Primary Central Nervous System Lymphoma: A Critical Review of the Role of Surgery for Resection

Deep learning-based overall survival prediction model in patients with rare cancer: a case study for primary central nervous system lymphoma

PURPOSE

Primary central nervous system lymphoma (PCNSL) is a rare, aggressive form of extranodal non-Hodgkin lymphoma. To predict the overall survival (OS) in advance is of utmost importance as it has the potential to aid clinical decision-making. Though radiomics-based machine learning (ML) has demonstrated the promising performance in PCNSL, it demands large amounts of manual feature extraction efforts from magnetic resonance images beforehand. deep learning (DL) overcomes this limitation.

METHODS

In this paper, we tailored the 3D ResNet to predict the OS of patients with PCNSL. To overcome the limitation of data sparsity, we introduced data augmentation and transfer learning, and we evaluated the results using r stratified k-fold cross-validation. To explain the results of our model, gradient-weighted class activation mapping was applied.

RESULTS

We obtained the best performance (the standard error) on post-contrast T1-weighted (T1Gd)-area under curve [Formula: see text], accuracy [Formula: see text], precision [Formula: see text], recall [Formula: see text] and F1-score [Formula: see text], while compared with ML-based models on clinical data and radiomics data, respectively, further confirming the stability of our model. Also, we observed that PCNSL is a whole-brain disease and in the cases where the OS is less than 1 year, it is more difficult to distinguish the tumor boundary from the normal part of the brain, which is consistent with the clinical outcome.

CONCLUSIONS

All these findings indicate that T1Gd can improve prognosis predictions of patients with PCNSL. To the best of our knowledge, this is the first time to use DL to explain model patterns in OS classification of patients with PCNSL. Future work would involve collecting more data of patients with PCNSL, or additional retrospective studies on different patient populations with rare diseases, to further promote the clinical role of our model.

Pretreatment findings on magnetic resonance imaging in primary central nervous system lymphoma may predict overall survival duration

BACKGROUND

and purpose: Primary central nervous system lymphoma (PCNSL) lesions often show avid contrast enhancement on T1-weighted contrast-enhanced MRI sequences. However, several case reports and a clinical study have described PCNSL in patients with no contrast enhancement on MRI. We assessed whether overall survival (OS) time was related to any tumor characteristics (lesion location, volume, and number; contrast enhancement; necrosis; proximity to the subarachnoid space; and edema) on MRI in patients with PCNSL.

MATERIALS AND METHODS

We retrospectively reviewed records (MRI features, pathology, and survival data) of all patients at our institution with PCNSL who had been seen from, 2007 through 2017, and had undergone pretreatment MRI.

RESULTS

We identified 79 patients (42 men, 37 women) with a mean age at diagnosis of 61.7 ± 10.4 years. The mean OS duration was 44.6 ± 41.7 months. The most common pathological diagnosis (74 patients) was diffuse large B-cell lymphoma. No associations were found between OS time and lesion location, volume, and number; contrast enhancement; necrosis; proximity to the subarachnoid space; or edema. However, a sole patient with non-enhancing PCNSL on MRI was found to have low-grade disease, with prolonged survival (>83 months). Several other patients with leptomeningeal disease had a mean OS time of 80 months. Patients with hemorrhagic lesions had a mean OS of 25.5 months.

CONCLUSIONS

The survival time for patients with PCNSL may be longer than previously thought, especially for patients with leptomeningeal seeding and lesions with hemorrhagic components Also, non-enhancing tumors may be less aggressive than enhancing tumors.

Neurosurgical Management of Central Nervous System Lymphoma: Lessons Learnt from a Neuro-Oncology Multidisciplinary Team Approach

