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Yamaguchi J, Ohka F, Lushun C, Motomura K, Aoki K, Takeuchi K, Nagata Y, Ito S, Mizutani N, Ohno M, Suzaki N, Takasu S, Seki Y, Kano T, Wakabayashi K, Oyama H, Kurahashi S, Tanahashi K, Hirano M, Shimizu H, Kitano Y, Maeda S, Yamazaki S, Wakabayashi T, Kondo Y, Natsume A, Saito R. CD79B Y196 mutation is a potent predictive marker for favorable response to R-MPV in primary central nervous system lymphoma. Cancer Med 2022; 12:7116-7126. [PMID: 36478416 PMCID: PMC10067082 DOI: 10.1002/cam4.5512] [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: 07/10/2022] [Revised: 11/10/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Rituximab, high-dose methotrexate (HD-MTX), procarbazine and vincristine (R-MPV), has significantly prolonged the survival of patients with primary central nervous system lymphoma (PCNSL), but predictive factors for response to R-MPV have not yet been investigated. Herein, we investigated the correlation of MYD88 L265P and CD79B Y196 mutations, which are the most frequently found molecular alterations in PCNSL, with prognosis of patients with PCNSL treated with R-MPV. METHODS We investigated the long-term clinical course and status of MYD88 and CD79B genes in 85 patients with PCNSL treated with R-MPV or HD-MTX treatment, and the correlation of these genetic mutations with prognosis. RESULTS R-MPV achieved an excellent tumor control rate (61.6% and 69.9% of 5-year progression-free and overall survival rates, respectively). While MYD88 L265P mutation had no significant effect on survival, patients with CD79B Y196 mutations exhibited prolonged survival (p < 0.05). However, the association of CD79B Y196 mutation with a better prognosis was not observed in the HD-MTX cohort, which indicated that CD79B Y196 mutation was a predictive marker for a favorable response to R-MPV. Furthermore, we established an all-in-one rapid genotyping system for these genetic mutations. CONCLUSIONS In conclusion, CD79B Y196 mutation is a potent predictive marker for favorable response to R-MPV in PCNSL. The rapid identification of MYD88 L265P and CD79B Y196 mutations can be helpful not only for the accurate molecular diagnosis of PCNSL but also for the prediction of response to R-MPV.
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Affiliation(s)
- Junya Yamaguchi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Fumiharu Ohka
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Chalise Lushun
- Department of Neurosurgery, Nagoya Central Hospital, Nagoya, Japan
| | - Kazuya Motomura
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kosuke Aoki
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuhito Takeuchi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuichi Nagata
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Satoshi Ito
- Department of Neurosurgery, Konan Kosei Hospital, Konan, Japan
| | | | - Masasuke Ohno
- Department of Neurosurgery, Aichi Cancer Center Hospital, Nagoya, Japan.,Department of Neurosurgery, Nagoya Medical Center, Nagoya, Japan
| | - Noriyuki Suzaki
- Department of Neurosurgery, Nagoya Medical Center, Nagoya, Japan
| | - Syuntaro Takasu
- Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Yukio Seki
- Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Takahisa Kano
- Department of Neurosurgery, Anjo Kosei Hospital, Anjo, Japan
| | | | - Hirofumi Oyama
- Department of Neurosurgery, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Shingo Kurahashi
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Kuniaki Tanahashi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masaki Hirano
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroyuki Shimizu
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yotaro Kitano
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Sachi Maeda
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shintaro Yamazaki
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toshihiko Wakabayashi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Neurosurgery, Nagoya Kyoritsu Hospital, Nagoya, Japan
| | - Yutaka Kondo
- Division of Cancer Biology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Atsushi Natsume
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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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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3
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Sasaki N, Kobayashi K, Saito K, Shimizu S, Suzuki K, Lee J, Yamagishi Y, Shibahara J, Takayama N, Shiokawa Y, Nagane M. Consecutive single-institution case series of primary central nervous system lymphoma treated by R-MPV or high-dose methotrexate monotherapy. Jpn J Clin Oncol 2020; 50:999-1008. [PMID: 32469065 DOI: 10.1093/jjco/hyaa073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 05/04/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE The optimal regimen for use of high dose-methotrexate-based chemotherapy in primary central nervous system lymphoma is still under debate. We conducted a retrospective study to evaluate the treatment outcome of a combination immunochemotherapy consisting of rituximab, methotrexate, procarbazine and vincristine followed by with or without whole brain radiotherapy and consolidation cytarabine, in comparison with high dose-methotrexate monotherapy followed by full dose whole brain radiotherapy. METHODS Newly diagnosed primary central nervous system lymphoma patients treated with either