Primary CNS lymphoma: a clinician's guide

All-cause and tumor-specific mortality trends in elderly primary central nervous system lymphoma (PCNSL) patients: a surveillance, epidemiology, and end results (SEER) analysis

BACKGROUND

Recent primary central nervous system lymphoma (PCNSL) literature indicates that younger patients benefit from improved survival; however, this benefit is not shared by those 70+ years of age. The purpose of this study was to examine mortality trends in PCNSL patients 70+ years of age to better understand why improved prognosis has not yet reached this rapidly growing population subset.

METHODS

Two thousand seventy-five cases (1973-2012, age at diagnosis 70+ years) within the Surveillance, Epidemiology, and End Results (SEER) database were included in Kaplan-Meier and multivariate Cox Regression analyses. Variables include age at diagnosis, decade of diagnosis (1=1973-1982, 2=1983-1992, 3=1993-2002, 4=2003-2012), sex, race and surgery.

RESULTS

Before stratification, both univariate and multivariate analyses agreed that patients aged 70-74 years at diagnosis lived the longest, while those 85+ years lived the shortest (median±SD; 6.0±0.5 months vs. 2.0±0.2 months, respectively, P<0.0005); women lived longer than men (5.0±0.3 months vs. 4.0±0.3 months, respectively, P=0.01); patients who received surgery (6.0±0.5 months) lived longer than those who did not (contraindicated=1.0±0.5 months, P<0.0005; not performed=4.0±0.3 months, P<0.0005). Univariate analysis showed decade 4 lived longer than only decade 3 (4.0±0.3 vs. 4.0±0.5, respectively, P=0.008), while multivariate analysis showed decade 4 lived longer than both 2 (5.0±0.8 months, P=0.03) and 3 (P<0.0005). Following stratification, decade and sex no longer influenced survival. Race did not influence survival.

CONCLUSIONS

Minimal clinically meaningful improvements in elderly PCNSL patient all-cause and tumor-specific mortality have been made since 1973, while the best predictors of longevity include younger age and surgery.

Diagnosis and management of primary central nervous system lymphoma: a Consensus Practice Statement from the Australasian Lymphoma Alliance

Primary central nervous system lymphoma is a clinicopathological disease entity that accounts for 1 % of all non-Hodgkin lymphoma (NHL). Advanced patient age, adverse disease biology and complexities of diagnosis and treatment render outcomes markedly inferior to systemic NHL. Despite this, an increasing evidence base including limited randomised controlled clinical trial data is informing optimal therapeutic strategies with methotrexate-based induction chemotherapy schedules and intensified consolidation in selected patients. This practice statement represents an evidence-based review of the literature and has been devised to assist healthcare professionals in the diagnosis and management of this disease. This article is protected by copyright. All rights reserved.

Primary cerebral lymphoma' characteristics, incidence, survival, and causes of death in the United States

PURPOSE

This study aimed to provide an updated overview of primary central lymphoma (PCL) using a large cohort of 33 years. That being said, we attempted to examine the patient demographics, management plans and their outcome, causes of death and the time trends in overall incidence and mortality rates of these patients.

METHODS

We conducted a retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER) database between 1983 and 2016. We calculated the frequencies and the average annual age-adjusted rate (AAR) of PCL patients. Uni- and multivariable accelerated failure time regression were used to identify possible prognostic factors affecting the patients' survival. Furthermore, detailed causes of death were extracted and joint point regression analysis was done to examine incidence and mortality trends.

RESULTS

We identified 2925 PCL cases. The AAR was 0.148 per 100,000. An increase in age was significantly associated with shorter survival (HR: 1.01, 95%CI = 1.01-1.01, P < .001), while a recent year of diagnosis after 1993-2002 and 2002 was associated with improved survival (HR: 0.76, CI = 0.65-0.89, P = .001), and (HR: 0.48, CI = 0.41-0.56, P < .001), respectively. Overall, the trend of mortality rates in PCL patients has declined over the past years (-1.38% per year).