Central nervous system lymphoma (CNSL) represents one of the most aggressive forms of extranodal lymphoma. The gold standard for CNSL diagnosis remains the stereotactic biopsy, with a limited role for cytoreductive surgery that has not been supported by historical data. Our study aims to provide a comprehensive overview of neurosurgery's role in the diagnosis of systemic relapsed and primary CNSL, with an emphasis on the impact on management and survival. This is a single center retrospective cohort study with data collected between August 2012 and August 2020, including patients referred with a potential diagnosis of CNSL to the local Neuro-oncology Multidisciplinary Team (MDT). The concordance between the MDT outcome and histopathological confirmation was assessed using diagnostic statistics. A Cox regression is used for overall survival (OS) risk factor analysis, and Kaplan-Meier statistics are performed for three prognostic models. The diagnosis of lymphoma is confirmed in all cases of relapsed CNSL, and in all but two patients who underwent neurosurgery. For the relapsed CNSL group, the highest positive predictive value (PPV) is found for an MDT outcome when lymphoma had been considered as single or topmost probable diagnosis. Neuro-oncology MDT has an important role in establishing the diagnosis in CNSL, not only to plan tissue diagnosis but also to stratify the surgical candidates. The MDT outcome based on history and imaging has good predictive value for cases where lymphoma is considered the most probable diagnosis, with the best prediction for cases of relapsed CNSL, questioning the need for invasive tissue diagnosis in the latter group.

Primary Brainstem Lymphoma: A Population-Based Study

Background

Primary brainstem lymphoma (PBSL) is rare and malignant. An understanding of this disease is lacking. We aimed to characterize clinical features, estimate survival, and explore survival-related factors of PBSL.

Methods

Patients with a histological diagnosis of primary lymphoma in the brainstem (C71.7) from 1975 to 2016 were retrieved from the Surveillance, Epidemiology, and End Results (SEER) program. Log-rank tests and univariate and multivariate Cox proportional hazard analyses were used to identify survival-related factors.

Results

PBSL constituted 2.7% of brainstem malignancies. The median age of the PBSL patients was 59.5 years. Diffuse large B cell lymphoma (n = 49, 84.5%) was the most prevalent histology among the 58 cases with reported specific lymphoma subtype. The majority of PBSLs were localized (n = 46, 52.3%), at low Ann Arbor Stage (I/II, n = 63, 70.5%), and presented as a single primary (n = 71, 80.7%). Chemotherapy was applied in 50 (56.8%) cases. Three-year overall survival (OS) and disease-specific survival (DSS) rates were 42.7% and 53.5%, respectively. Multivariate analyses showed that independent predictive/prognostic factors for OS were age (P = 0.004), tumor number (P = 0.029), and chemotherapy (P = 0.001); DSS-related factors only included age (P = 0.014) and chemotherapy (P = 0.008).

Conclusions

We estimated survival rates for PBSL patients. Factors associated with OS and DSS were also identified. Our findings addressed the importance of chemotherapy in treating PBSL patients.

Hemorrhagic Attitude in Frameless and Frame-Based Stereotactic Biopsy for Deep-Seated Primary Central Nervous System Lymphomas in Immunocompetent Patients: A Multicentric Analysis of the Last Twenty Years

BACKGROUND

Primary central nervous system lymphoma (PCNSL) is a rare manifestation of aggressive extranodal non-Hodgkin lymphoma. In patients with deep-seated lesions, stereotactic brain biopsy (SBB) is an accepted diagnostic procedure to obtain histopathologic confirmation.

OBJECTIVE

The aim of this study was to assess the feasibility, diagnostic yield, safety, and complications of stereotactic procedures in midline and deep-seated PCNSLs.

METHODS

Patients selected had received a histopathologic diagnosis of PCNSL localized in deep-seated midline structures, obtained by SBB. The intraoperative frozen section was executed as an integral part of the procedure. Computed tomography scan was performed after surgery.

RESULTS

A total of 476 SBBs were performed between January 2000 and December 2019 . Of these SBBs, 91 deep-seated lesions had a histologic diagnosis of PCNSL. A significant increase of the incidence of PCNSL compared with all other diseases was observed (P < 0.0001). Eight patients (8.7%) showed a symptomatic hemorrhage, 4 of whom required craniotomy. There were 4 deaths and 2 cases of permanent morbidity. The hemorrhage risk in the PCNSL group was statistically significant (P = 0.0003) compared with other histotypes.