rituximab, methotrexate, procarbazine and vincristine or high dose-methotrexate in Kyorin University Hospital were identified, and the response rates and survival were compared. Toxicities, post-treatment transition of Mini-Mental State Examination, Karnofsky performance status score, Fazekas scale and prognostic factors were analysed in the rituximab, methotrexate, procarbazine and vincristine group. RESULTS Ninety-five patients treated with rituximab, methotrexate, procarbazine and vincristine (n = 39) or high dose-methotrexate (n = 56) were analysed. The complete response/complete response unconfirmed rate was significantly higher in the rituximab, methotrexate, procarbazine and vincristine group (74.4 vs. 15.4%, P < 0.001). Accordingly, both median progression-free survival and overall survival were significantly longer in the rituximab, methotrexate, procarbazine and vincristine group (median progression-free survival: unreached vs. 14.75 months, P < 0.001) (median overall survival: unreached vs. 63.15 months, P = 0.005). Although the rate of grade 3/4 hematologic toxicities was high both during rituximab, methotrexate, procarbazine and vincristine and consolidation cytarabine, the rate of grade 3/4 infections was low, and no treatment related deaths were observed. Deterioration in Karnofsky performance status or Mini-Mental State Examination was rare, except on disease recurrence. Although whole brain radiotherapy was associated with Fazekas scale deterioration, its association with Karnofsky performance status or Mini-Mental State Examination deterioration was not significant. CONCLUSIONS Rituximab, methotrexate, procarbazine and vincristine was apparently promising in comparison with high dose-methotrexate monotherapy with manageable toxicity in this retrospective study, and further investigation is warranted.
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Affiliation(s)
- Nobuyoshi Sasaki
- Department of Neurosurgery, Kyorin University Graduate School of Medicine, Tokyo, Japan.,Department of Brain Tumor Translational Research, National Cancer Center Research Institute, Tokyo, Japan.,Department of Neurosurgery, Koyama Memorial Hospital, Kashima, Japan
| | - Keiichi Kobayashi
- Department of Neurosurgery, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Kuniaki Saito
- Department of Neurosurgery, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Saki Shimizu
- Department of Neurosurgery, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Kaori Suzuki
- Department of Neurosurgery, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Jeunghun Lee
- Department of Neurosurgery, Kanto Central Hospital, Tokyo, Japan
| | - Yuki Yamagishi
- Department of Neurosurgery, Kyorin University Graduate School of Medicine, Tokyo, Japan.,Department of Brain Tumor Translational Research, National Cancer Center Research Institute, Tokyo, Japan
| | - Junji Shibahara
- Department of Pathology, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Nobuyuki Takayama
- Department of Hematology, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Yoshiaki Shiokawa
- Department of Neurosurgery, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Motoo Nagane
- Department of Neurosurgery, Kyorin University Faculty of Medicine, Tokyo, Japan
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4
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Deguchi S, Nakashima K, Muramatsu K, Mitsuya K, Oishi T, Shirata K, Hayashi N, Sugino T, Endo M, Nakasu Y. Pretreatment intratumoral susceptibility signals correlate with response to high-dose methotrexate and progression-free survival in primary central nervous system lymphoma. J Clin Neurosci 2019; 69:43-50. [PMID: 31427235 DOI: 10.1016/j.jocn.2019.08.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 08/05/2019] [Indexed: 01/26/2023]
Abstract
We aimed to estimate the frequency of intratumoral susceptibility signals (ITSS) in susceptibility-weighted imaging (SWI) in consecutive patients with primary central nervous system lymphoma (PCNSL), and to determine if pretreatment heterogeneity of PCNSL is predictive of response to chemotherapy by using ITSS on SWI. We retrospectively examined 29 immunocompetent patients with PCNSL who underwent SWI-MRI before treatment. A univariate analysis was conducted with Fisher's exact test. Progression free survival (PFS) was calculated by the Kaplan-Meier method and compared by the log rank test. The patients, including 16 males, were initially treated at a median age of 69 years. All tissue types were diffuse large B-cell lymphoma. Nineteen patients (66%) presented lesions with ITSS. Sixteen patients (55%) received initial treatment with R-MTX (rituximab plus high-dose methotrexate). Seven out of nine patients with ITSS exhibited a poor response, whereas all seven without ITSS exhibited a good response to R-MTX. Regarding the absence of ITSS, the sensitivity, specificity, and diagnostic accuracy for a good response to R-MTX were 0.78, 1.00, and 0.88, respectively. Patients without ITSS showed significantly longer PFS compared to patients with ITSS (median PFS: 28.9 vs 2.1 months, P < 0.01). In conclusion, ITSS in PCNSL patients were more common than previously reported. We have to be careful to use ITSS for differentiating PCNSL and glioblastoma. Presence of ITSS correlated significantly with therapeutic response to R-MTX. ITSS may be a new marker for the response to chemotherapy in patients with PCNSL. A prospective multi-institutional analysis is needed.
