
| | | | - Hiroyuki Fujita
- Department of Hematology, Saiseikai Yokohama Nanbu Hospital, Yokohama, Japan
| | - Rika Sakai
- Department of Hematology and Medical Oncology, Kanagawa Cancer Center, Yokohama, Japan
| | - Shin Fujisawa
- Department of Hematology, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Hideaki Nakajima
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Yokohama, Japan
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Chua BJG, Low CE, Yau CE, Tan YH, Chiang J, Chang EWY, Chan JY, Poon EYL, Somasundaram N, Rashid MFBH, Tao M, Lim ST, Yang VS. Recent updates on central nervous system prophylaxis in patients with high-risk diffuse large B-cell lymphoma. Exp Hematol Oncol 2024; 13:1. [PMID: 38173015 PMCID: PMC10765685 DOI: 10.1186/s40164-023-00467-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
The use of central nervous system (CNS) prophylaxis for patients with diffuse large B-cell lymphoma (DLBCL) remains controversial. Although uncommon, CNS relapses are invariably fatal in this otherwise curable disease. Accurate identification of patients at risk and the optimal approach to CNS prophylaxis therefore remains an area of unmet need. The existing literature, largely retrospective in nature, provides mixed conclusions regarding the efficacy of CNS prophylaxis. The utility of CNS prophylaxis has itself been challenged. In this review, we dissect the issues which render the value of CNS prophylaxis uncertain. We first compare international clinical guidelines for CNS prophylaxis. We then interrogate the factors that should be used to identify high-risk patients accurately. We also explore how clinical patterns of CNS relapse have changed in the pre-rituximab and rituximab era. We then discuss the efficacy of CNS-directed approaches, intensification of systemic treatment and other novel approaches in CNS prophylaxis. Improved diagnostics for early detection of CNS relapses and newer therapeutics for CNS prophylaxis are areas of active investigation. In an area where prospective, randomized studies are impracticable and lacking, guidance for the use of CNS prophylaxis will depend on rigorous statistical review of retrospective data.
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Affiliation(s)
- Bernard Ji Guang Chua
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
| | - Chen Ee Low
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Chun En Yau
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Ya Hwee Tan
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
| | - Jianbang Chiang
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
| | - Esther Wei Yin Chang
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
| | - Jason Yongsheng Chan
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
- Duke-NUS Medical School, Oncology Academic Clinical Program, 8 College Road, Singapore, 169857, Singapore
| | - Eileen Yi Ling Poon
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
| | - Nagavalli Somasundaram
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
- Duke-NUS Medical School, Oncology Academic Clinical Program, 8 College Road, Singapore, 169857, Singapore
| | - Mohamed Farid Bin Harunal Rashid
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
- Duke-NUS Medical School, Oncology Academic Clinical Program, 8 College Road, Singapore, 169857, Singapore
| | - Miriam Tao
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
- Duke-NUS Medical School, Oncology Academic Clinical Program, 8 College Road, Singapore, 169857, Singapore
| | - Soon Thye Lim
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore
- Duke-NUS Medical School, Oncology Academic Clinical Program, 8 College Road, Singapore, 169857, Singapore
| | - Valerie Shiwen Yang
- Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610, Singapore.
- Duke-NUS Medical School, Oncology Academic Clinical Program, 8 College Road, Singapore, 169857, Singapore.
- Translational Precision Oncology Lab, Institute of Molecular and Cell Biology (IMCB), 61 Biopolis Dr Proteos, Singapore, 138673, A*STAR, Singapore.
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Lewis KL, Jakobsen LH, Villa D, Smedby KE, Savage KJ, Eyre TA, Cwynarski K, Bishton MJ, Fox CP, Hawkes EA, Maurer MJ, El-Galaly TC, Cheah CY. High-Dose Methotrexate as CNS Prophylaxis in High-Risk Aggressive B-Cell Lymphoma. J Clin Oncol 2023; 41:5376-5387. [PMID: 37797284 DOI: 10.1200/jco.23.00365] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 07/01/2023] [Accepted: 07/28/2023] [Indexed: 10/07/2023] Open
Abstract
PURPOSE CNS progression or relapse is an uncommon but devastating complication of aggressive B-cell lymphoma. There is no consensus regarding the optimal approach to CNS prophylaxis. This study was designed to determine whether high-dose methotrexate (HD-MTX) is effective at preventing CNS progression in patients at high risk of this complication. PATIENTS AND METHODS Patients age 18-80 years with aggressive B-cell lymphoma and high risk of CNS progression, treated with curative-intent anti-CD20-based chemoimmunotherapy, were included in this international, retrospective, observational study. Cause-specific hazard ratios (HRs) and cumulative risks of CNS progression were calculated according to use of HD-MTX, with time to CNS progression calculated from diagnosis for all patients (all-pts) and from completion of frontline systemic lymphoma induction therapy, for patients in complete response at completion of chemoimmunotherapy (CR-pts). RESULTS Two thousand four hundred eighteen all-pts (HD-MTX; n = 425) and 1,616 CR-pts (HD-MTX; n = 356) were included. CNS International Prognostic Index was 4-6 in 83.4% all-pts. Patients treated with HD-MTX had a lower risk of CNS progression (adjusted HR, 0.59 [95% CI, 0.38 to 0.90]; P = .014), but significance was not retained when confined to CR-pts (adjusted HR, 0.74 [95% CI, 0.42 to 1.30]; P = .29), with 5-year adjusted risk difference of 1.6% (95% CI, -1.5 to 4.4; all-pts) and 1.4% (95% CI, -1.5 to 4.1; CR-pts). Subgroups were underpowered to draw definitive conclusions regarding the efficacy of HD-MTX in individual high-risk clinical scenarios; however, there was no clear reduction in CNS progression risk with HD-MTX in any high-risk subgroup. CONCLUSION In this large study, high-risk patients receiving HD-MTX had a 7.2% 2-year risk of CNS progression, consistent with the progression risk in previously reported high-risk cohorts. Use of HD-MTX was not associated with a clinically meaningful reduction in risk of CNS progression.