CONCLUSIONS

In suspected cases of PCNSL, a histopathologic diagnosis is necessary to distinguish it from glioblastoma or other, nonmalignant conditions. Deep-seated PCNSLs present a higher risk of biopsy-related morbidity and mortality. Intraoperative frozen section increases the diagnostic yield and reduces the number of sampling procedures. Postoperative computed tomography seems to be warranted in patients with suspected PCNSL.

Outcome and Prognostic Factors of Primary Central Nervous System Lymphoma in Southern Thailand

Context:

Primary central nervous system lymphoma (PCNSL) is an uncommon type of brain tumor that has an aggressive disease course. Its outcomes, including factor-related outcomes, are therefore not well established in our country.

Aims:

This study aims to investigate the outcome and prognostic factors in PCNSL patients at our institute.

Settings and Design:

Retrospective study in a single university hospital.

Subjects and Methods:

We reviewed consecutive cases of newly diagnosed PCNSL at Prince of Songkla University from 2005 to 2018. The data were collected to evaluate the treatment outcomes and prognostic factors.

Statistical Analysis Used:

The Kaplan–Meier method for survival analysis, and Cox regression for variable analysis.

Results:

Eighty-seven patients met the inclusion criteria. Patients were predominantly male, and their mean age was 58.8 ± 11.2 years. Only four patients were infected with HIV. Motor weakness was the most common presentation, and neuroimaging revealed multiple lesions in 56.3% of patients. The patients were divided into four groups according to treatment modality: palliative treatment, whole-brain radiotherapy (WBRT) alone, chemotherapy (CMT) alone, and combined WBRT and CMT groups. The median overall survival was 7 months. The 1-, 2-, and 5-year survival rates were 29%, 21.5%, and 4.6%, respectively. The age of >60 years was a significant poor prognostic factor. In addition, patients who received combined treatment exhibited the highest survival rate.

Conclusions:

PCNSL has a low survival rate, even in the present era. Older age is the most substantial factor associated with unfavorable outcomes. The most effective treatment is combined with WBRT and CMT.

Image-Guided Brain Surgery

In neurosurgery, the extent of resection plays a critical role, especially in the management of malignant gliomas. These tumors are characterized through a diffuse infiltration into the surrounding brain parenchyma. Delineation between tumor and normal brain parenchyma can therefore often be challenging. During the recent years, several techniques, aiming at better intraoperative tumor visualization, have been developed and implemented in the field of brain tumor surgery. In this chapter, we discuss current strategies for intraoperative imaging in brain tumor surgery, comprising conventional techniques such as neuronavigation, techniques using fluorescence-guided surgery, and further highly precise developments such as targeted fluorescence spectroscopy or Raman spectroscopy.

Primary central nervous system lymphoma and 5-aminolevulinic acid

Background:

Despite surgical resection of primary central nervous system lymphomas (PCNSL) having been always discouraged, recent evidence supports that it might improve prognosis in this patient population. Five- aminolevulinic acid-derived fluorescence is widely used for the resection of malignant gliomas, but its role in PCNSL surgery remains unclear.

Case Description:

We present two patients with a solitary solid intraparenchymal mass. As high-grade glioma leaded the list of differential diagnosis (other possibilities were metastasis, abscess, and PCNSL), a five- aminolevulinic acid-guided complete resection (with strong fluorescence in both cases) was done. Surgery was uneventfully carried on with complete resection until five-aminolevulinic acid-induced fluorescence was no longer evident. After surgery, patients have no neurological deficits and had good recovery. Pathological examination revealed that both tumors were PCNSL. Adjuvant radiotherapy and chemotherapy were started. After 1 year of follow-up, patients have good evolution and have no recurrences.

Conclusion:

These cases add to the growing literature which shows that surgery might play an important role in the management of PCNSL with an accessible and single lesion. Five-aminolevulinic acid could also be a useful tool to achieve complete resection and improve prognosis in this group of patients.

Craniotomy and Survival for Primary Central Nervous System Lymphoma

BACKGROUND

Cytoreductive surgery is considered controversial for primary central nervous system lymphoma (PCNSL).

OBJECTIVE

To investigate survival following craniotomy or biopsy for PCNSL.