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Affiliation(s)
- Shoichi Deguchi
- Divisions of Neurosurgery, Shizuoka Cancer Center, Nagaizumi-cho, Shizuoka, Japan.
| | - Kazuaki Nakashima
- Diagnostic Radiology, Shizuoka Cancer Center, Nagaizumi-cho, Shizuoka, Japan
| | - Koji Muramatsu
- Diagnostic Pathology, Shizuoka Cancer Center, Nagaizumi-cho, Shizuoka, Japan
| | - Koichi Mitsuya
- Divisions of Neurosurgery, Shizuoka Cancer Center, Nagaizumi-cho, Shizuoka, Japan
| | - Takuma Oishi
- Diagnostic Pathology, Shizuoka Cancer Center, Nagaizumi-cho, Shizuoka, Japan
| | - Kensei Shirata
- Diagnostic Radiology, Shizuoka Cancer Center, Nagaizumi-cho, Shizuoka, Japan
| | - Nakamasa Hayashi
- Divisions of Neurosurgery, Shizuoka Cancer Center, Nagaizumi-cho, Shizuoka, Japan
| | - Takashi Sugino
- Diagnostic Pathology, Shizuoka Cancer Center, Nagaizumi-cho, Shizuoka, Japan
| | - Masahiro Endo
- Diagnostic Radiology, Shizuoka Cancer Center, Nagaizumi-cho, Shizuoka, Japan
| | - Yoko Nakasu
- Divisions of Neurosurgery, Shizuoka Cancer Center, Nagaizumi-cho, Shizuoka, Japan
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5
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Fox CP, Phillips EH, Smith J, Linton K, Gallop-Evans E, Hemmaway C, Auer DP, Fuller C, Davies AJ, McKay P, Cwynarski K. Guidelines for the diagnosis and management of primary central nervous system diffuse large B-cell lymphoma. Br J Haematol 2018; 184:348-363. [PMID: 30467845 DOI: 10.1111/bjh.15661] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Christopher P Fox
- Clinical Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Jeffery Smith
- Department of Haematology, Division of Cancer Sciences, School of Medical Sciences, Aintree Hospital NHS Trust, Liverpool, UK
| | - Kim Linton
- University of Manchester, Manchester, UK
| | | | - Claire Hemmaway
- Department of Haematology, Barking, Havering and Redbridge University Hospitals, Essex, UK
| | - Dorothee P Auer
- Division of Clinical Neuroscience, Radiological Sciences, University of Nottingham, Nottingham, UK
| | - Charlotte Fuller
- Department of Neuropsychology, Barking, Havering and Redbridge University Hospitals, Essex, UK
| | - Andrew J Davies
- Department of Medical Oncology, Southampton General Hospital, Southampton, UK
| | - Pamela McKay
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Kate Cwynarski
- Department of Haematology, University College Hospital, London, UK
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6
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Royer-Perron L, Hoang-Xuan K. Management of primary central nervous system lymphoma. Presse Med 2018; 47:e213-e244. [PMID: 30416008 DOI: 10.1016/j.lpm.2018.04.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 03/21/2018] [Accepted: 04/09/2018] [Indexed: 12/28/2022] Open
Abstract
A rare tumor, primary central nervous system lymphoma can affect immunocompetent and immunocompromised patients. While sensitive to radiotherapy or chemotherapy crossing the blood-brain barrier, it often recurs. Modern treatment consists of high-dose methotrexate-based induction chemotherapy, often followed by consolidation with either radiotherapy or further chemotherapy. Neurotoxicity is however a concern with radiotherapy, especially for patients older than 60 years. The benefit of the addition of rituximab to chemotherapy is unclear. Targeted therapies and immunotherapy have been effective in some patients and are tested on a larger scale. Survival has improved in the last decade, but remains poor in older patients.
