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von Roemeling C, Ferreri AJM, Soussain C, Tun HW, Grommes C. Targets and treatments in primary CNS lymphoma. Leuk Lymphoma 2024; 65:1055-1067. [PMID: 38659230 DOI: 10.1080/10428194.2024.2342560] [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: 02/29/2024] [Accepted: 04/08/2024] [Indexed: 04/26/2024]
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare and highly aggressive lymphoma entirely localized in the central nervous system or vitreoretinal space. PCNSL generally initially responds to methotrexate-containing chemotherapy regimens, but progressive or relapsing disease is common, and the prognosis is poor for relapsed or refractory (R/R) patients. PCNSL is often characterized by activation of nuclear factor kappa B (NF-κB) due to mutations in the B-cell receptor (BCR) or toll-like receptor (TLR) pathways, as well as immune evasion. Targeted treatments that inhibit key PCNSL mechanisms and pathways are being evaluated; inhibition of Bruton's tyrosine kinase (BTK) downstream of BCR activation has demonstrated promising results in treating R/R disease. This review will summarize the evidence and potential for targeted therapeutic agents to improve treatment outcomes in PCNSL. This includes immunotherapeutic and immunomodulatory approaches and inhibitors of the key pathways driving PCNSL, such as aberrant BCR and TLR signaling.
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Affiliation(s)
- Christina von Roemeling
- Preston A. Wells Center for Brain Tumor Therapy, Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Andrés J M Ferreri
- Department of Onco-Hematology, University Vita-Salute San Raffaele, Milano, Italy
- Department of Onco-Hematology, Lymphoma Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Carole Soussain
- Institut Curie, Service d'Hématologie, site de Saint-Cloud, France
- INSERM U932, Institut Curie, PSL Research University, Paris, France
| | - Han W Tun
- Department of Hematology, Mayo Clinic, Jacksonville, Florida, USA
| | - Christian Grommes
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Neurology, Weill Cornell Medical College, New York, New York, USA
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Choquet S, Soussain C, Azar N, Morel V, Metz C, Ursu R, Waultier-Rascalou A, di Blasi R, Houot R, Souchet L, Roos-Weil D, Uzunov M, Quoc SN, Jacque N, Boussen I, Gauthier N, Ouzegdouh M, Blonski M, Campidelli A, Ahle G, Guffroy B, Willems L, Corvilain E, Barrie M, Alcantara M, le Garff-Tavernier M, Psimaras D, Weiss N, Baron M, Bravetti C, Hoang-Xuan K, Davi F, Shor N, Alentorn A, Houillier C. CAR T-cell therapy induces a high rate of prolonged remission in relapsed primary CNS lymphoma: Real-life results of the LOC network. Am J Hematol 2024; 99:1240-1249. [PMID: 38586986 DOI: 10.1002/ajh.27316] [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: 11/27/2023] [Revised: 02/24/2024] [Accepted: 03/26/2024] [Indexed: 04/09/2024]
Abstract
The prognosis of relapsed primary central nervous system lymphoma (PCNSL) remains dismal. CAR T-cells are a major contributor to systemic lymphomas, but their use in PCNSL is limited. From the LOC network database, we retrospectively selected PCNSL who had leukapheresis for CAR-T cells from the third line of treatment, and, as controls, PCNSL treated with any treatment, at least in the third line and considered not eligible for ASCT. Twenty-seven patients (median age: 68, median of three previous lines, including ASCT in 14/27) had leukapheresis, of whom 25 received CAR T-cells (tisa-cel: N = 16, axi-cel: N = 9) between 2020 and 2023. All but one received a bridging therapy. The median follow-up after leukapheresis was 20.8 months. The best response after CAR-T cells was complete response in 16 patients (64%). One-year progression-free survival from leukapheresis was 43% with a plateau afterward. One-year relapse-free survival was 79% for patients in complete or partial response at CAR T-cell infusion. The median overall survival was 21.2 months. Twenty-three patients experienced a cytokine release syndrome and 17/25 patients (68%) a neurotoxicity (five grade ≥3). The efficacy endpoints were significantly better in the CAR T-cell group than in the control group (N = 247) (median PFS: 3 months; median OS: 4.7 months; p < 0.001). This series represents the largest cohort of PCNSL treated with CAR T-cells reported worldwide. CAR T-cells are effective in relapsed PCNSL, with a high rate of long-term remission and a reassuring tolerance profile. The results seem clearly superior to those usually observed in this setting.
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Affiliation(s)
- Sylvain Choquet
- Service d'Hématologie Clinique, Groupe Hospitalier Pitié-Salpêtrière, APHP-Sorbonne Université, Paris, France
| | - Carole Soussain
- Service d'Hématologie Clinique, Institut Curie, site de Saint Cloud, France and INSERM U932, Institut Curie, PSL Research University, Paris, France
| | - Nabih Azar
- Service d'Hématologie Clinique, Groupe Hospitalier Pitié-Salpêtrière, APHP-Sorbonne Université, Paris, France
| | - Véronique Morel
- Service d'Hématologie Clinique, Groupe Hospitalier Pitié-Salpêtrière, APHP-Sorbonne Université, Paris, France
| | - Carole Metz
- Unité REQPHARM, pharmacie à usage intérieur, Groupe Hospitalier Pitié-Salpêtrière, APHP, Paris, France
| | - Renata Ursu
- Service de Neurologie, Université de Paris Cité, APHP, Hôpital Saint Louis, Paris, France
| | | | - Roberta di Blasi
- Service d'Oncohématologie, Université de Paris Cité, APHP, Hôpital Saint Louis, Paris, France
| | - Roch Houot
- Service d'Hématologie Clinique, Centre Hospitalier Universitaire de Rennes, UMR U1236, INSERM Université de Rennes, Etablissement Français du Sang, Rennes, France
| | - Laetitia Souchet
- Service d'Hématologie Clinique, Groupe Hospitalier Pitié-Salpêtrière, APHP-Sorbonne Université, Paris, France
| | - Damien Roos-Weil
- Service d'Hématologie Clinique, Groupe Hospitalier Pitié-Salpêtrière, APHP-Sorbonne Université, Paris, France
| | - Madalina Uzunov
- Service d'Hématologie Clinique, Groupe Hospitalier Pitié-Salpêtrière, APHP-Sorbonne Université, Paris, France
| | - Stéphanie Nguyen Quoc
- Service d'Hématologie Clinique, Groupe Hospitalier Pitié-Salpêtrière, APHP-Sorbonne Université, Paris, France
| | - Nathalie Jacque
- Service d'Hématologie Clinique, Groupe Hospitalier Pitié-Salpêtrière, APHP-Sorbonne Université, Paris, France
| | - Inès Boussen
- Service d'Hématologie Clinique, Groupe Hospitalier Pitié-Salpêtrière, APHP-Sorbonne Université, Paris, France
| | - Nicolas Gauthier
- Service d'Hématologie Clinique, Groupe Hospitalier Pitié-Salpêtrière, APHP-Sorbonne Université, Paris, France
| | - Maya Ouzegdouh
- Service d'Hématologie Clinique, Groupe Hospitalier Pitié-Salpêtrière, APHP-Sorbonne Université, Paris, France
| | - Marie Blonski
- Service de Neuro-Oncologie, Centre Hospitalier Régional Universitaire (CHRU), Université de Lorraine, Centre de Recherche en Automatique de Nancy CRAN UMR 7039, CNRS, Nancy, France
| | - Arnaud Campidelli
- Service d'Hématologie Clinique, Hôpital Brabois, Centre Hospitalier Régional Universitaire (CHRU), Nancy, CNRS UMR 7563, Biopôle de l'Université de Lorraine, Vandoeuvre les Nancy, France
| | - Guido Ahle
- Service de Neurologie, Hôpital Pasteur-Hôpitaux civils de Colmar, France
| | - Blandine Guffroy
- Service d'Hématologie Clinique, Institut de Cancérologie Strasbourg Europe, Strasbourg, France
| | - Lise Willems
- Service d'Hématologie Clinique, Hôpital Cochin, APHP, Paris, France
| | - Emilie Corvilain
- Service d'Immunologie Clinique, Hôpital Saint Louis, APHP, Université de Paris, Paris, France
| | - Maryline Barrie
- Service de Neuro-oncologie, Assistance Publique-Hôpitaux de Marseille (AP-HM), Hôpital de la Timone, Marseille, France
| | - Marion Alcantara
- Service d'Hématologie Clinique, Institut Curie, site de Saint Cloud, France and INSERM U932, Institut Curie, PSL Research University, Paris, France
| | - Magali le Garff-Tavernier
- Service d'Hématologie Biologique, Groupe Hospitalier Pitié-Salpêtrière, APHP-Sorbonne Université, Paris, France
| | - Dimitri Psimaras
- Service de Neurooncologie, Groupe Hospitalier Pitié-Salpêtrière, APHP, Sorbonne Université, INSERM, CNRS, UMR S 1127, ICM, IHU, Paris, France
| | - Nicolas Weiss
- AP-HP, Sorbonne Université, Hôpital de la Pitié-Salpêtrière, département de neurologie, unité de Médecine Intensive Réanimation à orientation neurologique, Paris, France
- Brain Liver Pitié-Salpêtrière (BLIPS) Study Group, INSERM UMR_S 938, Centre de recherche Saint-Antoine, Maladies métaboliques, biliaires et fibro-inflammatoire du foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
- Groupe de Recherche Clinique en REanimation et Soins intensifs du Patient en Insuffisance Respiratoire aiguE (GRC-RESPIRE), Sorbonne Université, Paris, France
| | - Marine Baron
- Service d'Hématologie Clinique, Groupe Hospitalier Pitié-Salpêtrière, APHP-Sorbonne Université, Paris, France
| | - Clotilde Bravetti
- Service d'Hématologie Biologique, Groupe Hospitalier Pitié-Salpêtrière, APHP-Sorbonne Université, Paris, France
| | - Khê Hoang-Xuan
- Service de Neurooncologie, Groupe Hospitalier Pitié-Salpêtrière, APHP, Sorbonne Université, INSERM, CNRS, UMR S 1127, ICM, IHU, Paris, France
| | - Frédéric Davi
- Service d'Hématologie Biologique, Groupe Hospitalier Pitié-Salpêtrière, APHP-Sorbonne Université, Paris, France
| | - Natalia Shor
- Service de Neuroradiologie, Groupe Hospitalier Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
| | - Agusti Alentorn
- Service de Neurooncologie, Groupe Hospitalier Pitié-Salpêtrière, APHP, Sorbonne Université, INSERM, CNRS, UMR S 1127, ICM, IHU, Paris, France
| | - Caroline Houillier
- Service de Neurooncologie, Groupe Hospitalier Pitié-Salpêtrière, APHP, Sorbonne Université, INSERM, CNRS, UMR S 1127, ICM, IHU, Paris, France
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Wu J, Zhou D, Zhu X, Zhang Y, Xiao Y. Updates of primary central nervous system lymphoma. Ther Adv Hematol 2024; 15:20406207241259010. [PMID: 38883164 PMCID: PMC11177745 DOI: 10.1177/20406207241259010] [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: 12/17/2023] [Accepted: 05/16/2024] [Indexed: 06/18/2024] Open
Abstract
Lymphoma occurring in the central nervous system is considered primary central nervous system lymphoma (PCNSL), usually without systematic lesions. Over the last few decades, a deep understanding of PCNSL has been lacking due to the low incidence rate, and the overall survival and progression-free survival of patients with PCNSL are lower than those with other types of non-Hodgkin lymphoma. Recently, there have been several advancements in research on PCNSL. Advances in diagnosis of the disease are primarily reflected in the promising diagnostic efficiency of novel biomarkers. Pathogenesis mainly involves abnormal activation of nuclear factor kappa-B signaling pathways, copy number variations, and DNA methylation. Novel therapies such as Bruton's tyrosine kinase inhibitors, immunomodulatory drugs, immune checkpoint inhibitors, and phosphoinositide 3-kinase/mammalian target of rapamycin inhibitors are being evaluated as possible treatment options for PCNSL, especially for relapsed/refractory (R/R) cases. Several clinical trials also indicated the promising feasibility and efficacy of chimeric antigen receptor T-cell therapy for selected R/R PCNSL patients. This review focuses on discussing recent updates, including the diagnosis, pathogenesis, and novel therapy of PCNSL.