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Affiliation(s)
- Katharine L Lewis
- Linear Clinical Research, Nedlands, WA, Australia
- Division of Haematology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- Division of Internal Medicine, Medical School, University of Western Australia, Perth, WA, Australia
| | - Lasse H Jakobsen
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark
| | - Diego Villa
- BC Cancer Centre for Lymphoid Cancer, The University of British Columbia, Vancouver, BC, Canada
| | - Karin E Smedby
- Department of Medicine Solna, Division of Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - Kerry J Savage
- BC Cancer Centre for Lymphoid Cancer, The University of British Columbia, Vancouver, BC, Canada
| | - Toby A Eyre
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Kate Cwynarski
- University College London Hospital NHS Foundation Trust, London, United Kingdom
| | - Mark J Bishton
- Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- University of Nottingham, Nottingham, United Kingdom
| | - Christopher P Fox
- Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- University of Nottingham, Nottingham, United Kingdom
| | - Eliza A Hawkes
- Olivia Newton-John Cancer Research & Wellness Centre at Austin Health, Heidelberg, VIC, Australia
- Monash University School of Public Health and Preventive Medicine, Melbourne, VIC, Australia
| | - Matthew J Maurer
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | - Tarec C El-Galaly
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark
| | - Chan Y Cheah
- Linear Clinical Research, Nedlands, WA, Australia
- Division of Haematology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- Division of Internal Medicine, Medical School, University of Western Australia, Perth, WA, Australia
- Department of Haematology, PathWest, Nedlands, WA, Australia
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9
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Bobillo S, Wilson MR, Cwynarski K. Controversies in central nervous system prophylaxis of high-risk diffuse large B-cell lymphoma. Curr Opin Oncol 2023; 35:382-388. [PMID: 37551947 DOI: 10.1097/cco.0000000000000973] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
PURPOSE OF REVIEW Central nervous system (CNS) relapse in patients with diffuse large B-cell lymphoma (DLBCL) is an uncommon but devastating complication with an overall survival of less than 6 months. This article will review the recent updates on CNS prophylaxis including new potential advances in the identification of high-risk patients. RECENT FINDINGS The identification of patients at a high risk of CNS relapse is based on clinical and biological features has improved over recent years; however, the of different CNS prophylaxis strategies including intrathecal chemotherapy and high-dose methotrexate have been recently questioned in several large retrospective studies. The analysis of cell-free circulating tumor DNA (ctDNA) in the cerebrospinal fluid has been shown to identify patients with a high risk of CNS involvement and work is ongoing to identify how this can be used as a prognostic biomarker. SUMMARY Recent clinical retrospective data have questioned the effectiveness of intrathecal and high-dose methotrexate in the prevention of CNS relapse in high-risk DLBCL patients. The role of more sensitive methods to detect CNS involvement and the benefit of novel therapies in CNS relapse prevention are currently under evaluation.
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Affiliation(s)
- Sabela Bobillo
- Department of Haematology, Vall d'Hebron Institute of Oncology, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Matthew R Wilson
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow
| | - Kate Cwynarski
- Department of Haematology, University College London Hospital, London, UK
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10
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Ghione P, Lewis KL, Bobillo S, Nayak L, Schorb E, Nichelli L, Ng A, Savage KJ, McKay P, Nastoupil L, Soussain C, Cwynarski K. Central nervous system lymphomas-Assessment and treatment and prevention of central nervous system relapse. Hematol Oncol 2023. [PMID: 37381737 DOI: 10.1002/hon.3197] [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: 04/08/2023] [Revised: 05/30/2023] [Accepted: 06/07/2023] [Indexed: 06/30/2023]
Abstract
In this review focused on lymphoma and the central nervous system (CNS), we summarize recent developments in the management of primary (PCNSL) and secondary CNS lymphoma (SCNSL), treatment of CNS lymphoma in the older population, the neuroradiological assessment of CNS lymphoma and finally highlight the ongoing debate on optimal CNS prophylaxis. The section on PCNSL focuses on the different approaches available for frontline treatment in Europe and the United States and discusses consolidation strategies. We then highlight available strategies to treat PCNSL in the elderly population, an area of unmet need. New therapies aiming at minimizing toxicity and prioritizing quality of life are emerging for these patients. Secondary CNS lymphoma, especially in the relapsed/refractory setting is another area of unmet need, and the efficacy of CAR-T cell therapy is being explored. We provide an overview of the imaging challenges in the neuroradiological assessment of CNS lymphoma. Finally, the section on CNS prophylaxis summarizes recent findings from large retrospective studies challenging the efficacy of present approaches to prophylaxis in higher-risk patients with lymphoma.