METHODS

The National Cancer Database-Participant User File (NCDB, n = 8936), Surveillance, Epidemiology, and End Results Program (SEER, n = 4636), and an institutional series (IS, n = 132) were used. We retrospectively investigated the relationship between craniotomy, prognostic factors, and survival for PCNSL using case-control design.

RESULTS

In NCDB, craniotomy was associated with increased median survival over biopsy (19.5 vs 11.0 mo), independent of subsequent radiation and chemotherapy (hazard ratio [HR] 0.80, P < .001). We found a similar trend with survival for craniotomy vs biopsy in the IS (HR 0.68, P = .15). In SEER, gross total resection was associated with increased median survival over biopsy (29 vs 10 mo, HR 0.68, P < .001). The survival benefit associated with craniotomy was greater within recursive partitioning analysis (RPA) class 1 group in NCDB (95.1 vs 29.1 mo, HR 0.66, P < .001), but was smaller for RPA 2-3 (14.9 vs 10.0 mo, HR 0.86, P < .001). A surgical risk category (RC) considering lesion location and number, age, and frailty was developed. Craniotomy was associated with increased survival vs biopsy for patients with low RC (133.4 vs 41.0 mo, HR 0.33, P = .01), but not high RC in the IS.

CONCLUSION

Craniotomy is associated with increased survival over biopsy for PCNSL in 3 retrospective datasets. Prospective studies are necessary to adequately evaluate this relationship. Such studies should evaluate patients most likely to benefit from cytoreductive surgery, ie, those with favorable RPA and RC.

Risk Factors for Early Mortality in Patients with Primary Central Nervous System Lymphoma: A Large-Cohort Retrospective Study

OBJECTIVE

The present study assessed early mortality (within 1 and 3 months) in patients with primary central nervous system lymphoma (PCNSL) and identified the risk factors associated with early mortality.

METHODS

We extracted the data for patients with PCNSL from the Surveillance, Epidemiology, and End Results dataset using the SEER∗Stat, version 8.3.5, software.

RESULTS

A total of 8091 patients with PCNSL were enrolled in the present study. Of the 8091 patients, 57.94% were men and 42.06% were women. The mean age was 59.50 ± 16.11 years. The rate of death within 1 and 3 months was 10.67% and 29.16%, respectively. During the past 20 years, early mortality declined significantly. The common causes of early death were non-Hodgkin lymphoma and other infectious and parasitic diseases, including human immunodeficiency virus. Our results showed that gender, age at diagnosis, ethnicity, histological subtype, marital status, tumor location, surgery, radiotherapy, and chemotherapy were associated with early mortality within 1 or 3 months.

CONCLUSION

The rate of early mortality has declined significantly during the past 20 years. The risk factors for early mortality within 1 or 3 months after a PCNSL diagnosis included advanced age, male gender, black race, frontal lobe location, unmarried, diffuse large B-cell lymphoma, no surgery, no chemotherapy, and no radiotherapy.

Surgery plus adjuvant radiotherapy for primary central nervous system lymphoma

Objective: Recent studies of primary central nervous system lymphoma (PCNSL) have found a positive association between cytoreductive surgery and survival, challenging the traditional notion that surgery is not beneficial and potentially harmful. However, no studies have examined the potential added benefits of adjuvant treatment in the post-operative setting. Here, we investigate survival in PCNSL patients treated with surgery plus radiation therapy (RT).Methods: The Surveillance, Epidemiology, and End-Results Program was used to identify patients with PCNSL from 1995-2013. We retrospectively analyzed the relationship between treatment, prognostic factors, and survival using case-control design. Treatment categories were compared to biopsy alone.Results: We identified 5417 cases. Median survival times for biopsy alone (n = 1824, 34%), biopsy + RT (n = 1460, 27%), surgery alone (n = 1222, 27%), and surgery + RT (n = 911, 17%) were 7, 8, 20, and 27 months, respectively. On multivariable analysis, surgery + RT was associated with improved survival over surgery alone (hazard ratio [HR] = 0.58 [95% confidence interval = 0.53-0.64] vs. HR = 0.71 [0.65-0.77]). Adjuvant RT was associated with improved survival, regardless of the extent of resection. HR's for subtotal resection, gross-total resection, subtotal resection + RT, and gross-total resection + RT were 0.77 (0.66-0.89), 0.66 (0.57-0.76), 0.62 (0.52-0.72), and 0.54 (0.46-0.63), respectively. Survival improved after adjuvant RT in patients under and over 60 years old. All findings were confirmed by multivariable analysis of cause-specific survival.Conclusion: Adjuvant RT was associated with improved survival in PCNSL patients who underwent surgery. Although these data are hypothesis-generating, additional information on neurotoxicity, dosing, and concurrent chemotherapy will be necessary to validate these findings. Cytoreductive surgery for PCNSL is common in the general population, and more studies are needed to assess optimal treatment in the post-operative setting.