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Affiliation(s)
- Jiaying Wu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Delian Zhou
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiaojian Zhu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology. No. 1095 Jiefang Avenue, Qiaokou District, Wuhan, Hubei 430030, China
| | - Yicheng Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology. No. 1095 Jiefang Avenue, Qiaokou District, Wuhan, Hubei 430030, China
| | - Yi Xiao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology. No. 1095 Jiefang Avenue, Qiaokou District, Wuhan, Hubei 430030, China
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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. 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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5
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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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Roschewski M, Hodson DJ. Diffuse large B-cell lymphoma involving the central nervous system: biologic rationale for targeted therapy. Haematologica 2024; 109:388-400. [PMID: 37706315 PMCID: PMC10828633 DOI: 10.3324/haematol.2021.278613] [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: 05/03/2023] [Accepted: 09/04/2023] [Indexed: 09/15/2023] Open
Abstract
Diffuse large B-cell lymphoma (DLBCL) is an aggressive B-cell lymphoma curable even in advanced stages. DLBCL involving the central nervous system (CNS) is more difficult to cure and fewer treatment options exist. Primary CNS lymphoma (PCNSL) refers to aggressive lymphomas confined to the CNS, and are almost always DLBCL. Standard approaches for PCNSL use high-dose methotrexate-based combinations as induction therapy and younger patients often receive dose-intensive consolidation. However, dose-intensive therapies are not suitable for all patients, and older patients have fewer effective treatment options. Patients with relapsed or chemotherapy-refractory disease have a very poor prognosis. Secondary CNS lymphoma (SCNSL) describes aggressive lymphomas involving the CNS at initial presentation or relapses within the CNS after treatment for systemic DLBCL. Isolated CNS relapse is often managed as PCNSL, but patients with synchronous involvement of DLBCL in both the periphery and the CNS pose a unique clinical challenge. Insights into the molecular circuitry of DLBCL have identified distinct genetic subtypes including cases with a predilection for CNS invasion. PCNSL and subsets of SCNSL are characterized by chronically activated B-cell receptor and NFκB signaling along with genetic evidence of immune evasion which may be exploited therapeutically. Improved mechanistic understanding of targetable pathways underpinning CNS lymphomas has led to numerous clinical trials testing targeted agent combinations and immunotherapy approaches with promising early results. Biologically rational strategies may further improve the cure rate of CNS lymphomas, either by overcoming intrinsic or acquired treatment resistance and/or by being broadly applicable to patients of all ages.
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Affiliation(s)
- Mark Roschewski
- Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer nstitute, Bethesda, MD, 20892.
| | - Daniel J Hodson
- Wellcome MRC Cambridge Stem Cell Institute, University of Cambridge, Cambridge Biomedical Campus, Cambridge.
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7
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Seidel S, Kaulen L, von Baumgarten L. [New treatment strategies for primary lymphoma of the central nervous system]. DER NERVENARZT 2024; 95:117-124. [PMID: 37910181 DOI: 10.1007/s00115-023-01561-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/21/2023] [Indexed: 11/03/2023]
Abstract
Primary central nervous system lymphomas (PCNSL) are rare highly aggressive diffuse large B cell non-Hodgkin lymphomas confined to the brain, meninges, the spinal cord and the eyes. Although the implementation of high-dose methotrexate-based chemotherapy has significantly improved the prognosis of PCNSL during the last decades, about one third of patients show refractory disease and about half of the patients eventually relapse after having achieved complete response. This highlights the need for novel treatment strategies. The most promising progress has been made in the field of molecular targeted therapy that interferes with the oncogenic signaling pathways of PCNSL. These include inhibitors of Bruton tyrosine kinase and inhibitors of the PI3K/mTOR signaling pathway. In addition, the thalidomide analogues lenalidomide and pomalidomide, which belong to the class of immunomodulators, show efficacy in the treatment of PCNSL. As immune evasion appears to play a relevant pathogenetic role in PCNSL, immunotherapies in the treatment of PCNSL are the subject of intensive research. Promising initial clinical data are available for both immune checkpoint inhibitors and cellular immunotherapy with chimeric antigen receptor (CAR) T cells. Before the widespread clinical application of these novel therapies, the efficacy needs to be confirmed in larger prospective studies. Despite high response rates, targeted therapies and immunotherapy often fail to achieve lasting tumor control. Therefore, novel approaches are currently being investigated in combination protocols.
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Affiliation(s)
- Sabine Seidel
- Neurologische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Deutschland
| | - Leon Kaulen
- Neurologische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
- Klinische Kooperationseinheit Neuro-Onkologie, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Deutschland
| | - Louisa von Baumgarten
- Neurochirurgische Klinik, Ludwig Maximilians Universitätsklinikum München, München, Deutschland.
- Neuroonkologisches Zentrum der Neurochirurgische Klinik, Ludwig Maximilians Universitätsklinikum München, Marchioninistr. 15, 81377, München, Deutschland.
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8
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Ihlamur M, Akgul B, Zengin Y, Korkut ŞV, Kelleci K, Abamor EŞ. The mTOR Signaling Pathway and mTOR Inhibitors in Cancer: Next-generation Inhibitors and Approaches. Curr Mol Med 2024; 24:478-494. [PMID: 37165594 DOI: 10.2174/1566524023666230509161645] [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: 07/21/2022] [Revised: 02/03/2023] [Accepted: 02/07/2023] [Indexed: 05/12/2023]
Abstract
mTOR is a serine/threonine kinase that plays various roles in cell growth, proliferation, and metabolism. mTOR signaling in cancer becomes irregular. Therefore, drugs targeting mTOR have been developed. Although mTOR inhibitors rapamycin and rapamycin rapalogs (everolimus, rapamycin, temsirolimus, deforolimus, etc.) and new generation mTOR inhibitors (Rapalink, Dual PI3K/mTOR inhibitors, etc.) are used in cancer treatments, mTOR resistance mechanisms may inhibit the efficacy of these drugs. Therefore, new inhibition approaches are developed. Although these new inhibition approaches have not been widely investigated in cancer treatment, the use of nanoparticles has been evaluated as a new treatment option in a few types of cancer. This review outlines the functions of mTOR in the cancer process, its resistance mechanisms, and the efficiency of mTOR inhibitors in cancer treatment. Furthermore, it discusses the next-generation mTOR inhibitors and inhibition strategies created using nanoparticles. Since mTOR resistance mechanisms prevent the effects of mTOR inhibitors used in cancer treatments, new inhibition strategies should be developed. Inhibition approaches are created using nanoparticles, and one of them offers a promising treatment option with evidence supporting its effectiveness.
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Affiliation(s)
- Murat Ihlamur
- Department of Bioengineering, Faculty of Chemical and Metallurgical Engineering, Yildiz Technical University, Istanbul, Turkey
- Department of Electronics and Automation, Biruni University, Istanbul, Turkey
| | - Busra Akgul
- Department of Bioengineering, Faculty of Chemical and Metallurgical Engineering, Yildiz Technical University, Istanbul, Turkey
| | - Yağmur Zengin
- Biomedical Engineering Institute, Department of Biomedical Engineering, Bogazici University, Istanbul, Turkey
| | - Şenay Vural Korkut
- Department of Molecular Biology and Genetics, Faculty of Arts and Sciences, Yildiz Technical University, Istanbul, Turkey
| | - Kübra Kelleci
- Department of Bioengineering, Faculty of Chemical and Metallurgical Engineering, Yildiz Technical University, Istanbul, Turkey
- Department of Medical Services and Techniques, Beykoz University, Istanbul, Turkey
| | - Emrah Şefik Abamor
- Department of Bioengineering, Faculty of Chemical and Metallurgical Engineering, Yildiz Technical University, Istanbul, Turkey
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Agostinelli C, Morandi L, Righi S, Cirillo L, Iommi M, Tonon C, Mazzatenta D, Zoli M, Rossi M, Bagnato G, Broccoli A, Lodi R, Zinzani PL, Sabattini E, Giannini C, Asioli S. Genomic Profiling of Primary Diffuse Large B-Cell Lymphoma of the Central Nervous System Suggests Novel Potential Therapeutic Targets. Mod Pathol 2023; 36:100323. [PMID: 37678673 DOI: 10.1016/j.modpat.2023.100323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 08/22/2023] [Accepted: 08/23/2023] [Indexed: 09/09/2023]
Abstract
Primary diffuse large B-cell lymphoma of the primary central nervous system (CNS-DLBCL) is an aggressive disease, with dismal prognosis despite the use of high-dose methotrexate-based polychemotherapy. Our study aimed to expand the biologic profiles of CNS-DLBCL and to correlate them with clinical/imaging findings to gain diagnostic insight and possibly identify new therapeutic targets. We selected 61 CNS-DLBCL whose formalin-fixed paraffin-embedded samples were available at first diagnosis. These were investigated by immunohistochemistry, cMYC rearrangements were explored by fluorescence in situ hybridization, and CNS-DLBCL mutated genes were evaluated by next-generation sequencing. CD10, BCL6, and IRF4 were observed in 16%, 83.6%, and 93% of cases, respectively. As typical of CNS lymphoma, 10 (16.4%) of 61 cases were classified as germinal center (GCB) type and 51 (83.6%) of 61 as non-germinal center (non-GCB) type according to the Hans algorithm. Double-expression status for BCL2 and cMYC was detected in 36 (59%) of 61 cases whereas 25 (41%) of 61 were non-DE. Rearrangement of the cMYC gene was detected in 2 cases, associated with BCL6 translocation only in 1 case MYD88, PIM1, CD79B, and TP53 were mutated in 54.5%, 53.5%, 30.2%, and 18.4% cases, respectively. Novel mutations not previously reported in CNS-DLBCL were found: AIP in 23.1%, PI3KCA in 15%, NOTCH1 in 11.4%, GNAS in 8.1%, CASP8 in 7.9%, EGFR in 6.4%, PTEN in 5.1, and KRAS in 2.6% of cases. Survival was significantly longer for patients with mutated MYD88 (8.7 months vs 1.7 months; log-rank test = 5.43; P = .020) and for patients with mutated CD79B (10.8 months vs 2.5 months; log-rank test = 4.64; P = .031). MYD88 and CD79B predicted a longer survival in patients affected by CNS-DLBCL. Notably, we identified novel mutations that enrich the mutational landscape of CNS-DLBCL, suggest a role of PTEN-PI3K-AKT and receptor tyrosine kinase-RAS-mitogen-activated protein kinase signaling in a subset of CNS-DLBCL, and provide new potential therapeutic targets.
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Affiliation(s)
- Claudio Agostinelli
- Haematopathology Unit, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Luca Morandi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Functional and Molecular Neuroimaging Unit, Bologna, Italy
| | - Simona Righi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Luigi Cirillo
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Functional and Molecular Neuroimaging Unit, Bologna, Italy
| | - Marica Iommi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Caterina Tonon
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Functional and Molecular Neuroimaging Unit, Bologna, Italy
| | - Diego Mazzatenta
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Center for the Diagnosis and Treatment of Hypothalamic-Pituitary Diseases, Pituitary Unit
| | - Matteo Zoli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Functional and Molecular Neuroimaging Unit, Bologna, Italy
| | - Maura Rossi
- Haematopathology Unit, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy
| | - Gianmarco Bagnato
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; IRCCS Azienda Ospedaliero-Universitaria di Bologna Istituto di Ematologia "Seràgnoli" Bologna Italy
| | - Alessandro Broccoli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; IRCCS Azienda Ospedaliero-Universitaria di Bologna Istituto di Ematologia "Seràgnoli" Bologna Italy
| | - Raffaele Lodi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Functional and Molecular Neuroimaging Unit, Bologna, Italy
| | - Pier Luigi Zinzani
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; IRCCS Azienda Ospedaliero-Universitaria di Bologna Istituto di Ematologia "Seràgnoli" Bologna Italy
| | - Elena Sabattini
- Haematopathology Unit, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy
| | - Caterina Giannini
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Sofia Asioli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Center for the Diagnosis and Treatment of Hypothalamic-Pituitary Diseases, Pituitary Unit.
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10
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Wang N, Mo Z, Pan L, Zhou M, Ye X, Liu X, Cai X, Qian C, Chen F, Xiong Y, Fan F, Li W. Dual PI3K/HDAC Inhibitor BEBT-908 Exhibits Potent Efficacy as Monotherapy for Primary Central Nervous System Lymphoma. Target Oncol 2023; 18:941-952. [PMID: 37855991 DOI: 10.1007/s11523-023-01006-z] [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] [Accepted: 10/02/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND The efficacy of systemic treatment for primary central nervous system lymphoma (PCNSL) is limited because of the blood-brain barrier (BBB) and the ineffectiveness of chemotherapy. The dual PI3K/HDAC inhibitor BEBT-908 has exhibited favorable in vivo distribution and activity in various cancers. OBJECTIVES The aims of this study were to assess the efficacy of BEBT-908 in brain orthotopic mouse models of hematological malignancies, to investigate its pharmacologic properties, and to elucidate the underlying mechanism of action. METHODS We evaluated the anticancer activity of BEBT-908 in various hematological malignancies through cell viability assays. The impact of BEBT-908 on c-Myc expression and ferroptosis signaling pathways was assessed using Western blotting, qPCR, ROS detection, GSH/GSSG detection, and IHC. Pharmacokinetic and pharmacodynamic profiles were assessed through LC-MS/MS and Western blotting. The effects of BEBT-908 in vivo were examined using xenografts and brain orthotopic mouse models. RESULTS Our findings demonstrate that BEBT-908 exhibits promising anti-tumor activity in vitro and in vivo across multiple subtypes of hematological malignancies. Furthermore, BEBT-908 exhibits excellent BBB penetration and inhibits tumor growth in a brain orthotopic lymphoma model with prolonged survival of host mice. Mechanistically, BEBT-908 downregulated c-Myc expression, which contributed to ferroptosis, ultimately leading to tumor shrinkage. CONCLUSION Our study provides robust evidence for the dual PI3K/HDAC inhibitor BEBT-908 as an effective anti-cancer agent for PCNSL.