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Affiliation(s)
- Paola Ghione
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Katharine L Lewis
- Sir Charles Gairdner Hospital and Linear Clinical Research, Nedlands, Western Australia, Australia
| | | | - Laksmi Nayak
- Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Elisabeth Schorb
- Department of Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Lucia Nichelli
- Hôpitaux Universitaires La Pitié Salpêtrière, Paris, France
| | - Andrea Ng
- Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Kerry J Savage
- Centre for Lymphoid Cancer, Division of Medical Oncology, BC Cancer, Vancouver, British Columbia, Canada
| | | | - Loretta Nastoupil
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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11
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Rauschecker AM, Mo SS, Randall M, Shen-Sampas J, Rubenstein JL. Tafasitamab at the blood-brain barrier. Br J Haematol 2023; 201:154-157. [PMID: 36691708 DOI: 10.1111/bjh.18660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 01/09/2023] [Indexed: 01/25/2023]
Affiliation(s)
- Andreas M Rauschecker
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California, USA
| | - Shirley S Mo
- Department of Medicine, University of California, San Francisco, California, USA
| | - Michael Randall
- Department of Medicine, University of California, San Francisco, California, USA.,Hematology/Oncology, University of California, San Francisco, California, USA
| | - John Shen-Sampas
- School of Medicine, University of California, San Francisco, California, USA
| | - James L Rubenstein
- Department of Medicine, University of California, San Francisco, California, USA.,Hematology/Oncology, University of California, San Francisco, California, USA.,Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, California, USA
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12
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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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13
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Lewis KL, Cheah CY. About time: why central nervous system prophylaxis timing in diffuse large B-cell lymphoma matters and does the protocol need updating? Expert Rev Hematol 2022; 15:959-962. [PMID: 36278876 DOI: 10.1080/17474086.2022.2140138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Katharine Louise Lewis
- Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,University of Western Australia, Nedlands, Western Australia, Australia.,Linear Clinical Research, Nedlands, Western Australia, Australia
| | - Chan Yoon Cheah
- Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,University of Western Australia, Nedlands, Western Australia, Australia.,Pathwest, Nedlands, Western Australia, Australia
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14
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Simard J, Roschewski M. SOHO State of the Art Updates and Next Questions: Prophylaxis and Management of Secondary CNS Lymphoma. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:709-717. [PMID: 35787364 PMCID: PMC9529879 DOI: 10.1016/j.clml.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/01/2022] [Accepted: 06/04/2022] [Indexed: 06/15/2023]
Abstract
Secondary CNS lymphoma (SCNSL) is a rare but frequently fatal complication of systemic lymphoma. There is no standard treatment for SCNSL, and patients who develop SCNSL at diagnosis or after frontline therapy often receive highly intensive chemotherapy regimens that are inactive against primary chemorefractory disease and too toxic for older, frail patients to tolerate. Because the prognosis of SCNSL is so poor, management has historically emphasized prevention, but the current methods of CNS prophylaxis are not universally effective. To improve both the prevention and management of SCNSL, better characterization of the molecular determinants of CNS invasion is needed. Novel treatments that are currently being studied in SCNSL include targeted pathway inhibitors and cellular therapy, but SCNSL patients are often excluded from clinical trials of promising new therapies.
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Affiliation(s)
- Jillian Simard
- Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD
| | - Mark Roschewski
- Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD.
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15
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Renal involvement of lymphomas proven by kidney biopsy: report of 10 cases from a tertiary care center and comparison with the literature. Int J Hematol 2022; 116:678-695. [PMID: 35829895 DOI: 10.1007/s12185-022-03411-y] [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: 08/13/2021] [Revised: 06/17/2022] [Accepted: 06/19/2022] [Indexed: 10/17/2022]
Abstract
Lymphomas localized in the kidney are a rare entity that may be challenging to diagnose. We analyzed data from 10 patients with renal involvement of lymphoma diagnosed between 2009 and 2019 on fine needle biopsy from our tertiary center, and compared these with findings of 160 cases reported in the literature. Diffuse large B-cell lymphoma was the main histology subtype (40 and 38% in our sample and in the literature, respectively), followed by low-grade B-cell lymphomas, mostly from the marginal zone (MZ). Altogether, 106 patients had urological inaugural symptoms and 64 had general symptoms. Patients with urological presentation more often had renal masses than diffuse infiltration (p < 0.001), unilateral tumors (p = 0.0036) and low-grade B-cell lymphomas (17 vs 6%, p = 0.043). In both groups, nearly one-fourth of patients had diffuse (stage IV) lymphomas. Overall survival did not differ by the presence of urological/systemic symptoms, stage or aggressive lymphoma status. Notably, 3 of 10 patients from our series had MZ lymphomas associated with primary Sjögren syndrome revealed by acute kidney injury, including one where the autoimmune disease was detected. Lymphoproliferative disorders localized in the kidney are a challenging condition that can lead to detection of aggressive or diffuse lymphomas.