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Affiliation(s)
- Louis Royer-Perron
- Hôpital Pierre-Boucher, Longueuil, Canada; AP-HP, Sorbonne universités, UPMC université Paris 06, hôpitaux Universitaires La Pitié Salpêtrière, Charles Foix, service de neurologie, 2, Mazarin, 75013, Paris, France; LOC network, 75561 Paris cedex 13, France.
| | - Khê Hoang-Xuan
- Institut du Cerveau et de la Moelle épinière (ICM), Inserm U 1127, CNRS UMR 7225, Paris, France; AP-HP, Sorbonne universités, UPMC université Paris 06, hôpitaux Universitaires La Pitié Salpêtrière, Charles Foix, service de neurologie, 2, Mazarin, 75013, Paris, France; LOC network, 75561 Paris cedex 13, France
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7
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Strüßmann T, Fritsch K, Baumgarten A, Fietz T, Engelhardt M, Mertelsmann R, Ihorst G, Duyster J, Finke J, Marks R. Favourable outcomes of poor prognosis diffuse large B-cell lymphoma patients treated with dose-dense Rituximab, high-dose Methotrexate and six cycles of CHOP-14 compared to first-line autologous transplantation. Br J Haematol 2017. [PMID: 28643323 DOI: 10.1111/bjh.14802] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The optimal therapeutic approach for young diffuse large B-cell lymphoma (DLBCL) patients with high-intermediate and high-risk age-adjusted international prognostic index (aaIPI) remains unknown. Hereby we report a 10-year single-centre study of 63 consecutively treated patients. To optimize outcome, two approaches were carried out: Cohort 1 patients received four cycles R-CHOP-21 (rituximab, cyclophosphamide, daunorubicin, vincristine, prednisolone over 21 days) followed by first-line high-dose chemotherapy with autologous stem-cell support (HDCT-ASCT), resulting in 2-year progression-free (PFS) and overall survival (OS) of 60·6% and 67·9%. 39·4% of those patients were not transplanted upfront, mainly due to early progressive disease (24·2%). Cohort 2 patients received an early intensified protocol of six cycles of CHOP-14 (cyclophosphamide, daunorubicin, vincristine, prednisolone over 14 days) with dose-dense rituximab and high-dose methotrexate resulting in promising overall response- (93·3%) and complete remission (90%) rates and sustained survival (2-year PFS and OS: 93·3%). In an intention-to-treat analysis, 2-year PFS (60·6% vs. 93·3%, hazard ratio [HR] 7·2, P = 0·009) and OS (69·7% vs. 93·3%, HR 4·95, P = 0·038) differed significantly, in favour of the early intensified protocol (Cohort 2). In a multivariate Cox-regression model, PFS (HR 8·12, 95% confidence interval [CI] 1·83-35·9, P = 0·006) and OS (HR 5·86, 95% CI 1·28-26·8, P = 0·02) remained superior for Cohort 2 when adjusted for aaIPI3 as the most important prognostic factor. Survival of young poor-prognosis DLBCL patients appears superior after early therapy intensification.
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Affiliation(s)
- Tim Strüßmann
- Department Haematology, Oncology & Stem Cell Transplantation, Faculty of Medicine and Medical Centre - University of Freiburg, Freiburg, Germany
| | - Kristina Fritsch
- Department Haematology, Oncology & Stem Cell Transplantation, Faculty of Medicine and Medical Centre - University of Freiburg, Freiburg, Germany
| | - Axel Baumgarten
- Department Haematology, Oncology & Stem Cell Transplantation, Faculty of Medicine and Medical Centre - University of Freiburg, Freiburg, Germany
| | - Thomas Fietz
- Community-based private haematology-oncology practice, Singen, Germany
| | - Monika Engelhardt
- Department Haematology, Oncology & Stem Cell Transplantation, Faculty of Medicine and Medical Centre - University of Freiburg, Freiburg, Germany
| | - Roland Mertelsmann
- Department Haematology, Oncology & Stem Cell Transplantation, Faculty of Medicine and Medical Centre - University of Freiburg, Freiburg, Germany
| | - Gabriele Ihorst
- Clinical Trials Unit, Faculty of Medicine and Medical Centre - University of Freiburg, Freiburg, Germany
| | - Justus Duyster
- Department Haematology, Oncology & Stem Cell Transplantation, Faculty of Medicine and Medical Centre - University of Freiburg, Freiburg, Germany
| | - Jürgen Finke