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Affiliation(s)
- Ning Wang
- Guangdong Provincial People's Hospital Affiliated to Southern Medical University, Guangdong Academy of Medical Sciences, No. 123 Huifu West Road, Guangzhou, 510080, Guangdong, China
- School of Medicine, South China University of Technology, Guangzhou, China
| | - Zhenxian Mo
- Guangzhou BeBetter Med Inc., No. 25 Yayingshi Road, Guangzhou, 510660, Guangdong, China
- College of Life Science and Technology, Jinan University, 601 Huangpu Avenue West, Guangzhou, China
| | - Lu Pan
- Guangdong Provincial People's Hospital Affiliated to Southern Medical University, Guangdong Academy of Medical Sciences, No. 123 Huifu West Road, Guangzhou, 510080, Guangdong, China
- School of Medicine, South China University of Technology, Guangzhou, China
| | - Minhua Zhou
- Guangzhou BeBetter Med Inc., No. 25 Yayingshi Road, Guangzhou, 510660, Guangdong, China
| | - Xiaolan Ye
- Guangzhou BeBetter Med Inc., No. 25 Yayingshi Road, Guangzhou, 510660, Guangdong, China
| | - Xinjian Liu
- Guangzhou BeBetter Med Inc., No. 25 Yayingshi Road, Guangzhou, 510660, Guangdong, China
| | - Xiong Cai
- Guangzhou BeBetter Med Inc., No. 25 Yayingshi Road, Guangzhou, 510660, Guangdong, China
- Curis, Inc., Lexington, MA, USA
| | - Changgeng Qian
- Guangzhou BeBetter Med Inc., No. 25 Yayingshi Road, Guangzhou, 510660, Guangdong, China
- Curis, Inc., Lexington, MA, USA
| | - Feili Chen
- Guangdong Provincial People's Hospital Affiliated to Southern Medical University, Guangdong Academy of Medical Sciences, No. 123 Huifu West Road, Guangzhou, 510080, Guangdong, China
| | - Yan Xiong
- Guangzhou BeBetter Med Inc., No. 25 Yayingshi Road, Guangzhou, 510660, Guangdong, China
| | - Fushun Fan
- College of Pharmacy, Jinan University, 601 Huangpu Avenue West, Guangzhou, China.
- Guangzhou BeBetter Med Inc., No. 25 Yayingshi Road, Guangzhou, 510660, Guangdong, China.
| | - Wenyu Li
- Guangdong Provincial People's Hospital Affiliated to Southern Medical University, Guangdong Academy of Medical Sciences, No. 123 Huifu West Road, Guangzhou, 510080, Guangdong, China.
- School of Medicine, South China University of Technology, Guangzhou, China.
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11
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Yang H, Xun Y, Ke C, Tateishi K, You H. Extranodal lymphoma: pathogenesis, diagnosis and treatment. MOLECULAR BIOMEDICINE 2023; 4:29. [PMID: 37718386 PMCID: PMC10505605 DOI: 10.1186/s43556-023-00141-3] [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: 02/05/2023] [Accepted: 08/18/2023] [Indexed: 09/19/2023] Open
Abstract
Approximately 30% of lymphomas occur outside the lymph nodes, spleen, or bone marrow, and the incidence of extranodal lymphoma has been rising in the past decade. While traditional chemotherapy and radiation therapy can improve survival outcomes for certain patients, the prognosis for extranodal lymphoma patients remains unsatisfactory. Extranodal lymphomas in different anatomical sites often have distinct cellular origins, pathogenic mechanisms, and clinical manifestations, significantly influencing their diagnosis and treatment. Therefore, it is necessary to provide a comprehensive summary of the pathogenesis, diagnosis, and treatment progress of extranodal lymphoma overall and specifically for different anatomical sites. This review summarizes the current progress in the common key signaling pathways in the development of extranodal lymphomas and intervention therapy. Furthermore, it provides insights into the pathogenesis, diagnosis, and treatment strategies of common extranodal lymphomas, including gastric mucosa-associated lymphoid tissue (MALT) lymphoma, mycosis fungoides (MF), natural killer/T-cell lymphoma (nasal type, NKTCL-NT), and primary central nervous system lymphoma (PCNSL). Additionally, as PCNSL is one of the extranodal lymphomas with the worst prognosis, this review specifically summarizes prognostic indicators and discusses the challenges and opportunities related to its clinical applications. The aim of this review is to assist clinical physicians and researchers in understanding the current status of extranodal lymphomas, enabling them to make informed clinical decisions that contribute to improving patient prognosis.
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Affiliation(s)
- Hua Yang
- Department of Basic Medicine and Biomedical Engineering, School of Medicine, Foshan University, Foshan, 528000, China
| | - Yang Xun
- Department of Basic Medicine and Biomedical Engineering, School of Medicine, Foshan University, Foshan, 528000, China
| | - Chao Ke
- Department of Neurosurgery and Neuro-Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, China
| | - Kensuke Tateishi
- Department of Neurosurgery, Graduate School of Medicine, Yokohama City University, Yokohama, 2360004, Japan
| | - Hua You
- Laboratory for Excellence in Systems Biomedicine of Pediatric Oncology, Department of Pediatric Hematology and Oncology, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, National Clinical Research Center for Child Health and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, 401122, China.
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12
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Karatrasoglou EA, Dimou M, Piperidou A, Lakiotaki E, Korkolopoulou P, Vassilakopoulos TP. The Role of mTOR in B Cell Lymphoid Malignancies: Biologic and Therapeutic Aspects. Int J Mol Sci 2023; 24:14110. [PMID: 37762410 PMCID: PMC10531792 DOI: 10.3390/ijms241814110] [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: 08/11/2023] [Revised: 09/09/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
Non-Hodgkin lymphoma's (NHL) incidence is rising over time, and B cell lymphomas comprise the majority of lymphomas. The phosphoinositide 3-kinase (PI3K)/v-akt murine thymoma viral oncogene homologue 1 (Akt)/mammalian target of the rapamycin (mTOR) signaling pathway plays a critical role in a variety of cellular processes, such as cell proliferation and survival. Its role in lymphomagenesis is confirmed in many different types of B cell lymphomas. This review is mainly focused on the PI3K/v-akt/mTOR pathway-related oncogenic mechanisms in B cell NHLs with an emphasis on common B cell lymphoma types [diffuse large B cell lymphoma (DLBCL) and mantle cell lymphoma (MCL)]. Furthermore, it summarizes the literature regarding the clinical applications of the mTOR inhibitors temsirolimus and everolimus in B cell NHLs, which have been tested in a range of clinical trials enrolling patients with B cell malignancies, either as monotherapy or in combination with other agents or regimens.
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Affiliation(s)
- Eleni A. Karatrasoglou
- First Department of Pathology, National and Kapodistrian University of Athens, Laikon General Hospital, 15773 Athens, Greece; (E.L.); (P.K.)
| | - Maria Dimou
- Department of Hematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, Laikon General Hospital, 15773 Athens, Greece; (M.D.); (A.P.); (T.P.V.)
| | - Alexia Piperidou
- Department of Hematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, Laikon General Hospital, 15773 Athens, Greece; (M.D.); (A.P.); (T.P.V.)
| | - Eleftheria Lakiotaki
- First Department of Pathology, National and Kapodistrian University of Athens, Laikon General Hospital, 15773 Athens, Greece; (E.L.); (P.K.)
| | - Penelope Korkolopoulou
- First Department of Pathology, National and Kapodistrian University of Athens, Laikon General Hospital, 15773 Athens, Greece; (E.L.); (P.K.)
| | - Theodoros P. Vassilakopoulos
- Department of Hematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, Laikon General Hospital, 15773 Athens, Greece; (M.D.); (A.P.); (T.P.V.)
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13
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Bertucci A, Harlay V, Chinot O, Tabouret E. Primary central nervous system lymphoma (PCNSL) in older patients. Curr Opin Oncol 2023; 35:373-381. [PMID: 37498077 DOI: 10.1097/cco.0000000000000981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Primary central nervous system lymphoma (PCNSL) is a rare, chemo and radio-sensitive tumor limited to the central nervous system. The incidence of PCSNL increases notably in the elderly population which represented approximately half of the patients. The limit of 'elderly' population remained debated and nonuniform, including 60 years as a cutoff for brain radiotherapy, 65 years for autologous stem-cell transplantation, and 70 years for the last clinical trials. Current therapeutic options include first line treatment based on high-dose methotrexate based polychemotherapy, consolidation chemotherapy, and adapted autologous stem cell transplantation for highly selected patients. At relapse, single agent targeted therapies or salvage chemotherapy followed by intensive consolidation are promising therapeutic options. Nevertheless, improving management of elderly patients is an urgent medical need that currently remains unresolved. OBJECTIVE We will focus on elderly patients with PCNSL and their specificities including clinical presentations, available therapeutic options and adaptations to be made. CONCLUSION To improve survival, it will be necessary to personalized and adapt the treatments, to each patient and his comorbidities, to increase their effectiveness and limit their toxicity in this frail population. Finally, inclusion of these patients in clinical trials is one of the major challenges to significantly change PCNSL elderly patient prognosis.
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Affiliation(s)
| | | | - Olivier Chinot
- APHM, CHU Timone, Service de Neurooncologie
- Aix-Marseille University, CNRS, INP, Inst Neurophysiopathol, Marseille, France
| | - Emeline Tabouret
- APHM, CHU Timone, Service de Neurooncologie
- Aix-Marseille University, CNRS, INP, Inst Neurophysiopathol, Marseille, France
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14
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Calimeri T, Steidl C, Fiore P, Ferreri AJM. New hopes in relapsed refractory primary central nervous system lymphoma. Curr Opin Oncol 2023; 35:364-372. [PMID: 37551946 DOI: 10.1097/cco.0000000000000980] [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: 08/09/2023]
Abstract
PURPOSE OF REVIEW Patients with relapsed/refractory primary central nervous system lymphoma (rrPCNSL) have poor prognosis, with a median survival after relapse of 6.8 months. In this review, we discuss the evolving landscape and the possible future directions related to this important unmet clinical need. RECENT FINDINGS The modern two-phase approach for newly diagnosed PCNSL based on an induction using high-dose methotrexate (HD-MTX) combinations and a subsequent consolidation, has significantly improved the outcome in this setting. However, this strategy is able to cure more or less 50% of patients. rrPCNSL patients have a very poor prognosis with a reported 5-year overall survival of 18%. Late relapses (after third year) and use of high-dose chemotherapy and autologous stem cell transplantation (HDT-ASCT) represent important factors associated with a better outcome in this setting. On the basis of the growing acquisition of knowledge on the molecular characteristics of PCNSL, the use of non-chemotherapeutic drugs such as bruton tyrosine kinase inhibitors (BTK-is), immunomodulatory drugs (IMiDs) and immune checkpoint blockers (ICBs) is increasing in the last years along with the introduction of novel approaches (CAR-T cells and blood--brain barrier disruption). However, despite high responses in some cases, durations are often short, translating in outcome results still unsatisfactory. SUMMARY Treatment of rrPCNSL patients is challenging. As no standard of care exist in this setting, it is of paramount importance to acquire new knowledge related to this condition and start multidisciplinary collaboration in order to improve pts outcome.
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Affiliation(s)
| | | | - Paolo Fiore
- Lymphoma Unit, IRCCS San Raffaele Scientific Institute
- University 'Vita-Salute San Raffaele', Milan, Italy
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15
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Grommes C, Pentsova E, Schaff LR, Nolan CP, Kaley T, Reiner AS, Panageas KS, Mellinghoff IK. Preclinical and clinical evaluation of Buparlisib (BKM120) in recurrent/refractory Central Nervous System Lymphoma. Leuk Lymphoma 2023; 64:1545-1553. [PMID: 37317993 PMCID: PMC10529084 DOI: 10.1080/10428194.2023.2223734] [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: 01/12/2023] [Revised: 04/07/2023] [Accepted: 05/30/2023] [Indexed: 06/16/2023]
Abstract
Central Nervous System (CNS) Lymphomas are aggressive brain tumors with limited treatment options. Targeting the phosphoinositide 3-kinase (PI3K) pathway yields promising responses across B-cell malignancies, but its therapeutic potential in CNS lymphomas remains unexplored. We present pre-clinical and clinical data on the pan-PI3K inhibitor Buparlisib in CNS lymphomas. In a primary CNS lymphoma-patient-derived cell line, we define the EC50. Four patients with recurrent CNS lymphoma were enrolled in a prospective trial. We evaluated Buparlisib plasma and cerebrospinal fluid pharmacokinetics, clinical outcomes, and adverse events. Treatment was well tolerated. Common toxicities include hyperglycemia, thrombocytopenia, and lymphopenia. The presence of Buparlisib in plasma and CSF was confirmed 2h post-treatment with a median CSF concentration below the EC50 defined in the cell line All four patients were evaluated for response and the median time to progression was 39 days. Buparlisib monotherapy did not lead to meaningful responses and the trial was prematurely stopped.Clinical Trial Registration: NCT02301364.