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16
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Shichijo T, Tatetsu H, Nosaka K, Higuchi Y, Kikukawa Y, Inoue Y, Toyoda K, Yasunaga J, Matsuoka M. Predictive impact of soluble interleukin‐2 receptor and number of extranodal sites for identification of patients at very high risk of CNS relapse in diffuse large B‐cell lymphoma. EJHAEM 2022; 3:385-393. [PMID: 35846027 PMCID: PMC9175809 DOI: 10.1002/jha2.393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/14/2022] [Accepted: 01/18/2022] [Indexed: 11/23/2022]
Abstract
There remains an unmet clinical need to identify which patients with diffuse large B‐cell lymphoma (DLBCL) would benefit from central nervous system (CNS) prophylaxis, due to the low positive predictive value (PPV; 10%–15%) of the currently available predictive models. To stratify patients at high risk of developing CNS relapse, we retrospectively analyzed 182 patients with DLBCL initially treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R‐CHOP), or a R‐CHOP‐like regimen. Among them, 17 patients relapsed with CNS involvement, and the 2‐year rate of CNS relapse was 7.9%. Upon carrying out multivariate analysis, ≥3 extranodal sites and elevated soluble interleukin‐2 receptor (sIL‐2R) levels at diagnosis were identified as independent risk factors for CNS relapse. The 2‐year and 3.5‐year rates of CNS relapse were 57.1% and 78.6%, respectively, in patients with both elevated sIL‐2R and ≥3 extranodal sites. Furthermore, combined use of these risk factors of both elevated sIL‐2R and ≥3 extranodal sites resulted in a high PPV (71.4%), negative predictive value (93.1%), and overall accuracy (92.3%) for undergoing CNS relapse. In conclusion, we propose a simple and valuable tool to predict patients with DLBCL at very high risk of CNS relapse.
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Affiliation(s)
- Takafumi Shichijo
- Department of Hematology, Rheumatology and Infectious Diseases Kumamoto University Hospital Kumamoto Japan
| | - Hiro Tatetsu
- Department of Hematology, Rheumatology and Infectious Diseases Kumamoto University Hospital Kumamoto Japan
| | - Kisato Nosaka
- Department of Hematology, Rheumatology and Infectious Diseases Kumamoto University Hospital Kumamoto Japan
| | - Yusuke Higuchi
- Department of Hematology, Rheumatology and Infectious Diseases Kumamoto University Hospital Kumamoto Japan
| | - Yoshitaka Kikukawa
- Department of Hematology and Oncology Kumamoto City Hospital Kumamoto Japan
| | - Yoshitaka Inoue
- Department of Hematology, Rheumatology and Infectious Diseases Kumamoto University Hospital Kumamoto Japan
| | - Kosuke Toyoda
- Department of Hematology, Rheumatology and Infectious Diseases Kumamoto University Hospital Kumamoto Japan
| | - Jun‐ichirou Yasunaga
- Department of Hematology, Rheumatology and Infectious Diseases Kumamoto University Hospital Kumamoto Japan
| | - Masao Matsuoka
- Department of Hematology, Rheumatology and Infectious Diseases Kumamoto University Hospital Kumamoto Japan
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17
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Berhan A, Bayleyegn B, Getaneh Z. HIV/AIDS Associated Lymphoma: Review. Blood Lymphat Cancer 2022; 12:31-45. [PMID: 35517869 PMCID: PMC9063794 DOI: 10.2147/blctt.s361320] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 04/19/2022] [Indexed: 11/23/2022] Open
Abstract
Lymphoma is one of the hematologic malignancies that occur at a higher rate in human immunodeficiency virus-infected individuals. It is one of the most frequent neoplastic causes of death in those individuals. Non-Hodgkin’s lymphoma and Hodgkin’s lymphomas are acquired immunodeficiency syndrome defining lymphoma and non-acquired immunodeficiency syndrome defining lymphoma, respectively. Non-Hodgkin’s lymphoma is the most common type of lymphoma in human immunodeficiency virus-positive people. The lymphoma that develops in patients infected with the human immunodeficiency virus/acquired immunodeficiency syndrome is heterogeneous in terms of morphology, pathogenesis pathways, and cellular derivation. A narrative review was conducted on the basis of relevant literature on the current topic to summarize the current epidemiology, pathogenesis, laboratory diagnosis, and treatment of lymphoma in human immunodeficiency virus-infected patients. The finding showed that although the incidence of non-Hodgkin’s lymphoma has decreased after the advent of highly active antiretroviral therapy, it has remained higher in human immunodeficiency virus-infected people than in the general population. On the other hand, the incidence of Hodgkin’s lymphoma has increased after the introduction of highly active antiretroviral therapy. Therefore, it is recommended that people living with human immunodeficiency virus/ acquired immunodeficiency syndrome be screened for the development of lymphoma to increase their survival time and quality of life, and further research is required regarding the pathogenesis, treatment, and laboratory diagnosis of human immunodeficiency virus/ acquired immunodeficiency syndrome-associated lymphoma.