CONCLUSION

Our results support the previous evidence by showing an increase in patients' survival over time. While most PCL-related deaths occur within the first year, subsequent slow progression was observed after the first few years of survival. More attention should be given to the other possible non-PCL causes of death, especially beyond ten years of survival.

Radiotherapy as an alternative treatment option for primary central nervous system lymphoma patients who are noncandidates for chemotherapy

The standard treatment for primary central nervous system (CNS) lymphoma is based on chemotherapy. However, there are patients who are not indicated for chemotherapy and when left untreated, the expected functional outcomes for these patients are devastating since the disease causes various neurologic symptoms. Therefore, we assessed the effects of radiotherapy as an alternative therapy in primary CNS lymphoma. Thirty-two patients were diagnosed with primary CNS lymphoma and treated with radiotherapy alone. Patients received whole brain radiotherapy (WBRT) to a median dose of 30 Gy (range, 14.4–50 Gy) and the median total radiotherapy dose was 50 Gy (range, 30–54 Gy). The status on neurologic symptoms before and after radiotherapy was inquired during the regular follow-ups. The progression-free survival (PFS) and overall survival (OS) rates for the enrolled patients were calculated. The median follow-up time was 21 months. All but one of the patients presented with neurologic symptoms. The most common symptoms were hemiparesis and headache. After radiotherapy, these symptoms were relieved in 27 patients (84.4%). The median PFS and OS rates were 15.8 and 16.3 months, respectively. Twenty patients (62.5%) experienced recurrent disease at follow up and among them, fifteen patients (46.9%) had intracranial recurrence. The median intracranial PFS was 19.3 months. Untreated primary CNS lymphoma causes neurologic deficits and the survival after only supportive care is poor. Therefore, when chemotherapy is unfeasible, an alternative treatment should be applied and radiotherapy can be a practical option.

What is known and unknown about chemotherapy-related cognitive impairment in patients with haematological malignancies and areas of needed research

Cancer-related cognitive impairment (CRCI) is an important clinical problem for cancer patients and survivors. In this review, we summarize studies investigating the occurrence of impaired cognition in patients with haematological malignancies. Most published studies focus on survivors of childhood acute lymphoblastic leukaemia and primary central nervous system lymphoma. We also discuss studies conducted in acute myeloid leukaemia, myelodysplastic syndromes, chronic myeloid leukaemia, Hodgkin lymphoma (HL), non-HL and chronic lymphocytic leukaemia. Although research in this area is still emerging, it appears that a subset of chemotherapy-treated haematological malignancy survivors experience CRCI. Future research should focus on expanding the literature reviewed here with larger studies appropriately powered to assess cognition via objective and subjective measures in a longitudinal fashion to tease apart the impact of disease and the various forms of cancer treatment.

Fluorescein sodium-guided surgery in cerebral lymphoma

OBJECTIVES

Growth and progress of primary central nervous lymphoma (PCNSL) severely disrupt the blood brain barrier (BBB). Such disruptions can be intraoperatively visualized by injecting fluorescein sodium (FL) and applying a YELLOW 560 nm surgical microscope filter. Here, we report a small cohort of patients with PCNSL that mimicked high grade gliomas (HGG) or cerebral metastases (CM), who had been operated on with the use of FL.

PATIENTS AND METHODS

Retrospectively, seven patients with PCNSL were identified, who had been operated on by means of microsurgery after intravenous FL injection. The surgical reports were screened for statements on the grade of fluorescent staining in the tumor area. One representative case was chosen to show the staining under white light as well as under filtered light at different distances to the tumor area.

RESULTS

All patients had shown bright and homogenous fluorescent staining of the tumor (n=7. 100%). No adverse effects had been observed.

CONCLUSION

Similar to patients with HGG or CM, patients with PCNSL may benefit from use of FL and the dedicated YELLOW 560 nm filter in open surgery.