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Affiliation(s)
- Christian Grommes
- Department of Neurology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York NY 10065, USA
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York NY 10065, USA
- Department of Neurology, Weill Cornell Medical College, New York, NY 10021, USA
| | - Elena Pentsova
- Department of Neurology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York NY 10065, USA
- Department of Neurology, Weill Cornell Medical College, New York, NY 10021, USA
| | - Lauren R. Schaff
- Department of Neurology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York NY 10065, USA
- Department of Neurology, Weill Cornell Medical College, New York, NY 10021, USA
| | - Craig P Nolan
- Department of Neurology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York NY 10065, USA
- Department of Neurology, Weill Cornell Medical College, New York, NY 10021, USA
| | - Thomas Kaley
- Department of Neurology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York NY 10065, USA
- Department of Neurology, Weill Cornell Medical College, New York, NY 10021, USA
| | - Anne S Reiner
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York NY 10065, USA
| | - Katherine S Panageas
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York NY 10065, USA
| | - Ingo K Mellinghoff
- Department of Neurology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York NY 10065, USA
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York NY 10065, USA
- Department of Neurology, Weill Cornell Medical College, New York, NY 10021, USA
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16
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Glaviano A, Foo ASC, Lam HY, Yap KCH, Jacot W, Jones RH, Eng H, Nair MG, Makvandi P, Geoerger B, Kulke MH, Baird RD, Prabhu JS, Carbone D, Pecoraro C, Teh DBL, Sethi G, Cavalieri V, Lin KH, Javidi-Sharifi NR, Toska E, Davids MS, Brown JR, Diana P, Stebbing J, Fruman DA, Kumar AP. PI3K/AKT/mTOR signaling transduction pathway and targeted therapies in cancer. Mol Cancer 2023; 22:138. [PMID: 37596643 PMCID: PMC10436543 DOI: 10.1186/s12943-023-01827-6] [Citation(s) in RCA: 143] [Impact Index Per Article: 143.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 07/18/2023] [Indexed: 08/20/2023] Open
Abstract
The PI3K/AKT/mTOR (PAM) signaling pathway is a highly conserved signal transduction network in eukaryotic cells that promotes cell survival, cell growth, and cell cycle progression. Growth factor signalling to transcription factors in the PAM axis is highly regulated by multiple cross-interactions with several other signaling pathways, and dysregulation of signal transduction can predispose to cancer development. The PAM axis is the most frequently activated signaling pathway in human cancer and is often implicated in resistance to anticancer therapies. Dysfunction of components of this pathway such as hyperactivity of PI3K, loss of function of PTEN, and gain-of-function of AKT, are notorious drivers of treatment resistance and disease progression in cancer. In this review we highlight the major dysregulations in the PAM signaling pathway in cancer, and discuss the results of PI3K, AKT and mTOR inhibitors as monotherapy and in co-administation with other antineoplastic agents in clinical trials as a strategy for overcoming treatment resistance. Finally, the major mechanisms of resistance to PAM signaling targeted therapies, including PAM signaling in immunology and immunotherapies are also discussed.
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Affiliation(s)
- Antonino Glaviano
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies, University of Palermo, 90123, Palermo, Italy
| | - Aaron S C Foo
- Department of Surgery, National University Hospital Singapore, National University of Singapore, Singapore, Singapore
| | - Hiu Y Lam
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117600, Singapore
- NUS Centre for Cancer Research (N2CR), Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 119077, Singapore
| | - Kenneth C H Yap
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117600, Singapore
- NUS Centre for Cancer Research (N2CR), Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 119077, Singapore
| | - William Jacot
- Department of Medical Oncology, Institut du Cancer de Montpellier, Inserm U1194, Montpellier University, Montpellier, France
| | - Robert H Jones
- Cardiff University and Velindre Cancer Centre, Museum Avenue, Cardiff, CF10 3AX, UK
| | - Huiyan Eng
- Department of Surgery, National University Hospital Singapore, National University of Singapore, Singapore, Singapore
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117600, Singapore
| | - Madhumathy G Nair
- Division of Molecular Medicine, St. John's Research Institute, St. John's Medical College, Bangalore, 560034, India
| | - Pooyan Makvandi
- The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, Quzhou, 324000, Zhejiang, China
| | - Birgit Geoerger
- Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Center, Inserm U1015, Université Paris-Saclay, Paris, France
| | - Matthew H Kulke
- Section of Hematology and Medical Oncology, Boston University and Boston Medical Center, Boston, MA, USA
| | - Richard D Baird
- Cancer Research UK Cambridge Centre, Hills Road, Cambridge, CB2 0QQ, UK
| | - Jyothi S Prabhu
- Division of Molecular Medicine, St. John's Research Institute, St. John's Medical College, Bangalore, 560034, India
| | - Daniela Carbone
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies, University of Palermo, 90123, Palermo, Italy
| | - Camilla Pecoraro
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies, University of Palermo, 90123, Palermo, Italy
| | - Daniel B L Teh
- Departments of Ophthalmology and Anatomy, Yong Loo Lin School of Medicine, National University of Singapore, and Neurobiology Programme, National University of Singapore, Singapore, Singapore
| | - Gautam Sethi
- Department of Surgery, National University Hospital Singapore, National University of Singapore, Singapore, Singapore
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117600, Singapore
| | - Vincenzo Cavalieri
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies, University of Palermo, 90123, Palermo, Italy
| | - Kevin H Lin
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | | | - Eneda Toska
- Department of Biochemistry and Molecular Biology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Matthew S Davids
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Jennifer R Brown
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Patrizia Diana
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies, University of Palermo, 90123, Palermo, Italy
| | - Justin Stebbing
- Division of Cancer, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK
| | - David A Fruman
- Department of Molecular Biology and Biochemistry, University of California, 216 Sprague Hall, Irvine, CA, USA
| | - Alan P Kumar
- Department of Surgery, National University Hospital Singapore, National University of Singapore, Singapore, Singapore.
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117600, Singapore.
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17
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Chien HC, Yeh LR, Hung KC, Lim SW, Cheng CY, Lee YC, Chen JH, Ko CC. Pretreatment diffusion-weighted imaging for prediction of relapsed and refractory primary central nervous system lymphoma. Front Neurol 2023; 14:1227607. [PMID: 37638189 PMCID: PMC10447899 DOI: 10.3389/fneur.2023.1227607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/28/2023] [Indexed: 08/29/2023] Open
Abstract
Objectives A subset of primary central nervous system lymphoma (PCNSL) has been shown to undergo an early relapsed/refractory (R/R) period after first-line chemotherapy. This study investigated the pretreatment clinical and MRI features to predict R/R in PCNSL, emphasizing the apparent diffusion coefficient (ADC) values in diffusion-weighted imaging (DWI). Methods This retrospective study investigated the pretreatment MRI features for predicting R/R in PCNSL. Only patients who had undergone complete preoperative and postoperative MRI follow-up studies were included. From January 2006 to December 2021, 52 patients from two medical institutions with a diagnosis of PCNSL were included (median follow-up time, 26.3 months). Among these, 24 (46.2%) had developed R/R (median time to relapse, 13 months). Cox proportional hazard regression analyses were performed to determine hazard ratios for all parameters. Results Significant predictors of R/R in PCNSL were female sex, complete response (CR) to first-line chemotherapy, and ADC value/ratio (p < 0.05). Cut-off points of ADC values and ADC ratios for prediction of R/R were 0.68 × 10-3 mm2/s and 0.97, with AUCs of 0.78 and 0.77, respectively (p < 0.05). Multivariate Cox proportional hazards analysis showed that failure of CR to first-line chemotherapy and low ADC values (<0.68 × 10-3 mm2/s) were significant risk factors for R/R, with hazard ratios of 5.22 and 14.45, respectively (p < 0.05). Kaplan-Meier analysis showed that lower ADC values and ratios predicted significantly shorter progression-free survival (p < 0.05). Conclusion Pretreatment ADC values in DWI offer quantitative valuable information for the treatment planning in PCNSL.
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Affiliation(s)
- Hsi-Cheng Chien
- Department of Medical Imaging, Chi Mei Medical Center, Tainan, Taiwan
| | - Lee-Ren Yeh
- Department of Medical Imaging, E-Da Hospital, Kaohsiung, Taiwan
- Department of Medical Imaging and Radiological Sciences, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
- Department of Hospital and Health Care Administration, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Sher-Wei Lim
- Department of Neurosurgery, Chi Mei Medical Center, Chiali, Tainan, Taiwan
- Department of Nursing, Min-Hwei College of Health Care Management, Tainan, Taiwan
| | - Chung-Yu Cheng
- Department of Medical Imaging, E-Da Hospital, Kaohsiung, Taiwan
| | - Yu-Chang Lee
- Department of Medical Imaging, E-Da Hospital, Kaohsiung, Taiwan
| | - Jeon-Hor Chen
- Department of Medical Imaging, E-Da Hospital, Kaohsiung, Taiwan
- Department of Radiological Sciences, University of California, Irvine, Irvine, CA, United States
| | - Ching-Chung Ko
- Department of Medical Imaging, Chi Mei Medical Center, Tainan, Taiwan
- Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
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18
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Sun X, Lv L, Wu Y, Cui Q, Sun S, Ji N, Liu Y. Challenges in the management of primary central nervous system lymphoma. Crit Rev Oncol Hematol 2023:104042. [PMID: 37277008 DOI: 10.1016/j.critrevonc.2023.104042] [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: 09/08/2022] [Revised: 03/24/2023] [Accepted: 05/30/2023] [Indexed: 06/07/2023] Open
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare extranodal non-Hodgkin lymphoma. Stereotactic biopsy remains the gold standard for the pathological diagnosis of PCNSL. However, certain new auxiliary diagnostic methods are considered to have good application prospects; these include cytokine and tumor circulating DNA, among others. Although new drugs such as immunomodulators, immune checkpoint inhibitors, chimeric antigen receptor T-cells, and Bruton tyrosine kinase inhibitors have brought hope owing to their improved efficacy, the high recurrence rate and subsequent high mortality remain barriers to long-term survival. Increasing emphasis is therefore being placed on consolidation treatments. Consolidation treatment strategies include whole brain radiotherapy, autologous hematopoietic stem cell transplantation, and non-myeloablative chemotherapy. As studies directly comparing the effectiveness and safety of different consolidation treatment schemes are lacking, the optimal consolidation strategy remains uncertain. This article will review the diagnosis and treatment of PCNSL, focusing on the progress in research pertaining to consolidation therapy.
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Affiliation(s)
- Xuefei Sun
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liwei Lv
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuchen Wu
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qu Cui
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shengjun Sun
- Neuroimaging Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Nan Ji
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuanbo Liu
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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19
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Rachdi A, Hernandez-Tost H, Herzi D, Morales-Martinez A, Hernández-Verdin I, Houillier C, Alentorn A, Hoang-Xuan K. Recent advances in the diagnosis and the treatment of primary CNS lymphoma. Rev Neurol (Paris) 2023; 179:481-489. [PMID: 37045615 DOI: 10.1016/j.neurol.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/11/2023] [Indexed: 04/14/2023]
Abstract
This review focuses on the recent progress in the management of primary central nervous system lymphoma (PCNSL). Multiomic analyses allowed to better understand the tumorigenesis of PCNSL and to establish a molecular classification with prognostic value that will optimize patient management and guide future targeted approaches. Cooperative clinical trials have demonstrated the feasibility and efficacy, in selected fit patients, of high-dose chemotherapy with autologous stem cell transplantation as post-induction consolidation, that will progressively replace whole brain radiotherapy associated with a much higher risk of delayed neurotoxicity. Several novel treatments have shown efficacy and overall good tolerance in PCNSL patients, such as Bruton's tyrosine kinase (BTK) inhibitors, imids, immune checkpoint inhibitors and chimeric antigen receptor T-cells (CAR-T). This opens promising therapeutic perspectives to improve the current standard treatment, especially for elderly and unfit patients who represent a growing population.
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Affiliation(s)
- A Rachdi
- Service de neurologie 2, CHU Pitié-Salpêtrière, AP-HP, Sorbonne université, 47, boulevard de l'hôpital, 75013 Paris, France; Institut Mongi Ben Hamida de neurologie de Tunis, Tunis, Tunisia
| | - H Hernandez-Tost
- Service de neurologie 2, CHU Pitié-Salpêtrière, AP-HP, Sorbonne université, 47, boulevard de l'hôpital, 75013 Paris, France
| | - D Herzi
- Service de neurologie 2, CHU Pitié-Salpêtrière, AP-HP, Sorbonne université, 47, boulevard de l'hôpital, 75013 Paris, France
| | - A Morales-Martinez
- Service de neurologie 2, CHU Pitié-Salpêtrière, AP-HP, Sorbonne université, 47, boulevard de l'hôpital, 75013 Paris, France
| | | | - C Houillier
- Service de neurologie 2, CHU Pitié-Salpêtrière, AP-HP, Sorbonne université, 47, boulevard de l'hôpital, 75013 Paris, France; LOC network, France
| | - A Alentorn
- Service de neurologie 2, CHU Pitié-Salpêtrière, AP-HP, Sorbonne université, 47, boulevard de l'hôpital, 75013 Paris, France; Brain Institute-ICM, Inserm, Sorbonne université, CNRS, Paris, France; LOC network, France
| | - K Hoang-Xuan
- Service de neurologie 2, CHU Pitié-Salpêtrière, AP-HP, Sorbonne université, 47, boulevard de l'hôpital, 75013 Paris, France; Brain Institute-ICM, Inserm, Sorbonne université, CNRS, Paris, France; LOC network, France.