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Affiliation(s)
- Ayenew Berhan
- Department of Medical Laboratory Science, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
- Correspondence: Ayenew Berhan, Tel +251910613151, Email
| | - Biruk Bayleyegn
- Department of Hematology and Immunohematology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Zegeye Getaneh
- Department of Hematology and Immunohematology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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18
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Kurch L, Georgi TW, Monecke A, Seehofer D, Borte G, Sabri O, Kluge R, Heyn S, Pierer M, Platzbecker U, Kayser S. Vital Hepatic Lymphoma Residuum or Excessive Immune Response? Challenging Treatment Decisions in a Patient With Systemic Lupus Erythematosus and Liver-Dominant Diffuse Large B-Cell Lymphoma: Case Report. Front Oncol 2022; 11:798757. [PMID: 35117998 PMCID: PMC8803907 DOI: 10.3389/fonc.2021.798757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 12/06/2021] [Indexed: 12/02/2022] Open
Abstract
A 28-year-old female patient with active and difficult-to-treat systemic lupus erythematosus (SLE) was diagnosed with liver-dominant diffused large B-cell lymphoma. Repeated response 18F-FDG-PET studies showed persistently high, and, despite intensified immunochemotherapy, further increasing metabolic activity of one of the hepatic lymphoma residuals, whereas all other initial lymphoma manifestations had achieved complete metabolic remission. As biopsy of the 18F-FDG-PET-positive liver residual turned out to be inconclusive, complete resection was performed. Subsequent histopathological examination, however, revealed only necrotic tissue. Thus, no further lymphoma treatment was scheduled. The patient undergoes regular surveillance and is disease-free 13 months after resection. Similarly, treatment of SLE is no longer required due to lack of activity already after the first two cycles of lymphoma treatment. The case shows how closely SLE and diffused large B-cell lymphoma can be connected and stresses the importance of interdisciplinary treatment approaches. In the future, artificial intelligence may help to further classify 18F-FDG-PET-positive lymphoma residuals. This could lead to an increase of the positive predictive value of interim- and end-of-treatment 18F-FDG-PET. The patient’s point of view enables another instructive perspective on the course of treatment, which often remains hidden to treating physicians due to lack of time in clinical routine.
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Affiliation(s)
- Lars Kurch
- Department of Nuclear Medicine, University Hospital Leipzig, Leipzig, Germany
- *Correspondence: Lars Kurch,
| | - Thomas W. Georgi
- Department of Nuclear Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Astrid Monecke
- Department of Pathology, University Hospital Leipzig, Leipzig, Germany
| | - Daniel Seehofer
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Gudrun Borte
- Department of Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Osama Sabri
- Department of Nuclear Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Regine Kluge
- Department of Nuclear Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Simone Heyn
- Department of Hematology, Cellular Therapy and Hemostaseology, University Hospital Leipzig, Leipzig, Germany
| | - Matthias Pierer
- Department of Rheumatology, University Hospital Leipzig, Leipzig, Germany
| | - Uwe Platzbecker
- Department of Hematology, Cellular Therapy and Hemostaseology, University Hospital Leipzig, Leipzig, Germany
| | - Sabine Kayser
- Department of Hematology, Cellular Therapy and Hemostaseology, University Hospital Leipzig, Leipzig, Germany
- NCT Trial Center, National Center of Tumor Diseases, German Cancer Research Center (DKFZ), Heidelberg, Germany
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19
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Timing of high dose methotrexate CNS prophylaxis in DLBCL: a multicenter international analysis of 1,384 patients. Blood 2022; 139:2499-2511. [DOI: 10.1182/blood.2021014506] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 12/30/2021] [Indexed: 11/20/2022] Open
Abstract
Prophylactic high-dose methotrexate (HD-MTX) is often used for diffuse large B-cell lymphoma (DLBCL) patients at high risk of central nervous system (CNS) relapse, despite limited evidence demonstrating efficacy or the optimal delivery method. We conducted a retrospective, international analysis of 1,384 patients receiving HD-MTX CNS prophylaxis either intercalated (i-HD-MTX) (n=749) or at the end (n=635) of R-CHOP/R-CHOP-like therapy (EOT). There were 78 CNS relapses (3-year rate 5.7%), with no difference between i-HD-MTX and EOT; 5.7% vs 5.8%, p=0.98, 3-year difference: 0.04% (-2.0% to 3.1%). Conclusions were unchanged on adjusting for baseline prognostic factors or on 6-month landmark analysis (n=1,253). In patients with high CNS international prognostic index (n=600), 3-year CNS relapse rate was 9.1% with no difference between i-HD-MTX and EOT. On multivariable analysis, increasing age and renal/adrenal involvement were the only independent risk factors for CNS relapse. Concurrent intrathecal prophylaxis was not associated with reduction in CNS relapse. R-CHOP delays of ≥7 days were significantly increased with i-HD-MTX versus EOT, with 308/1573 (19.6%) i-HD-MTX treatments resulting in delay to subsequent R-CHOP (median 8 days). Increased risk of delay occurred in older patients when delivery was later than day 10 in the R-CHOP cycle. In summary, we found no evidence that EOT delivery increases CNS relapse risk versus i-HD-MTX. Findings in high-risk subgroups were unchanged. Rates of CNS relapse in this HD-MTX-treated cohort were similar to comparable cohorts receiving infrequent CNS prophylaxis. If HD-MTX is still considered for certain high-risk patients, delivery could be deferred until R-CHOP completion.