Primary central nervous system lymphoma mimicking recurrent depressive disorder: A case report

Primary central nervous system lymphoma (PCNSL) is a rare subtype of extranodal non-Hodgkin lymphoma, which is limited to the central nervous system. Few studies are available reporting psychiatric symptoms as the initial and dominant presentation of PCNSL. The current study reports the case of a PCNSL patient with a history of major depressive disorder and coexisting rheumatoid arthritis (treated with methotrexate), who initially presented with recurrent depressive disorder that showed no response to antidepressant drug therapy. Magnetic resonance imaging revealed multiple mass lesions in the brain, and pathological examination of the biopsy confirmed the diagnosis of diffuse large B cell lymphoma of the central nervous system. The present case demonstrated that PCNSL may affect mood in the early stages of the disease and thus, clinicians must be aware of this manifestation in patients with depressive disorder co-existing with immunosuppressive conditions, as early detection and appropriate treatment are important prognostic factors for PCNSL.

Lymphomatosis cerebri mimicking iatrogenic Creutzfeldt-Jakob disease

Lymphomatosis cerebri (LC) is a rare variant of primary central nervous system lymphoma (PCNSL) whereby individual lymphoma cells infiltrate the cerebral white matter without causing a mass effect. The disease characteristically presents as a rapidly progressive dementia, which opens an ample differential diagnosis of toxic, metabolic, neurodegenerative and infective causes. Other presentations also include changes in personality, myoclonus and psychotic symptoms. Here we report a patient who presented with a rapidly progressive dementia with a unique surgical history of a dural mater graft in the 1970s. The diagnosis of iatrogenic Creutzfeldt-Jakob disease (iCJD) was initially considered. However, the patient's clinical status deteriorated rapidly with no response to symptomatic treatment and she died 2 months after symptom onset. A diagnosis of T-type LC was reached at autopsy.

Hyperosmolar and methotrexate therapy avoiding surgery in the acute presentation of primary central nervous system lymphoma

Background:

Primary central nervous system lymphoma (PCNSL) is an aggressive type of extra-nodal non-Hodgkin lymphoma. Without treatment, PCNSL is associated with significant morbidity and mortality, including rapid neurological deterioration. In contrast to other high-grade intracranial neoplasms, PCNSL is considered to have a high response rate to conventional medical therapy, especially in younger patients, and therefore warrants particular attention in terms of nonsurgical treatment.

Case Description:

We report a case of the medical management of acute deterioration due to rapidly growing PCNSL with mass effect to highlight the efficacy of temporization with hyperosmolar therapy while awaiting the known rapid effects of dexamethasone and methotrexate (MTX) treatment. Surgical intervention was avoided, and tumor response was rapid. The patient had corresponding clinical resolution of symptoms of elevated intracranial pressure with return to neurologic baseline.

Conclusions:

Despite the evidence that PCNSL responds well to steroids and MTX, the rapidity of onset with which this occurs can vary. In patients presenting with mass effect and rapid neurologic decline, there is little evidence to support medical over surgical intervention. Herein we present an illustrative case of a large PCNSL lesion presenting with rapid decline. With clinical improvement in one day and a 50% reduction in tumor volume over less than seven days, the authors present the specific time frame with which PCNSL responds to medical therapy and a safe strategy for medical temporization.