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20
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Seidel S, Kowalski T, Nilius-Eliliwi V, Schroers R, Schlegel U. Survival, prognostic factors, hospitalization time and clinical performance status after first cerebral relapse or progression in 54 patients with primary CNS lymphoma not eligible for high dose chemotherapy: a retrospective analysis. Neurol Res Pract 2023; 5:8. [PMID: 36814351 PMCID: PMC9948364 DOI: 10.1186/s42466-023-00234-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 02/08/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Treatment of relapsed or refractory primary CNS lymphoma (r/r PCNSL) is difficult, particularly in patients not eligible for high dose chemotherapy with autologous stem cell transplantation (HDC-ASCT). No standard treatment has been defined for these patients yet. METHODS We retrospectively analyzed survival, prognostic factors, hospitalization time and Karnofsky performance score (KPS) before and after treatment in 54 r/r PCNSL patients with isolated cerebral relapse or progression (n = 23 refractory, n = 31 relapsed) not eligible for HDC-ASCT, who received heterogenous salvage treatments. RESULTS Treatments were temozolomide (+ rituximab) (n = 21), high dose methotrexate (HD-MTX)-based therapy (n = 11), whole brain radiotherapy (WBRT)/focal radiotherapy (n = 11), other systemic treatments (n = 2) and best supportive care (BSC, n = 9). Median progression free survival (PFS) and overall survival (OS) were 2.6 months (95% CI 1.0-4.2 months) and 4.8 months (95% CI 3.3-6.3 months), respectively. Eight patients survived for ≥ 3 years (13.1%, n = 3 received temozolomide, n = 3 WBRT, n = 2 HD-MTX-based treatment). Application of any salvage treatment (vs. BSC), younger age at relapse and asymptomatic (vs. symptomatic) relapse were positive prognostic factors. No significant differences in OS were found for the different salvage treatments. Median hospitalization time for treatment was 15/13 days for temozolomide (+ rituximab)/radiotherapy compared to 55 days for HD-MTX-based therapy. Median KPS in assessable patients (n = 41) was 60 (range 30-100) before treatment and 50 (range 20-90) after treatment. In patients with response to treatment (n = 16) KPS improved from 60 (range 40-90) before treatment to 70 (range 50-90) after treatment, while patients with PD (n = 25) deteriorated from 60 (range 30-100) to 40 (range 20-70). CONCLUSION Survival for this cohort of r/r PCNSL patients with isolated cerebral relapse or progression was poor. Considering long hospital stays associated with HD-MTX-based chemotherapy and neurotoxicity associated with WBRT, temozolomide might be worth considering with a chance of prolonged survival and avoidance of long hospitalization. Novel therapeutic agents are urgently needed to improve survival in r/r PCNSL patients.
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Affiliation(s)
- Sabine Seidel
- Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23-25, 44892, Bochum, Germany.
| | - Thomas Kowalski
- grid.5570.70000 0004 0490 981XDepartment of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23-25, 44892 Bochum, Germany
| | - Verena Nilius-Eliliwi
- grid.5570.70000 0004 0490 981XDepartment of Hematology and Oncology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23-25, 44892 Bochum, Germany
| | - Roland Schroers
- grid.5570.70000 0004 0490 981XDepartment of Hematology and Oncology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23-25, 44892 Bochum, Germany
| | - Uwe Schlegel
- grid.5570.70000 0004 0490 981XDepartment of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23-25, 44892 Bochum, Germany
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21
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Bagal B, Sarma R, Dey S, Nayak L, Bonda A, Goda J, Khanna N, Dasgupta A, Kakoti S, Chatarjee A, Jain H, Epari S, Laskar S, Sengar M, Gupta T. Lenalidomide following whole-brain radiotherapy in patients with primary central nervous system lymphoma ineligible for intensive systemic therapy. Br J Haematol 2023; 201:150-153. [PMID: 36682363 DOI: 10.1111/bjh.18659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/31/2022] [Accepted: 01/08/2023] [Indexed: 01/24/2023]
Affiliation(s)
- Bhausaheb Bagal
- Medical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India
| | - Rup Sarma
- Medical Oncology, Tata Memorial Centre, Mumbai, India
| | - Sayak Dey
- Medical Oncology, Tata Memorial Centre, Mumbai, India
| | - Lingaraj Nayak
- Medical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India
| | - Avinash Bonda
- Medical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India
| | - Jayant Goda
- Medical Oncology, Tata Memorial Centre, Mumbai, India.,Radiation Oncology, Tata Memorial Centre, Mumbai, India
| | - Nehal Khanna
- Medical Oncology, Tata Memorial Centre, Mumbai, India.,Radiation Oncology, Tata Memorial Centre, Mumbai, India
| | - Archya Dasgupta
- Medical Oncology, Tata Memorial Centre, Mumbai, India.,Radiation Oncology, Tata Memorial Centre, Mumbai, India
| | - Sangeeta Kakoti
- Medical Oncology, Tata Memorial Centre, Mumbai, India.,Radiation Oncology, Tata Memorial Centre, Mumbai, India
| | - Abhishek Chatarjee
- Medical Oncology, Tata Memorial Centre, Mumbai, India.,Radiation Oncology, Tata Memorial Centre, Mumbai, India
| | - Hasmukh Jain
- Medical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India
| | - Sridhar Epari
- Medical Oncology, Tata Memorial Centre, Mumbai, India.,Pathology, Tata Memorial Centre, Mumbai, India
| | - Siddhartha Laskar
- Medical Oncology, Tata Memorial Centre, Mumbai, India.,Radiation Oncology, Tata Memorial Centre, Mumbai, India
| | - Manju Sengar
- Medical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India
| | - Tejpal Gupta
- Medical Oncology, Tata Memorial Centre, Mumbai, India.,Radiation Oncology, Tata Memorial Centre, Mumbai, India
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22
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Hoang-Xuan K, Deckert M, Ferreri AJM, Furtner J, Gallego Perez-Larraya J, Henriksson R, Hottinger AF, Kasenda B, Lefranc F, Lossos A, McBain C, Preusser M, Roth P, Rudà R, Schlegel U, Soffietti R, Soussain C, Taphoorn MJB, Touitou V, Weller M, Bromberg JEC. European Association of Neuro-Oncology (EANO) guidelines for treatment of primary central nervous system lymphoma (PCNSL). Neuro Oncol 2023; 25:37-53. [PMID: 35953526 PMCID: PMC9825335 DOI: 10.1093/neuonc/noac196] [Citation(s) in RCA: 47] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Indexed: 01/12/2023] Open
Abstract
The management of primary central nervous system (PCNSL) is one of the most controversial topics in neuro-oncology because of the complexity of the disease and the limited number of controlled studies available. In 2021, given recent advances and the publication of practice-changing randomized trials, the European Association of Neuro-Oncology (EANO) created a multidisciplinary task force to update the previously published evidence-based guidelines for immunocompetent adult patients with PCNSL and added a section on immunosuppressed patients. The guideline provides consensus considerations and recommendations for the treatment of PCNSL, including intraocular manifestations and specific management of the elderly. The main changes from the previous guideline include strengthened evidence for the consolidation with ASCT in first-line treatment, prospectively assessed chemotherapy combinations for both young and elderly patients, clarification of the role of rituximab even though the data remain inconclusive, of the role of new agents, and the incorporation of immunosuppressed patients and primary ocular lymphoma. The guideline should aid the clinicians in everyday practice and decision making and serve as a basis for future research in the field.
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Affiliation(s)
- Khê Hoang-Xuan
- APHP, Department of Neurology, Groupe Hospitalier Pitié-Salpêtrière; Sorbonne Université; IHU; ICM. Paris, France
| | - Martina Deckert
- Institute of Neuropathology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | | | - Julia Furtner
- Department of Biomedical and Imaging Image-guided Therapy Medical University of Vienna, Vienna, Austria
| | - Jaime Gallego Perez-Larraya
- Health Research Institute of Navarra (IdiSNA), Program in Solid Tumors, Foundation for the Applied Medical Research, Department of Neurology, Clinica Universidad de Navarra, Pamplona, Navarra, Spain
| | - Roger Henriksson
- Department of Radiation Sciences, Oncology, University of Umeå, S-901 85 Umea, Sweden
| | - Andreas F Hottinger
- Department of Oncology and Clinical Neurosciences, CHUV University Hospital Lausanne and University of Lausanne, LausanneSwitzerland
| | - Benjamin Kasenda
- Department of Hematology/Oncology and Palliative Care, Klinikum Stuttgart, Stuttgart, Germany
| | - Florence Lefranc
- Department of Neurosurgery, Hôpital Erasme, Université Libre de Bruxelles, Belgium
| | - Alexander Lossos
- Head, Leslie and Michael Gaffin Center for Neuro-Oncology; Department of Oncology and Neurology; Hadassah-Hebrew University Medical Center; Jerusalem, Israel
| | - Catherine McBain
- Department of Clinical Oncology, The Christie NHS FT; Manchester; United Kingdom
| | - Matthias Preusser
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna,Austria
| | - Patrick Roth
- Department of Neurology & Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Roberta Rudà
- Department of Neurology, Castelfranco Veneto/Treviso Hospital, Italy
- Division of Neuro-Oncology, Department of Neuroscience, University of Turin, and City of Health and Science University Hospital, Turin, Italy
| | - Uwe Schlegel
- Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Germany
| | - Riccardo Soffietti
- Division of Neuro-Oncology, Department of Neuroscience, University of Turin, and City of Health and Science University Hospital, Turin, Italy
| | - Carole Soussain
- Department of Hematology, Institut Curie, Site Saint-Cloud, France and INSERM U932 Institut Curie, PSL Research University, Paris, France
| | - Martin J B Taphoorn
- Department of Neurology, Leiden University Medical Center and Department of Neurology, Haaglanden Medical Center The Hague, The Netherlands
| | - Valérie Touitou
- APHP, Department of Ophtalmology, Groupe Hospitalier Pitié-Salpêtrière; Sorbonne Université. Paris, France
| | - Michael Weller
- Department of Neurology & Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Jacoline E C Bromberg
- Department of Neuro-Oncology, Erasmus MC University Medical Center Cancer Institute, Rotterdam. The Netherlands
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23
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Shen J, Liu J. Bruton's tyrosine kinase inhibitors in the treatment of primary central nervous system lymphoma: A mini-review. Front Oncol 2022; 12:1034668. [PMID: 36465385 PMCID: PMC9713408 DOI: 10.3389/fonc.2022.1034668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 10/31/2022] [Indexed: 09/19/2023] Open
Abstract
Primary central nervous system lymphoma (PCNSL) is a highly aggressive brain tumor with poor prognosis if no treatment. The activation of the NF-κB (nuclear factor kappa-B) is the oncogenic hallmark of PCNSL, and it was driven by B cell receptor (BCR) and Toll-like receptor (TLR) signaling pathways. The emergence of Bruton's tyrosine kinase inhibitors (BTKis) has brought the dawn of life to patients with PCNSL. This review summarizes the management of PCNSL with BTKis and potential molecular mechanisms of BTKi in the treatment of PCNSL. And the review will focus on the clinical applications of BTKi in the treatment of PCNSL including the efficacy and adverse events, the clinical trials currently being carried out, the underlying mechanisms of resistance to BTKi and possible solutions to drug resistance.
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Affiliation(s)
- Jing Shen
- Department of Hematology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, China
| | - Jinghua Liu
- Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Hematology, Northern Theater General Hospital, Shenyang, China
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24
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Treatment Options for Recurrent Primary CNS Lymphoma. Curr Treat Options Oncol 2022; 23:1548-1565. [PMID: 36205806 DOI: 10.1007/s11864-022-01016-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2022] [Indexed: 01/30/2023]
Abstract
OPINION STATEMENT Primary CNS lymphoma (PCNSL) constitutes a rare extranodal variant of non-Hodgkin lymphoma (NHL) with an annual incidence of 0.45/100,000. Given the paucity of large prospective clinical trials, there is no consensus treatment for refractory or relapsed (r/r) PCNSL, and available strategies are largely based on retrospective analyses. Patient age, performance status, previously administered treatment, duration of response, and molecular characteristics guide selection of salvage therapy. Patients with a good performance status (KPS >70), particularly ≤65 years, and adequate organ function should be considered for salvage polychemotherapy. Based on its high overall response rate even in the relapsed setting, we choose high-dose (≥ 3.5g/m2) methotrexate (HD-MTX) based regimens, e.g., R-MPV (rituximab, HD-MTX, procarbazine, and vincristine), for remission re-induction as long as patients were sensitive to first line HD-MTX-based regimens, especially when duration of previous response was ≥ 1 year. Following successful remission induction, we choose myeloablative chemotherapy (e.g., thiotepa, busulfan, cyclophosphamide) and subsequent autologous stem cell transplant in curative intent whenever feasible. Alternatively, conventional chemotherapy regimens (for example, monthly HD-MTX) or low-dose whole-brain radiation therapy (WBRT) are selected for consolidation in non-transplant candidates in complete remission. In cases of HD-MTX refractory disease or contraindications, we use pemetrexed; temozolomide/rituximab; high-dose cytarabine; or whole brain radiation for remission induction. Clinical trial participation is considered as well. Emerging therapies for upfront or salvage therapy under ongoing investigation include bruton tyrosine kinase inhibition (e.g., ibrutinib), immunomodulatory drugs (e.g., lenalidomide), immune checkpoint inhibitors (ICI, e.g., nivolumab), and chimeric antigen receptor T (CAR-T) cell therapy.
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25
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Schaff LR, Grommes C. Primary central nervous system lymphoma. Blood 2022; 140:971-979. [PMID: 34699590 PMCID: PMC9437714 DOI: 10.1182/blood.2020008377] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 09/27/2021] [Indexed: 11/20/2022] Open
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare extranodal lymphomatous malignancy that affects the brain, spinal cord, leptomeninges, or vitreoretinal space, without evidence of systemic involvement. The diagnosis of PCNSL requires a high level of suspicion because clinical presentation varies depending upon involved structures. Initiation of treatment is time sensitive for optimal neurologic recovery and disease control. In general, the prognosis of PCNSL has improved significantly over the past few decades, largely as a result of the introduction and widespread use of high-dose methotrexate (MTX) chemotherapy, which is considered the backbone of first-line polychemotherapy treatment. Upon completion of MTX-based treatment, a consolidation strategy is often required to prolong duration of response. Consolidation can consist of radiation, maintenance therapy, nonmyeloablative chemotherapy, or myeloablative treatment followed by autologous stem cell transplant. Unfortunately, even with consolidation, relapse is common, and 5-year survival rates stand at only 30% to 40%. Novel insights into the pathophysiology of PCNSL have identified key mechanisms in tumor pathogenesis, including activation of the B-cell receptor pathway, immune evasion, and a suppressed tumor immune microenvironment. These insights have led to the identification of novel small molecules targeting these aberrant pathways. The Bruton tyrosine kinase inhibitor ibrutinib and immunomodulatory drugs (lenalidomide or pomalidomide) have shown promising clinical response rates for relapsed/refractory PCNSL and are increasingly used for the treatment of recurrent disease. This review provides a discussion of the clinical presentation of PCNSL, the approach to work-up and staging, and an overview of recent advancements in the understanding of the pathophysiology and current treatment strategies for immunocompetent patients.