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20
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Gogia A, Sasi A. Preventing central nervous system relapses of diffuse large B-cell lymphoma: A brief summary of current evidence. CANCER RESEARCH, STATISTICS, AND TREATMENT 2022. [DOI: 10.4103/crst.crst_151_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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21
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Gini G, Di Rocco A, Nassi L, Arcari A, Tisi MC, Loseto G, Olivieri A, Gentile M, Annibali O, Cabras MG, Chiappella A, Rusconi C, Ferreri AJM, Balzarotti M. CNS Prophylaxis: How Far Is Routine Practice From the Guidelines? Focus on a Nationwide Survey by the Fondazione Italiana Linfomi (FIL). Front Oncol 2021; 11:730194. [PMID: 34804924 PMCID: PMC8602788 DOI: 10.3389/fonc.2021.730194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/27/2021] [Indexed: 11/25/2022] Open
Affiliation(s)
- Guido Gini
- Clinic of Hematology, Ospedali Riuniti, Ancona, Italy
| | - Alice Di Rocco
- Department of Traslational and Precision Medicine, Sapienza University, Roma, Italy
| | - Luca Nassi
- Hematology, Department of Translational Medicine, University of Eastern Piedmont and AOU Maggiore della Carità, Novara, Italy
| | - Annalisa Arcari
- Division of Hematology, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Maria Chiara Tisi
- Department of Hematology and Cell Therapy, San Bortolo Hospital, Vicenza, Italy
| | - Giacomo Loseto
- Division of Hematology, IRCCS Ospedale Oncologico, Bari, Italy
| | | | - Massimo Gentile
- Department of Onco-Hematology, Hematology Unit, A.O of Cosenza, Cosenza, Italy
| | - Ombretta Annibali
- Unit of Hematology and Stem Cell Transplantation, University "Campus Bio-Medico", Rome, Italy
| | | | - Annalisa Chiappella
- Department of Hematology, Azienda Ospedaliero Universitaria Citta`della Salute e della Scienza di Torino, Torino, Italy
| | - Chiara Rusconi
- Division of Hematology, Ospedale Niguarda Ca' Granda, Milan, Italy
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22
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Ho G, Tan C, de Mel S, Poon L, Chan EHL, Lee J, Liu X, Chng WJ, Chee YL, Soon YY, Jeyasekharan AD. Central nervous system (CNS) prophylaxis in antiCD20-CHOP treated DLBCL at intermediate to high risk for CNS relapse: A systematic review and meta-analysis. Crit Rev Oncol Hematol 2021; 167:103507. [PMID: 34656744 DOI: 10.1016/j.critrevonc.2021.103507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/10/2021] [Indexed: 12/27/2022] Open
Abstract
CNS prophylaxis is commonly used in Diffuse Large B-Cell Lymphoma (DLBCL) patients with risk features for CNS relapse. This systematic review and meta-analysis compares CNS relapse rates with and without CNS prophylaxis, for patients at intermediate to high CNS relapse risk. Studies reporting CNS relapse risk category and CNS outcomes with and without CNS prophylaxis for antiCD20-CHOP treated DLBCL patients were included. 10 studies with 3770 patients at intermediate to high CNS relapse risk were analyzed. No significant difference in the pooled Absolute Risk Difference (ARD 0.01, 95 % CI -0.01 to 0.02, P = 0.61) or Risk (RR 1.22, 95 % CI 0.81-1.83, P = 0.34) was noted in patients with and without CNS prophylaxis. There were also no differences within pre-specified subgroups of IV Methotrexate or IT chemotherapy. However, the quality of evidence supporting these observations was low. A meta-analysis of individual patient data will help evaluate the benefit of CNS prophylaxis strategies.
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Affiliation(s)
- Guiyi Ho
- Department of Haematology-Oncology, National University Hospital, Singapore
| | - Cherie Tan
- Department of Haematology-Oncology, National University Hospital, Singapore
| | - Sanjay de Mel
- Department of Haematology-Oncology, National University Hospital, Singapore
| | - Limei Poon
- Department of Haematology-Oncology, National University Hospital, Singapore
| | - Esther H L Chan
- Department of Haematology-Oncology, National University Hospital, Singapore
| | - Joanne Lee
- Department of Haematology-Oncology, National University Hospital, Singapore
| | - Xin Liu
- Department of Haematology-Oncology, National University Hospital, Singapore
| | - Wee Joo Chng
- Department of Haematology-Oncology, National University Hospital, Singapore; Cancer Science Institute of Singapore, National University of Singapore, Singapore
| | - Yen Lin Chee
- Department of Haematology-Oncology, National University Hospital, Singapore
| | - Yu Yang Soon
- Department of Radiation Oncology, National University Hospital, Singapore.
| | - Anand D Jeyasekharan
- Department of Haematology-Oncology, National University Hospital, Singapore; Cancer Science Institute of Singapore, National University of Singapore, Singapore.
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23
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Detection of clonotypic DNA in the cerebrospinal fluid as a marker of central nervous system invasion in lymphoma. Blood Adv 2021; 5:5525-5535. [PMID: 34551072 PMCID: PMC8714713 DOI: 10.1182/bloodadvances.2021004512] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 07/16/2021] [Indexed: 11/30/2022] Open
Abstract
The NGS-MRD assay detected clonotypic DNA in 100% of CSF samples from patients who had lymphoma with parenchymal CNS involvement. Clonotypic DNA in CSF was present in 36% of newly diagnosed aggressive lymphomas and was associated with a 29% risk of CNS recurrence.