Identification of miRNAs as potential new biomarkers for nervous system cancer

Several recent studies have indicated the possibility of detecting dysregulated microRNAs (miRNAs) to diagnose nervous system cancer (NSC). Our study was conducted to explore the clinical applicability of miRNAs as potential ideal biomarkers for the diagnosis of NSC. For this meta-analysis, a systematic literature search was conducted in the Embase, Medline, Cochrane, Wangfang, and Sinomed databases. A standard quality tool-quality assessment of diagnostic accuracy studies was employed to assess the quality of the included studies. Specificity, sensitivity, diagnostic odds ratio (DOR), and area under curve (AUC) were pooled to assess overall test accuracy. In total, 25 studies from 7 articles, including 388 patients with NSC and 435 controls (healthy controls and patients with neurologic disorders), were included in this meta-analysis. For the studied miRNAs, the pooled sensitivity, specificity, and DOR for predicting NSC were 85% (95% confidence interval [CI] 80-89%), 85% (95% CI 80-89%), and 32 (95% CI 19-55), respectively. The pooled AUC for miRNAs identifying NSC was 0.92. In addition, results from subgroup analyses indicated that using miRNA panels yield a much better diagnostic accuracy when compared with using a particular miRNA. The current evidence suggests that miRNAs, especially miRNA panels on body fluids, may be suitable for use as diagnostic biomarkers for NSC patients. However, more prospective studies using larger cohorts should be conducted to confirm their degree of accuracy.

MicroRNAs as Potential Biomarkers for Diagnosing Cancers of Central Nervous System: a Meta-analysis

Recent studies have shown abnormal microRNA (miRNA) expression levels in the central nervous system (CNS) of cancer patients, suggesting that miRNAs may serve as promising biomarkers for cancers of CNS. However, other studies have arrived at conflicting results. Therefore, this meta-analysis aims to systematically measure the potential diagnostic value of miRNAs for CNS cancers. Electronic databases as well as other sources were searched until to April 12, 2014 for relevant articles. Data from different studies were pooled using the random-effects model. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative LR (NLR), diagnostic odds ratio (DOR), together with the summary receiver operator characteristic (SROC) curve, and area under the SROC curve (AUC) value were used to estimate overall diagnostic performance. Twenty-three studies from 6 articles were included in the current meta-analysis with a total of 299 CNS cancer patients and 418 controls. The pooled sensitivity, specificity, PLR, NLR, DOR, and AUC were 0.85 (95% CI, 0.80-0.89), 0.83 (95% CI, 0.76-0.88), 5.1 (95% CI, 3.4-7.5), 0.18 (95% CI, 0.12-0.26), 28 (95% CI, 14-58), and 0.91 (95% CI, 0.88-0.93), respectively. Subgroup analyses showed that cerebrospinal fluid (CSF)-based miRNAs assays yielded more accurate results and seemed to be more sensitive in diagnosing of primary central nervous system lymphoma (PCNSL). In conclusion, miRNAs may be suitable for serving as noninvasive biomarkers for CNS cancers detection. However, further validation based on a larger sample of patients and controls is still required.

Serum miR-21 is a diagnostic and prognostic marker of primary central nervous system lymphoma

The standard of care for primary central nervous system lymphoma (PCNSL) is systemic chemotherapy with or without whole brain radiotherapy or intrathecal chemotherapy. In contrast to treatment for other brain tumors, efforts at resection are discouraged. However, it is difficult to distinguish PCNSL from other central nervous system tumors which need aggressive surgery in both CT and MRI images. In this study, we assessed whether measurement of miR-21 in the serum could improve diagnostic accuracy for PCNSL. We found that serum miR-21 significantly increased in PCNSL when compared with other brain tumors and normal controls in both test and validation cohort. Further, serum miR-21 could discriminate PCNSL from all controls with an area under the curve of 0.930 for the test cohort and 0.916 for the validation cohort in ROC analysis. Similar results were also obtained in the validation cohort. Besides, raised concentrations of miR-21 in serum could differentiate PCNSL from glioblastoma under the curve of 0.883 for the test cohort and 0.851 for the validation cohort in ROC analysis. Furthermore, Kaplan-Meier curve analysis (p = 0.03 for test cohort and 0.02 for validation cohort) and Multivariable Cox regression (p = 0.03 for test cohort and 0.01 for validation cohort) revealed serum miR-21 as an independent and powerful predictor of overall survival. Taken together, our results demonstrate that serum miR-21 may represent a diagnostic and prognostic marker for PCNSL.