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Affiliation(s)
- Lauren R Schaff
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY; and
- Department of Neurology, Weill Cornell Medical College, New York, NY
| | - Christian Grommes
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY; and
- Department of Neurology, Weill Cornell Medical College, New York, NY
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26
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Ma J, Lin Z, Ding T, Li Q, Zhang M, Kang H, Johnston PB, Ma Y, Chen B. Pemetrexed Plus Lenalidomide for Relapsed/Refractory Primary Central Nervous System Lymphoma: A Prospective Single-Arm Phase II Study. Front Oncol 2022; 12:938421. [PMID: 35898888 PMCID: PMC9309305 DOI: 10.3389/fonc.2022.938421] [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: 05/07/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
The prognosis of relapsed/refractory (R/R) primary central nervous system lymphoma (PCNSL) is dismal, and there are limited treatment options for these patients. This was a prospective single-arm phase II study of combined pemetrexed and lenalidomide for salvage treatment of R/R PCNSL. Patients with R/R PCNSL (n = 38) who had undergone two or more different therapeutic regimens and experienced disease progression or recurrence were enrolled. The primary endpoint was overall response rate (ORR). Secondary endpoints were progression-free survival (PFS) and overall survival (OS). Patients were followed up for a median of 18 (range, 1–36) months. ORR was 68.4%, with median PFS and OS of 6 and 18 months, respectively. Adverse events (AEs) included myelosuppression, fatigue, nausea, fever, infection, cardiac disease, and thrombogenesis. Commonly observed grade ≥ 3 AEs included neutropenia (5.3%), leukopenia (2.6%), thrombocytopenia (7.9%), and infection (2.6%). Elevated lactate dehydrogenase (LDH) levels (χ2 = 13.25; P = 0.0003) and bulky disease (P = 0.032; χ2 = 4.580) were associated with short PFS. Elevated serum LDH level (P = 0.011; χ2 = 6.560), abnormal lymphoma cells in the cerebrospinal fluid (CSF) [P = 0.011; χ2 = 6.445], and multiple lesions (P = 0.036; χ2 = 4.404) were significantly associated with poorer OS. Abnormal lymphoma cells in the CSF were an independent predictor of poor prognosis on multivariate analysis (P = 0.034; hazard ratio (HR) = 2.836; 95% confidence interval, 1.082–7.434). Our results indicate that pemetrexed plus lenalidomide is effective for heavily treated R/R PCNSL, with moderate toxicity. Trial registration: #ChiCTR1900028070.
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Affiliation(s)
- Jingjing Ma
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai, China
- Department of Hematology, Huashan Hospital North, Fudan University, Shanghai, China
| | - Zhiguang Lin
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai, China
- Department of Hematology, Huashan Hospital North, Fudan University, Shanghai, China
| | - Tianling Ding
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai, China
- Department of Hematology, Huashan Hospital North, Fudan University, Shanghai, China
| | - Qing Li
- Department of Hematology, Huashan Hospital North, Fudan University, Shanghai, China
| | - Mengxue Zhang
- Department of Hematology, Huashan Hospital North, Fudan University, Shanghai, China
| | - Hui Kang
- Department of Hematology, Huashan Hospital North, Fudan University, Shanghai, China
| | - Patrick B Johnston
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Yan Ma
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai, China
- Department of Hematology, Huashan Hospital North, Fudan University, Shanghai, China
| | - Bobin Chen
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai, China
- Department of Hematology, Huashan Hospital North, Fudan University, Shanghai, China
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27
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Khorasanchi A, Benson Z, Hall M, Ebadirad N, Gharavi MH, Willard P, Chimzar M, McKay J, Simmons G, Yazbeck V. Systemic Relapse in a Young Adult Patient with Primary CNS Diffuse Large B-Cell Lymphoma. Case Rep Hematol 2022; 2022:7139661. [PMID: 35774056 PMCID: PMC9239761 DOI: 10.1155/2022/7139661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/06/2022] [Indexed: 12/11/2022] Open
Abstract
Primary central nervous system diffuse large B-cell lymphoma (PCNS-DLBCL) is a rare form of non-Hodgkin's lymphoma, characterized by an aggressive disease course. While CNS relapse is common, systemic relapse is rare with no consensus on optimal treatment. This paper presents an unusual case of advanced PCNS-DLBCL with systemic relapse, including adrenal gland involvement. A review of the existing literature and a discussion on the management of systemic relapse in PCNS-DLBCL is also provided.
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Affiliation(s)
- Adam Khorasanchi
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Zachary Benson
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Misty Hall
- Department of Pathology, Virginia Commonwealth University, Richmond, VA, USA
| | - Nelya Ebadirad
- Department of Radiology, Virginia Commonwealth University, Richmond, VA, USA
| | - Mohammad H. Gharavi
- Department of Radiology, Virginia Commonwealth University, Richmond, VA, USA
| | - Patrick Willard
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Miranda Chimzar
- School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - John McKay
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Gary Simmons
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
- Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Victor Yazbeck
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
- Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
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28
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Zhai Y, Zhou X, Wang X. Novel insights into the biomarkers and therapies for primary central nervous system lymphoma. Ther Adv Med Oncol 2022; 14:17588359221093745. [PMID: 35558005 PMCID: PMC9087239 DOI: 10.1177/17588359221093745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 03/24/2022] [Indexed: 11/17/2022] Open
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare and highly aggressive extranodal type of non-Hodgkin lymphoma. After the introduction and widespread use of high-dose-methotrexate (HD-MTX)-based polychemotherapy, treatment responses of PCNSL have been improved. However, long-term prognosis for patients who have failed first-line therapy and relapsed remains poor. Less invasive diagnostic markers, including the circulating tumor DNAs (ctDNAs), microRNAs, metabolomic markers, and other novel biomarkers, such as a proliferation inducing ligand (APRIL) and B-cell activating factor of the TNF family (BAFF), have shown potential to distinguish PCNSL at an early stage, and some of them are related with prognosis to a certain extent. Recent insights into novel therapies, including Bruton tyrosine kinase (BTK) inhibitors, immunomodulatory drugs, immune checkpoint inhibitors, PI3K/mTOR inhibitors, and chimeric antigen receptor (CAR) T cells, have revealed encouraging efficacy in treatment response, whereas the duration of response and long-term survival of patients with relapsed or refractory PCNSL (r/r PCNSL) need further improvement. In addition, the diagnostic efficiency of novel markers and the antitumor efficacy of novel therapies are needed to be assessed further in larger clinical trials. This review provides an overview of recent research on novel diagnostic markers and therapeutic strategies for PCNSL.
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Affiliation(s)
- Yujia Zhai
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiangxiang Zhou
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong, ChinaSchool of Medicine, Shandong University, Jinan, China
- Shandong Provincial Engineering Research Center of Lymphoma, Jinan, China
- Branch of National Clinical Research Center for Hematologic Diseases, Jinan, China
- National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xin Wang
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, No. 324, Jingwu Road, Jinan 250021, Shandong, China
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- School of Medicine, Shandong University, Jinan, China
- Shandong Provincial Engineering Research Center of Lymphoma, Jinan, China
- Branch of National Clinical Research Center for Hematologic Diseases, Jinan, China
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29
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Ramadan S, Radice T, Ismail A, Fiori S, Tarella C. Advances in therapeutic strategies for primary CNS B-cell lymphomas. Expert Rev Hematol 2022; 15:295-304. [PMID: 35467473 DOI: 10.1080/17474086.2022.2061455] [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: 11/04/2022]
Abstract
INTRODUCTION Primary CNS lymphoma (PCNSL) has traditionally been treated with induction HD-MTX-based chemotherapy, followed by consolidation whole-brain radiotherapy. However, this approach is associated with significant neurocognitive complications, especially in older patients. Therefore, different consolidation protocols have been evaluated. High-dose chemotherapy followed by autologous stem cell transplantation (HD-ASCT) has the best long-term survival outcomes in younger patients. AREAS COVERED In this review of the literature, we focus on the overall therapeutic strategy and advances in the management of the aggressive primary CNS B-cell lymphomas. EXPERT OPINION In young and fit PCNSL patients, HD-ASCT is the preferred consolidation strategy to achieve long-term survivals. Older patients with good performance status should also be evaluated for MTX-based induction polychemotherapy followed by ASCT. However, management of PCNSL patients remains challenging, and new avenues with targeted therapies are under investigation. To date, ibrutinib, lenalidomide, and immune checkpoint inhibitors appearto be promising in PCNSL. However, as monotherapy, durable responses are less likely to be achieved. Unfortunately, when combined with chemoimmunotherapy, considerable toxicity and mortality have been reported. Clinical trials on these molecules are aiming to reduce toxicity and maintain responses. CAR-T-cell therapy has recently emerged as a further option. It has shown efficacy in patients with secondary CNS lymphoma, with few but encouraging results in primary CNSL.
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Affiliation(s)
- Safaa Ramadan
- Division of Onco-Hematology, European Institute of Oncology, IRCCS, Milan, Italy.,Department of Medical Oncology, NCI-Cairo University, Cairo, Egypt
| | - Tommaso Radice
- Division of Onco-Hematology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Ahmed Ismail
- Hematology Department at Maadi Military Hospital, Armed Forces College of Medicine Cairo, Egypt.,Hematology Department, Maadi Military Hospital, Armed forces college of medicine, Cairo, Egypt
| | - Stefano Fiori
- Division of Diagnostic Hematopathology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Corrado Tarella
- Division of Onco-Hematology, European Institute of Oncology, IRCCS, Milan, Italy.,Dipartimento Universitario di Scienze della Salute (DISS), Universita' di Milano, Milan, Italy
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30
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Tang D, Chen Y, Shi Y, Tao H, Tao S, Zhang Q, Ding B, He Z, Yu L, Wang C. Epidemiologic Characteristics, Prognostic Factors, and Treatment Outcomes in Primary Central Nervous System Lymphoma: A SEER-Based Study. Front Oncol 2022; 12:817043. [PMID: 35223498 PMCID: PMC8867087 DOI: 10.3389/fonc.2022.817043] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/18/2022] [Indexed: 11/20/2022] Open
Abstract
Objective This study was conducted in order to study the clinical characteristics, prognostic factors, and treatment outcomes in patients with primary central nervous system lymphoma (PCNSL). Materials and Methods The data of a total of 5,166 PCNSL patients diagnosed between 2000 and 2018 from the Surveillance, Epidemiology, and End Results (SEER) database were obtained. Results The mean age was 63.1 ± 14.9 years, with a male to female ratio of 1.1:1.0. The most common histologic subtype was diffuse large B-cell lymphoma (DLBCL) (84.6%). The 1-, 3-, and 5-year overall survival (OS) rates were 50.1%, 36.0%, and 27.2%, respectively, and the corresponding disease-specific survival (DSS) rates were 54.4%, 41.3%, and 33.5%, respectively. Multivariate analysis with Cox regression showed that race, sex, age, marital status, surgical resection, and chemotherapy were independent prognostic factors for OS and DSS, but radiotherapy was only for OS. Nomograms specially for DLBCL were established to predict the possibility of OS and DSS. The concordance index (C-index) values of OS and DSS were 0.704 (95% CI 0.687–0.721) and 0.698 (95% CI 0.679–0.717), suggesting the high discrimination ability of the nomograms. Conclusion Surgical resection and/or chemotherapy was favorably associated with better OS and DSS. However, radiotherapy was not beneficial for OS and DSS in the long term. A new predictive nomogram and a web-based survival rate calculator we developed showed favorable applicability and accuracy to predict the long-term OS for DLBCL patients specifically.
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Affiliation(s)
- Dongsheng Tang
- Department of Hematology, The Huaian Clinical College of Xuzhou Medical University, Huai'an, China
| | - Yue Chen
- Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, China
| | - Yuye Shi
- Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, China
| | - Hong Tao
- Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, China
| | - Shandong Tao
- Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, China
| | - Quan'e Zhang
- Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, China
| | - Banghe Ding
- Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, China
| | - Zhengmei He
- Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, China
| | - Liang Yu
- Department of Hematology, The Huaian Clinical College of Xuzhou Medical University, Huai'an, China.,Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, China
| | - Chunling Wang
- Department of Hematology, The Huaian Clinical College of Xuzhou Medical University, Huai'an, China.,Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, China
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Abstract
OPINION STATEMENT Primary central nervous system lymphomas (PCNSLs) are very rare neoplasms and continue to be challenging to treat. While high-dose methotrexate (HD-MTX)-based regimens are the currently accepted standard first-line therapy for newly diagnosed patients, the optimal induction therapies are still unknown. The role of consolidation therapies continues to evolve with a variety of chemotherapy regimens, including high-dose chemotherapy with stem cell rescue and reduced or deferred whole brain radiotherapy being used. Importantly, several recent advances have been made in the treatment of PCNSL. The incorporation of targeted therapy and immune therapy remain promising strategies. Several agents, successfully used in treatment of systemic lymphomas, have shown activity in PCNSL, frequently leading to durable responses in the relapsed/refractory patients. Many ongoing studies will likely lead to a better understanding of the roles of these treatments, especially as the first line and potentially also as maintenance. In addition, the use of molecular profiling to predict disease response to targeted agents and understand relapse patterns will become increasingly important. Clinical trials in PCNSL are critical yet frequently challenging to conduct given the rarity of the condition and lack of suitable subjects. Therefore, multi-institutional and international collaboration is of utmost importance to accelerate progress in understanding the biology and design better treatments for this disease. It is critical to consider patients of all demographics in the design and study of future treatment algorithms to have the largest impact on patient care and outcomes.