The diagnosis of parenchymal central nervous system (CNS) invasion and prediction of risk for future CNS recurrence are major challenges in the management of aggressive lymphomas, and accurate biomarkers are needed to supplement clinical risk predictors. For this purpose, we studied the results of a next-generation sequencing (NGS)–based assay that detects tumor-derived DNA for clonotypic immunoglobulin gene rearrangements in the cerebrospinal fluid (CSF) of patients with lymphomas. Used as a diagnostic tool, the NGS-minimal residual disease (NGS-MRD) assay detected clonotypic DNA in 100% of CSF samples from 13 patients with known CNS involvement. They included 7 patients with parenchymal brain disease only, whose CSF tested negative by standard cytology and flow cytometry, and 6 historical DNA aliquots collected from patients at a median of 39 months before accession, which had failed to show clonal rearrangements using standard polymerase chain reaction. For risk prognostication, we prospectively collected CSF from 22 patients with newly diagnosed B-cell lymphomas at high clinical risk of CNS recurrence, of whom 8 (36%) had detectable clonotypic DNA in the CSF. Despite intrathecal prophylaxis, a positive assay of CSF was associated with a 29% cumulative risk of CNS recurrence within 12 months of diagnosis, in contrast with a 0% risk among patients with negative CSF (P = .045). These observations suggest that detection of clonotypic DNA can aid in the diagnosis of suspected parenchymal brain recurrence in aggressive lymphoma. Furthermore, the NGS-MRD assay may enhance clinical risk assessment for CNS recurrence among patients with newly diagnosed lymphomas and help select those who may benefit most from novel approaches to CNS-directed prophylaxis.
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24
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Roschewski M. Preventing central nervous system spread in diffuse large B-cell lymphoma - novel approaches needed. Haematologica 2021; 106:2298-2300. [PMID: 34465081 PMCID: PMC8409019 DOI: 10.3324/haematol.2021.278559] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Indexed: 01/05/2023] Open
Affiliation(s)
- Mark Roschewski
- Lymphoid Malignancies Branch, Center for Cancer Research, National Institutes of Health, Bethesda, MD.
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25
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High-dose methotrexate is effective for prevention of isolated CNS relapse in diffuse large B cell lymphoma. Blood Cancer J 2021; 11:143. [PMID: 34385415 PMCID: PMC8361130 DOI: 10.1038/s41408-021-00535-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 12/24/2022] Open
Abstract
The role of central nervous system (CNS) prophylaxis with high-dose methotrexate (HDMTX) in DLBCL is controversial. In this retrospective study, we evaluated the efficacy of prophylactic HDMTX on isolated CNS relapse, concomitant CNS and systemic relapse, systemic relapse, and survival outcomes in 226 patients with newly diagnosed DLBCL and high-risk CNS International Prognostic Index (CNS-IPI) score treated with RCHOP. The three-year risk of isolated CNS relapse was significantly lower in patients who received HDMTX, at 3.1% compared to 14.6% (P = 0.032) in those who did not. However, neither concomitant CNS-systemic relapse rates, systemic relapse rates, nor three-year PFS and OS were significantly different between treatment groups in multivariable analysis. Among propensity score-matched patients (N = 102), HDMTX was also associated with significantly lower isolated CNS relapse rates (HR 0.06, 95% CI 0.004–0.946, P = 0.046). HDMTX was well tolerated with manageable toxicities when given at a dose of 3 g/m2 by day 3 of RCHOP chemotherapy. Using propensity score matching and multivariable regression to yield treatment groups with well-balanced covariates, we showed that prophylactic HDMTX improved isolated CNS relapse rates but did not decrease concomitant CNS-systemic relapse rates, systemic relapse rates, or improve survival outcomes.
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26
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Zhang XY, Collins GP, Cutter DJ, Eyre TA. Limited-stage diffuse large B-cell lymphoma: current management and challenges. Br J Haematol 2021; 194:508-517. [PMID: 33618434 DOI: 10.1111/bjh.17359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 01/17/2021] [Indexed: 11/29/2022]
Abstract
Twenty-five to thirty per cent of diffuse large B-cell lymphoma (DLBCL) presents as limited stage (I-II). Prognosis is generally excellent with four to six cycles of R-CHOP alone (rituximab, cyclophosphamide, vincristine, doxorubicin, prednisolone) or combined-modality therapy with three or four cycles and involved-site radiotherapy (RT). There is growing interest in optimising algorithms to retain disease control whilst minimising long-term toxicity, with several recent studies focusing on the safety of abbreviating chemotherapy and omitting RT in low-risk patients and the utility of PET-based response-adapted approaches. As these studies are limited to younger patients without risk factors, application of similar approaches in elderly or higher-risk patients is hampered by a lack of evidence. Whilst there has been a move away from using RT in low-risk patients, it remains a useful adjunct in specific situations. Current evidence cannot exclude a clinically meaningful benefit from RT even in low-risk patients and, given the low expected toxicity from modern RT techniques, a risk-benefit assessment should be individualised and considered in a multidisciplinary fashion. The optimal approach for extranodal limited-stage DLBCL (~40% of cases) varies according to site of origin. Herein we discuss the latest clinical trial evidence and how this can be applied in routine practice.