Top Ten Tips Palliative Care Clinicians Should Know When Caring for Patients with Brain Cancer

The diagnosis of an aggressive, primary brain tumor is life altering for those affected and too often portends a poor prognosis. Despite decades of research, neither a cure nor even a therapy that reliably and dramatically prolongs survival has been found. Fortunately, there are a number of treatments that may prolong the life of select brain tumor patients although the symptom burden can sometimes be high. This article brings together neuro-oncologists, neurologists, and palliative care (PC) physicians to help shine a light on these diseases, their genetics, treatment options, and the symptoms likely to be encountered both from the underlying illness and its treatment. We hope to increase the understanding that PC teams have around these illnesses to improve care for patients and families.

The role of surgery in intracranial PCNSL

This aimed to evaluate the effect of surgery for overall survival (OS) and progression-free survival (PFS) in intracranial primary CNS lymphoma (PCNSL) of all patients diagnosed at a single center. A prospective database at Oslo University Hospital of PCNSL was reviewed over a 12-year period (2003-2014). Seventy-nine patients with intracranial PCNSL were identified. Deep brain involvement was shown in 63 patients. Thirty-two patients underwent craniotomy with resection, while all other patients had a biopsy. Fifty-seven patients were given chemotherapy: 18 were treated with the MSKCC (Memorial Sloan-Kettering Cancer Center) with rituximab, 21 with the MSKCC without rituximab, and 14 within a Nordic prospective phase II protocol. Forty-four patients achieved complete response (CR) and had OS of 46.3 months. Patients who underwent resection had a median OS of 28.6 versus 11.7 months for those who had a biopsy performed. Resection showed an insignificant prolongation of OS. Multivariate analysis confirmed statistical significance of deep brain involvement only (p < 0.005). Neither chemotherapy regimen, Karnofsky Performance Status (KPS), type of surgery, nor patient age was significant factors for OS or PFS. Resective surgery played no role in significantly improving either OS or PFS and therefore it is not recommended as treatment for PCNSL.

Assessing the Safety of Craniotomy for Resection of Primary Central Nervous System Lymphoma: A Nationwide Inpatient Sample Analysis

Background

Unlike many other central nervous system (CNS) tumors, the surgical management of primary central nervous system lymphomas (PCNSL) is traditionally limited by diagnostic biopsy. Studies that predate the use of modern neurosurgical techniques have reported a prohibitive operative morbidity for this surgery. These early experiences have dictated the non-surgical management of PCNSL, whereas resection for cytoreduction is a mainstay of treatment in other CNS malignancies. Recent studies have suggested that craniotomy with the goal of cytoreduction might be associated with a favorable overall and progression-free survival for some patients with PCNSL. To challenge the traditional non-surgical paradigm, it is essential to first investigate the safety of resection for PCNSL.

Methods

To determine the operative morbidity of resection for this disease, we performed a population-based assessment of complications using the nationwide inpatient sample database for the years 1998–2013 for biopsies and open craniotomies for PCNSL and other brain tumors.

Results

Among 95 patients who underwent biopsy and 34 patients who underwent craniotomy, we found no significant difference in complication rates between craniotomy for resection and biopsy procedures for PCNSL (23.16 versus 20.59%). The types of complications differ between diagnoses, with the PCNSL cohort suffering mainly medical complications and the non-PCNSL cohort suffering mainly from neurological complications.

Conclusion

These findings support the safety of craniotomies in PCNSL and help provide a rationale for future prospective studies to evaluate the safety and efficacy of resection for this disease.