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32
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Zhou Y, Xu X. Application of new targeted drugs in relapsed/refractory primary central nervous system lymphoma. Hematology 2022; 27:105-112. [PMID: 35068379 DOI: 10.1080/16078454.2021.2019363] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Ying Zhou
- Department of Oncology, Affiliated Tumor Hospital of Nantong University, Nantong, People’s Republic of China
| | - Xiaohong Xu
- Department of Oncology, Affiliated Tumor Hospital of Nantong University, Nantong, People’s Republic of China
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33
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Update on Novel Therapeutics for Primary CNS Lymphoma. Cancers (Basel) 2021; 13:cancers13215372. [PMID: 34771535 PMCID: PMC8582401 DOI: 10.3390/cancers13215372] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 10/19/2021] [Accepted: 10/20/2021] [Indexed: 12/11/2022] Open
Abstract
Simple Summary Primary central nervous system lymphoma is a rare and aggressive form of non-Hodgkin lymphoma. While it is highly responsive to first-line chemo and radiation treatments, rates of relapse are high, demonstrating the need for improved therapeutic strategies. Recent advancements in the understanding of the pathophysiology of this disease have led to the identification of new potential treatment targets and the development of novel agents. This review aims to discuss different targeted strategies and review some of the data supporting these approaches, and discusses recently completed and ongoing clinical trials using these novel agents. Abstract Primary central nervous system lymphoma (PCNSL) is a rare lymphoma isolated to the central nervous system or vitreoretinal space. Standard treatment consists of cytotoxic methotrexate-based chemotherapy, with or without radiation. Despite high rates of response, relapse is common, highlighting the need for novel therapeutic approaches. Recent advances in the understanding of PCNSL have elucidated mechanisms of pathogenesis and resistance including activation of the B-cell receptor and mammalian target of rapamycin pathways. Novel treatment strategies such as the Bruton’s tyrosine kinase (BTK) inhibitor ibrutinib, phosphatidylinositol-3 kinase (PI3K) inhibitors, and immunomodulatory drugs are promising. Increasingly, evidence suggests immune evasion plays a role in PCNSL pathogenesis and several immunotherapeutic strategies including checkpoint inhibition and targeted chimeric antigen receptor T (CAR-T) cells are under investigation. This review provides a discussion on the challenges in development of targeted therapeutic strategies, an update on recent treatment advances, and offers a look toward ongoing clinical studies.
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34
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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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35
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Calimeri T, Steffanoni S, Foppoli M, Ponzoni M, Ferreri AJM. Implications of recent molecular achievements in early diagnosis and precision treatments for primary CNS lymphoma. Expert Opin Ther Targets 2021; 25:749-760. [PMID: 34606736 DOI: 10.1080/14728222.2021.1988927] [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: 10/20/2022]
Abstract
Introduction: Primary diffuse large B-cell lymphoma (DLBCL) of the central nervous system (PCNSL) represents a relevant challenge in onco-hematology. PCNSL has specific molecular profile and biological characteristics that distinguish it from systemic DLBCL. Several translational studies have allowed for significant improvement in the knowledge about its genomic and molecular profile. High-dose-methotrexate-based chemotherapy followed whole-brain irradiation or autologous stem cell transplantation is the most commonly used therapeutic approach in PCNSL patients.Areas covered: This work provides an overview of the new biomarkers of PCNSL, focusing on their potential diagnostic, predictive and prognostic role. Publications in English language, peer-reviewed, high-quality international journals, were identified on PubMed.Expert opinion: Early diagnosis, a better antitumor response definition and recognition of new effective treatments are important research fields aiming to improve PCNSL outcome and management. The acquisition of new molecular and genomic knowledge in PCNSL has allowed for the attainment of promising diagnostic and prognostic tools as well as the development of clinical trials with new therapeutic approaches beyond chemotherapy agents, which have demonstrated activity in refractory/relapsed PCNSL and deserve to be investigated in first-line therapy.
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Affiliation(s)
- Teresa Calimeri
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sara Steffanoni
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Foppoli
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maurilio Ponzoni
- Universita' di Medicina e Chirurgia, Vita -Salute San Raffaele, Milano, Italy.,Department of Pathology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrés J M Ferreri
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
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36
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Zhang X, Liu Y. Targeting the PI3K/AKT/mTOR Signaling Pathway in Primary Central Nervous System Lymphoma: Current Status and Future Prospects. CNS & NEUROLOGICAL DISORDERS-DRUG TARGETS 2021; 19:165-173. [PMID: 32416683 DOI: 10.2174/1871527319666200517112252] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/10/2020] [Accepted: 04/11/2020] [Indexed: 12/22/2022]
Abstract
Primary Central Nervous System Lymphoma (PCNSL) is a rare invasive extranodal non- Hodgkin lymphoma, a vast majority of which is Diffuse Large B-Cell Lymphoma (DLBCL). Although high-dose methotrexate-based immunochemotherapy achieves a high remission rate, the risk of relapse and related death remains a crucial obstruction to long-term survival. Novel agents for the treatment of lymphatic malignancies have significantly broadened the horizons of therapeutic options for PCNSL. The PI3K/AKT/mTOR signaling pathway is one of the most important pathways for Bcell malignancy growth and survival. Novel therapies that target key components of this pathway have shown antitumor effects in many B-cell malignancies, including DLBCL. This review will discuss the aberrant status of the PI3K/AKT/mTOR signaling pathways in PCNSL and the application prospects of inhibitors in hopes of providing alternative clinical therapeutic strategies and improving prognosis.
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Affiliation(s)
- Xiaowei Zhang
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Nan Si Huan Xi Lu 119, Fengtai District, Beijing 100070, China
| | - Yuanbo Liu
- Department of Hematology, Beijing Tiantan Hospital, Capital Medical University, Nan Si Huan Xi Lu 119, Fengtai District, Beijing 100070, China
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37
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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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38
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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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Primary central nervous system lymphoma: clinicopathological and genomic insights for therapeutic development. Brain Tumor Pathol 2021; 38:173-182. [PMID: 34255226 DOI: 10.1007/s10014-021-00408-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/06/2021] [Indexed: 12/16/2022]
Abstract
Primary central nervous system lymphoma (PCNSL) is a highly aggressive, extra-nodal non-Hodgkin lymphoma that is confined to the central nervous system (CNS) and the eyes. Most PCNSLs arise in immunocompetent older patients and less frequently in immunocompromised patients with Epstein-Barr virus infection. Although a patient's initial response to chemotherapy and radiation therapy is favorable, the clinical outcome of PCNSL remains poor compared to that of systemic lymphoma. Radiation-induced neurotoxicity is also a critical problem for patients with PCNSL. Therefore, a novel therapeutic strategy is required to overcome these challenges. Recent studies have largely uncovered the genomic landscape and associated histopathological features of PCNSL. Based on this background, novel therapeutic agents, such as Bruton's tyrosine kinase inhibitors and immune checkpoint inhibitors, have been introduced for patients with PCNSL. Here, we provide an overview of the updated histopathological and genomic characterization of PCNSL and summarize the current therapeutic strategies. We also review current preclinical PCNSL models for translational research.
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Targeted Therapies and Immune Checkpoint Inhibitors in Primary CNS Lymphoma. Cancers (Basel) 2021; 13:cancers13123073. [PMID: 34203062 PMCID: PMC8234854 DOI: 10.3390/cancers13123073] [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: 05/16/2021] [Revised: 06/08/2021] [Accepted: 06/12/2021] [Indexed: 02/07/2023] Open
Abstract
This review article outlines the current development of emerging treatment strategies for primary central nervous system lymphoma, a rare brain tumor with, thus far, limited therapeutic options. Small molecule targeted tyrosine kinase inhibitors, immunomodulatory agents, and immune checkpoint inhibitors will be discussed. The mechanisms of action, results of completed clinical studies, ongoing clinical trials, and future perspectives are summarized. Among the most promising clinical developments in the field of CNS lymphomas is ibrutinib, an inhibitor of Bruton's tyrosine kinase, which relays activation of nuclear factor kappa B upon integration of constitutive B cell receptor and Toll-like receptor signals. Down-stream of nuclear factor kappa B, the thalidomide analogs lenalidomide and pomalidomide exert immunomodulatory functions and are currently explored against CNS lymphomas. Finally, immune checkpoint inhibitors, such as drugs targeting the PD-1 pathway, may become novel therapeutic options to unleash anti-tumor immunity in patients with primary CNS lymphoma.
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Improving the antitumor activity of R-CHOP with NGR-hTNF in primary CNS lymphoma: final results of a phase 2 trial. Blood Adv 2021; 4:3648-3658. [PMID: 32766857 DOI: 10.1182/bloodadvances.2020002270] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 06/20/2020] [Indexed: 01/01/2023] Open
Abstract
Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) is the standard treatment of diffuse large B-cell lymphoma (DLBCL). Primary DLBCL of the central nervous system (CNS) (primary central nervous system lymphoma [PCNSL]) is an exception because of the low CNS bioavailability of related drugs. NGR-human tumor necrosis factor (NGR-hTNF) targets CD13+ vessels, enhances vascular permeability and CNS access of anticancer drugs, and provides the rationale for the treatment of PCNSL with R-CHOP. Herein, we report activity and safety of R-CHOP preceded by NGR-hTNF in patients with PCNSL relapsed/refractory to high-dose methotrexate-based chemotherapy enrolled in a phase 2 trial. Overall response rate (ORR) was the primary endpoint. A sample size of 28 patients was considered necessary to demonstrate improvement from 30% to 50% ORR. NGR-hTNF/R-CHOP would be declared active if ≥12 responses were recorded. Treatment was well tolerated; there were no cases of unexpected toxicities, dose reductions or interruptions. NGR-hTNF/R-CHOP was active, with confirmed tumor response in 21 patients (75%; 95% confidence interval, 59%-91%), which was complete in 11. Seventeen of the 21 patients with response to treatment received consolidation (ASCT, WBRT, and/or lenalidomide maintenance). At a median follow-up of 21 (range, 14-31) months, 5 patients remained relapse-free and 6 were alive. The activity of NGR-hTNF/R-CHOP is in line with the expression of CD13 in both pericytes and endothelial cells of tumor vessels. High plasma levels of chromogranin A, an NGR-hTNF inhibitor, were associated with proton pump inhibitor use and a lower remission rate, suggesting that these drugs should be avoided during TNF-based therapy. Further research on this innovative approach to CNS lymphomas is warranted. The trial was registered as EudraCT: 2014-001532-11.
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Abstract
Central nervous system lymphoma (CNSL) is a rare form of extranodal non-Hodgkin lymphoma. Central nervous system lymphoma can be primary (isolated to the central nervous space) or secondary in the setting of systemic disease. Treatment of CNSL has improved since the introduction of high-dose methotrexate and aggressive consolidation regimens. However, results after treatment are durable in only half of patients, and long-term survivors may experience late neurotoxicity, impacting quality of life. Given the rarity of this disease, few randomized prospective trials exist. This leaves many questions unanswered regarding optimal first-line and salvage treatments. Recent advances in the knowledge of pathophysiology of CNSL will hopefully help the development of future treatments. This review gives an overview of the epidemiology, pathophysiology, clinical presentation, diagnosis, and treatment of immunocompetent patients with CNSL.
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Tao K, Wang X, Tian X. Relapsed Primary Central Nervous System Lymphoma: Current Advances. Front Oncol 2021; 11:649789. [PMID: 33996566 PMCID: PMC8118624 DOI: 10.3389/fonc.2021.649789] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/22/2021] [Indexed: 12/13/2022] Open
Abstract
Primary central nervous system lymphoma is an invasive malignant lymphoma confined to the central nervous system. Although patients undergoing first-line treatment can achieve complete response, most of them still relapse within two years. Relapsed lymphoma is derived from occult lymphoma cells, and B cell receptor pathway activation and immune escape are the key mechanisms for the pathogenesis of PCNSL. Most relapses are in the central nervous system, a small number of relapses are isolated systemic relapses, and clinical symptoms occur early and vary. Current treatments for relapse include high-dose methotrexate rechallenge and other regimens of chemotherapy, whole-brain radiation therapy, hematopoietic stem-cell transplantation, targeted therapy and immunotherapy, which have become promising treatments. The overall prognosis of relapsed PCNSL is very poor, although it is affected by many factors. This article summarizes the mechanisms, related factors, clinical features, follow-up, treatment and prognosis of relapsed primary central nervous system lymphoma.