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Affiliation(s)
- Xiao-Yin Zhang
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Graham P Collins
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - David J Cutter
- Department of Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Toby A Eyre
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Puckrin R, El Darsa H, Ghosh S, Peters A, Owen C, Stewart D. Ineffectiveness of high-dose methotrexate for prevention of CNS relapse in diffuse large B-cell lymphoma. Am J Hematol 2021; 96:764-771. [PMID: 33811794 DOI: 10.1002/ajh.26181] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/24/2021] [Accepted: 04/01/2021] [Indexed: 12/12/2022]
Abstract
Central nervous system (CNS) relapse affects 5% of diffuse large B-cell lymphoma (DLBCL) patients and portends a poor prognosis. Prophylactic intravenous high-dose methotrexate (HD-MTX) is frequently employed to reduce this risk, but there is limited evidence supporting this practice. We conducted a multicenter retrospective study to determine the CNS relapse risk with HD-MTX in DLBCL patients aged 18-70 years treated in Alberta, Canada between 2012 and 2019. Provincial guidelines recommended HD-MTX for patients at high-risk of CNS relapse based upon CNS-IPI score, double-hit lymphoma, or testicular involvement. Among 906 patients with median follow-up 35.3 months (range 0.29-105.7), CNS relapse occurred in 1.9% with CNS-IPI 0-1, 4.9% with CNS-IPI 2-3, and 12.2% with CNS-IPI 4-6 (p < .001). HD-MTX was administered to 115/326 (35.3%) high-risk patients, of whom 96 (83.5%) had CNS-IPI score 4-6, 45 (39.1%) had double-hit lymphoma, and four (3.5%) had testicular lymphoma. The median number of HD-MTX doses was two (range 1-3). Central nervous system relapse risk was similar with versus without HD-MTX (11.2% vs. 12.2%, p = .82) and comparable to previous reports of high-risk patients who did not receive CNS prophylaxis (10-12%). In multivariate and propensity score analyses, HD-MTX demonstrated no association with CNS relapse, progression-free survival, or overall survival. This study did not demonstrate a benefit of prophylactic HD-MTX in this high-risk patient population. Further study is required to determine the optimal strategy to prevent CNS relapse in DLBCL.
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Affiliation(s)
- Robert Puckrin
- Postgraduate Medical Education, University of Calgary, Calgary, Alberta, Canada
| | - Haidar El Darsa
- Postgraduate Medical Education, University of Alberta, Edmonton, Alberta, Canada
| | - Sunita Ghosh
- Alberta Health Services Cancer Control Alberta, Edmonton, Alberta, Canada
| | - Anthea Peters
- University of Alberta and Cancer Cross Institute, Edmonton, Alberta, Canada
| | - Carolyn Owen
- University of Calgary and Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Douglas Stewart
- University of Calgary and Tom Baker Cancer Centre, Calgary, Alberta, Canada
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Levins KJ, Khan M, Drago T, Roman E, Suiter C, Nasa A, Roddy DW, Murphy P. Blame it on the pump. Clin Case Rep 2021; 9:e04195. [PMID: 34136231 PMCID: PMC8190513 DOI: 10.1002/ccr3.4195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 03/17/2021] [Accepted: 04/06/2021] [Indexed: 11/24/2022] Open
Abstract
Although intrathecal pumps may lead to spinal symptoms that are likely related to the pump itself, the case presented herein underscores the importance of casting a broad differential diagnosis at the time of initial presentation.
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Affiliation(s)
- Kirk John Levins
- Department of Anaesthesia, Intensive Care and Pain MedicineSt. Vincent’s University HospitalDublin 4Ireland
| | - Mohamed Khan
- Department of HaematologyUniversity Hospital LimerickDooradoyleIreland
| | - Thomas Drago
- Trinity College Institute of NeuroscienceTrinity College DublinDublin 2Ireland
| | | | - Cillian Suiter
- Department of Anaesthesia, Intensive Care and Pain MedicineSt. Vincent’s University HospitalDublin 4Ireland
| | - Anurag Nasa
- Trinity College Institute of NeuroscienceTrinity College DublinDublin 2Ireland
| | | | - Paul Murphy
- Department of Anaesthesia, Intensive Care and Pain MedicineSt. Vincent’s University HospitalDublin 4Ireland
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Roschewski M. Central nervous system prophylaxis in diffuse large B-cell lymphoma: a race to the bottom. Haematologica 2021; 106:332-334. [PMID: 33522784 PMCID: PMC7849335 DOI: 10.3324/haematol.2020.266635] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Indexed: 01/04/2023] Open
Affiliation(s)
- Mark Roschewski
- Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD.
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Calimeri T, Ferreri AJM. Prevention of CNS relapse in diffuse large B-cell lymphoma: common sense prevails where science fails. Br J Haematol 2020; 190:645-647. [PMID: 32394433 DOI: 10.1111/bjh.16719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/13/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Teresa Calimeri
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Andrés J M Ferreri
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milano, Italy
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