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Affiliation(s)
- Kaiyan Tao
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
| | - Xuefeng Wang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
| | - Xin Tian
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
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Narita Y, Nagane M, Mishima K, Terui Y, Arakawa Y, Yonezawa H, Asai K, Fukuhara N, Sugiyama K, Shinojima N, Kitagawa J, Aoi A, Nishikawa R. Phase I/II study of tirabrutinib, a second-generation Bruton's tyrosine kinase inhibitor, in relapsed/refractory primary central nervous system lymphoma. Neuro Oncol 2021; 23:122-133. [PMID: 32583848 PMCID: PMC7850159 DOI: 10.1093/neuonc/noaa145] [Citation(s) in RCA: 102] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background The safety, tolerability, efficacy, and pharmacokinetics of tirabrutinib, a second-generation, highly selective oral Bruton’s tyrosine kinase inhibitor, were evaluated for relapsed/refractory primary central nervous system lymphoma (PCNSL). Methods Patients with relapsed/refractory PCNSL, Karnofsky performance status ≥70, and normal end-organ function received tirabrutinib 320 and 480 mg once daily (q.d.) in phase I to evaluate dose-limiting toxicity (DLT) within 28 days using a 3 + 3 dose escalation design and with 480 mg q.d. under fasted conditions in phase II. Results Forty-four patients were enrolled; 20, 7, and 17 received tirabrutinib at 320, 480, and 480 mg under fasted conditions, respectively. No DLTs were observed, and the maximum tolerated dose was not reached at 480 mg. Common grade ≥3 adverse events (AEs) were neutropenia (9.1%), lymphopenia, leukopenia, and erythema multiforme (6.8% each). One patient with 480 mg q.d. had grade 5 AEs (pneumocystis jirovecii pneumonia and interstitial lung disease). Independent review committee assessed overall response rate (ORR) at 64%: 60% with 5 complete responses (CR)/unconfirmed complete responses (CRu) at 320 mg, 100% with 4 CR/CRu at 480 mg, and 53% with 6 CR/CRu at 480 mg under fasted conditions. Median progression-free survival was 2.9 months: 2.1, 11.1, and 5.8 months at 320, 480, and 480 mg under fasted conditions, respectively. Median overall survival was not reached. ORR was similar among patients harboring CARD11, MYD88, and CD79B mutations, and corresponding wild types. Conclusion These data indicate favorable efficacy of tirabrutinib in patients with relapsed/refractory PCNSL. Trial registration JapicCTI-173646.
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Affiliation(s)
- Yoshitaka Narita
- Department of Neurosurgery and Neuro-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Motoo Nagane
- Department of Neurosurgery, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Kazuhiko Mishima
- Department of Neuro-Oncology/Neurosurgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Yasuhito Terui
- Department of Hematology and Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshiki Arakawa
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hajime Yonezawa
- Department of Neurosurgery, Kagoshima University Hospital, Kagoshima, Japan
| | - Katsunori Asai
- Department of Neurosurgery, Osaka International Cancer Institute, Osaka, Japan
| | - Noriko Fukuhara
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Kazuhiko Sugiyama
- Department of Medical Oncology, Hiroshima University Hospital, Hiroshima, Japan
| | - Naoki Shinojima
- Department of Neurosurgery, Kumamoto University Hospital, Kumamoto, Japan
| | | | - Arata Aoi
- Ono Pharmaceutical Co, Ltd, Osaka, Japan
| | - Ryo Nishikawa
- Department of Neuro-Oncology/Neurosurgery, Saitama Medical University International Medical Center, Saitama, Japan
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Schaff LR, Ambady P, Doolittle ND, Grommes C. Primary central nervous system lymphoma: a narrative review of ongoing clinical trials and goals for future studies. ACTA ACUST UNITED AC 2021; 5. [PMID: 33912868 PMCID: PMC8078860 DOI: 10.21037/aol-20-47] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare disease of the brain, spine, cerebrospinal fluid (CSF) and/or vitreoretinal space. PCNSL is chemo and radiosensitive but relapse is common even years after initial treatment. Outside of consensus regarding the use of high-dose methotrexate (HD-MTX) for first line treatment, there is little uniformity in the management of newly diagnosed or relapsed PCNSL. The lack of consensus is driven by a paucity of randomized trials in this disease. Prospective studies are troubled by low enrollment, the lack of a standard induction regimen, and a varied approach to consolidation strategies. Moreover, the PCNSL patient population is heterogeneous and includes a high proportion of elderly or frail patients and consists of patients manifesting disease in varied compartments of the central nervous system (CNS). As a result, current treatment strategies vary widely and are often dictated by physician and institutional preference or regional practice. This review provides an overview of recently completed and ongoing therapeutic studies for patients with newly diagnosed and recurrent or refractory PCNSL. It discusses the existing evidence behind common approaches to induction and consolidation or maintenance regimens as well as the recent data regarding management of recurrent disease. Finally, it highlights the complexity of trial design in this disease and provides a framework for the design of future studies, which are needed to identify patient populations likely to benefit from specific induction, consolidation, or maintenance therapies.
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Affiliation(s)
- Lauren R Schaff
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Prakash Ambady
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | - Nancy D Doolittle
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | - Christian Grommes
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Liu Y, Yao Q, Zhang F. Diagnosis, prognosis and treatment of primary central nervous system lymphoma in the elderly population (Review). Int J Oncol 2021; 58:371-387. [PMID: 33650642 PMCID: PMC7864151 DOI: 10.3892/ijo.2021.5180] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 01/18/2021] [Indexed: 12/14/2022] Open
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare subtype of extranodal non-Hodgkin lymphoma that is unique and different from systemic diffuse large B-cell lymphomas. The median age at diagnosis of PCNSL is 65 years and its incidence is rising rapidly in the elderly population. A total of ≥20% of all patients with PCNSL are ≥80 years old. Notably, age has been identified as an independent poor prognostic factor for PCNSL. Elderly patients have an inferior prognosis to that of younger patients and are more severely affected by iatrogenic toxicity; therefore, elderly patients represent a unique and vulnerable treatment subgroup. The present review summarized the available literature to provide an improved understanding of the epidemiology, clinical characteristics, diagnosis, prognosis and management of PCNSL in the elderly population. Notably, the incidence of PCNSL in immunocompetent elderly patients, predominantly in men, is increasing. For the diagnosis of CNSL, imaging-guided stereotactic biopsy is considered the gold standard. When stereotactic biopsy is not possible or conclusive, certain biomarkers have been described that can help establish a diagnosis. PCNSL has a very poor prognosis in the elderly, even though several prognostic scoring systems exist and several prognostic markers have been reported in patients with PCNSL. Furthermore, the treatment of elderly patients remains challenging; it is unlikely that a novel agent could be used as a curative monotherapy; however, a combination of novel agents with polychemotherapy or its combination with other novel drugs may have therapeutic potential.
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Affiliation(s)
- Yanxia Liu
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong 250021, P.R. China
| | - Qingmin Yao
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong 250021, P.R. China
| | - Feng Zhang
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong 250021, P.R. China
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Chihara D, Dunleavy K. Primary Central Nervous System Lymphoma: Evolving Biologic Insights and Recent Therapeutic Advances. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 21:73-79. [PMID: 33288483 DOI: 10.1016/j.clml.2020.10.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/03/2020] [Accepted: 10/25/2020] [Indexed: 11/17/2022]
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare and clinically aggressive disease entity associated with poor survival. Though high-dose methotrexate-based immunochemotherapy approaches are effective at inducing responses, few patients experience long-term durable remissions. Recently, novel insights into the biology of this unique disease have been elucidated and have paved the way for the investigation of rational approaches such as Bruton tyrosine kinase inhibition and immunomodulation. Although these strategies can induce high response rates in PCNSL, remissions are short lived, with median progression-free survivals in the range of 6 months or less. Moving forward, understanding the mechanisms of treatment resistance with these and other novel agents is key to developing optimal combinatorial strategies. New approaches such as immune checkpoint inhibition and chimeric antigen receptor T-cell therapy are under investigation for PCNSL and thus far demonstrate activity in anecdotal clinical experiences. Future trials should focus on investigating novel rational combinations designed to optimally target the biology of PCNSL and simultaneously investigate mechanisms of resistance leading to treatment failure.
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MESH Headings
- Agammaglobulinaemia Tyrosine Kinase/antagonists & inhibitors
- Agammaglobulinaemia Tyrosine Kinase/metabolism
- Antineoplastic Combined Chemotherapy Protocols/antagonists & inhibitors
- Antineoplastic Combined Chemotherapy Protocols/pharmacology
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Biomarkers, Tumor/antagonists & inhibitors
- Biomarkers, Tumor/genetics
- Biomarkers, Tumor/metabolism
- Central Nervous System Neoplasms/genetics
- Central Nervous System Neoplasms/immunology
- Central Nervous System Neoplasms/mortality
- Central Nervous System Neoplasms/therapy
- Combined Modality Therapy/methods
- Drug Resistance, Neoplasm
- Humans
- Immune Checkpoint Inhibitors/pharmacology
- Immune Checkpoint Inhibitors/therapeutic use
- Immunotherapy, Adoptive/methods
- Lymphoma, Non-Hodgkin/genetics
- Lymphoma, Non-Hodgkin/immunology
- Lymphoma, Non-Hodgkin/mortality
- Lymphoma, Non-Hodgkin/therapy
- Mutation
- Progression-Free Survival
- Protein Kinase Inhibitors/pharmacology
- Protein Kinase Inhibitors/therapeutic use
- Receptors, Chimeric Antigen/immunology
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Affiliation(s)
- Dai Chihara
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer, Houston, TX
| | - Kieron Dunleavy
- Division of Hematology & Oncology, George Washington University Cancer Center, Washington, DC.
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Abstract
PURPOSE OF REVIEW Primary central nervous system (CNS) lymphoma is a rare, aggressive extranodal non-Hodgkin lymphoma confined to the brain, eyes, CSF, or spinal cord without systemic, non-CNS involvement. This article reviews the clinical presentation, imaging characteristics, diagnostic workup, novel pathophysiologic insights, and treatment of immunocompetent patients with primary CNS lymphoma. RECENT FINDINGS The prognosis of primary CNS lymphoma has significantly improved over the past few decades because of the introduction of and widespread use of high-dose methotrexate, which is now the backbone of all first-line combination chemotherapy treatments. Despite this progress, durable remission is still observed in only approximately 50% of patients. Novel insights into the pathophysiology of primary CNS lymphoma have identified the B-cell receptor pathway as well as the suppressed tumor immune microenvironment and immune evasion as key mechanisms in the pathogenesis of primary CNS lymphoma. Novel, small molecules and agents targeting these aberrant pathways have been introduced into clinical trials of recurrent/refractory primary CNS lymphomas. Agents such as the Bruton tyrosine kinase (BTK) inhibitor ibrutinib or immunomodulatory drugs such as lenalidomide and pomalidomide have shown promising response rates in the relapsed setting. SUMMARY Diagnosis of primary CNS lymphoma requires a high level of suspicion because clinical signs and deficits can vary and depend on the involved CNS compartments. Rapid initiation of therapy is essential for recovery and prognosis. The optimal treatment regimen has not been defined, but methotrexate-based chemotherapy regimens are considered the standard treatment approach for induction treatment. Novel, targeted agents have recently been introduced into the therapeutic arsenal.
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Holdhoff M, Mrugala MM, Grommes C, Kaley TJ, Swinnen LJ, Perez-Heydrich C, Nayak L. Challenges in the Treatment of Newly Diagnosed and Recurrent Primary Central Nervous System Lymphoma. J Natl Compr Canc Netw 2020; 18:1571-1578. [PMID: 33152700 DOI: 10.6004/jnccn.2020.7667] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 10/07/2020] [Indexed: 11/17/2022]
Abstract
Primary central nervous system lymphomas (PCNSLs) are rare cancers of the central nervous system (CNS) and are predominantly diffuse large B-cell lymphomas of the activated B-cell (ABC) subtype. They typically present in the sixth and seventh decade of life, with the highest incidence among patients aged >75 years. Although many different regimens have demonstrated efficacy in newly diagnosed and relapsed or refractory PCNSL, there have been few randomized prospective trials, and most recommendations and treatment decisions are based on single-arm phase II trials or even retrospective studies. High-dose methotrexate (HD-MTX; 3-8 g/m2) is the backbone of preferred standard induction regimens. Various effective regimens with different toxicity profiles can be considered that combine other chemotherapies and/or rituximab with HD-MTX, but there is currently no consensus for a single preferred regimen. There is controversy about the role of various consolidation therapies for patients who respond to HD-MTX-based induction therapy. For patients with relapsed or refractory PCNSL who previously experienced response to HD-MTX, repeat treatment with HD-MTX-based therapy can be considered depending on the timing of recurrence. Other more novel and less toxic regimens have been developed that show efficacy in recurrent disease, including ibrutinib, or lenalidomide ± rituximab. There is uniform agreement to delay or avoid whole-brain radiation therapy due to concerns for significant neurotoxicity if a reasonable systemic treatment option exists. This article aims to provide a clinically practical approach to PCNSL, including special considerations for older patients and those with impaired renal function. The benefits and risks of HD-MTX or high-dose chemotherapy with autologous stem cell transplantation versus other, better tolerated strategies are also discussed. In all settings, the preferred treatment is always enrollment in a clinical trial if one is available.
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Affiliation(s)
- Matthias Holdhoff
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
| | | | - Christian Grommes
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Thomas J Kaley
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Lode J Swinnen
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
| | | | - Lakshmi Nayak
- Center for CNS Lymphoma, Dana-Farber Cancer Institute, Boston, Massachusetts
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