- Department Haematology, Oncology & Stem Cell Transplantation, Faculty of Medicine and Medical Centre - University of Freiburg, Freiburg, Germany
| | - Reinhard Marks
- Department Haematology, Oncology & Stem Cell Transplantation, Faculty of Medicine and Medical Centre - University of Freiburg, Freiburg, Germany
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8
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Kasenda B, Ihorst G, Schroers R, Korfel A, Schmidt-Wolf I, Egerer G, von Baumgarten L, Röth A, Bloehdorn J, Möhle R, Binder M, Keller U, Lamprecht M, Pfreundschuh M, Valk E, Fricker H, Schorb E, Fritsch K, Finke J, Illerhaus G. High-dose chemotherapy with autologous haematopoietic stem cell support for relapsed or refractory primary CNS lymphoma: a prospective multicentre trial by the German Cooperative PCNSL study group. Leukemia 2017; 31:2623-2629. [PMID: 28559537 DOI: 10.1038/leu.2017.170] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 05/08/2017] [Accepted: 05/15/2017] [Indexed: 01/08/2023]
Abstract
To investigate safety and efficacy of high-dose chemotherapy followed by autologous stem cell transplantation (HCT-ASCT) in relapsed/refractory (r/r) primary central nervous system lymphoma (PCNSL), we conducted a single-arm multicentre study for immunocompetent patients (<66 years) with PCNSL failing high-dose methotrexate)-based chemotherapy. Induction consisted of two courses of rituximab (375 mg/m2), high-dose cytarabine (2 × 3 g/m2) and thiotepa (40 mg/m2) with collection of stem cells in between. Conditioning for HCT-ASCT consisted of rituximab 375 mg/m2, carmustine 400 mg/m2 and thiotepa (4 × 5 mg/kg). Patients commenced HCT-ASCT irrespective of response after induction. Patients not achieving complete remission (CR) after HCT-ASCT received whole-brain radiotherapy. Primary end point was CR after HCT-ASCT. We enrolled 39 patients; median age and Karnofsky performance score are 57 years and 90%, respectively. About 28 patients had relapsed and 8 refractory disease. About 22 patients responded to induction and 32 patients commenced HCT-ASCT. About 22 patients (56.4%) achieved CR after HCT-ASCT. Respective 2-year progression-free survival (PFS) and overall survival (OS) rates were 46.0% (median PFS 12.4 months) and 56.4%; median OS not reached. We recorded four treatment-related deaths. Thiotepa-based HCT-ASCT is an effective treatment option in eligible patients with r/r PCNSL. Comparative studies are needed to further scrutinise the role of HCT-ASCT in the salvage setting.
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Affiliation(s)
- B Kasenda
- Department of Haematology/Oncology, Klinikum Stuttgart, Stuttgart, Germany.,Department of Medical Oncology & Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - G Ihorst
- Clinical Trials Unit, Medical Centre - University of Freiburg, Freiburg, Germany
| | - R Schroers
- Department of Medicine, Hematology and Oncology, Ruhr-University of Bochum, Knappschaftskrankenhaus Bochum-Langendreer, Bochum, Germany
| | - A Korfel
- Department of Hematology, Oncology and Tumor Immunology, Charite University Medicine, Berlin, Germany
| | - I Schmidt-Wolf
- Department of Internal Medicine III, Center for Integrated Oncology (CIO), University Hospital Bonn, Bonn, Germany
| | - G Egerer
- Department of Haematology and Oncology, Heidelberg University, Heidelberg, Germany
| | - L von Baumgarten
- Department of Neurology, University Hospital Munich LMU, Munich, Germany
| | - A Röth
- Medical Faculty, Department of Haematology, University of Duisburg-Essen, Essen, Germany
| | - J Bloehdorn
- Department of Internal Medicine III, University of Ulm, Ulm, Germany
| | - R Möhle
- Department of Haematology and Oncology, University Tübingen, Tübingen, Germany
| | - M Binder
- Department of Oncology and Hematology, University of Hamburg, Hamburg, Germany
| | - U Keller
- III Medical Department, Technische Universität München, Munich, Germany
| | - M Lamprecht
- Department of Internal Medicine II, University Hospital of Schleswig-Holstein, Campus Kiel, Germany
| | - M Pfreundschuh
- Klinik für Innere Medizin I, Universität des Saarlandes, Homburg, Germany
| | - E Valk
- Department of Haematology/Oncology, Klinikum Stuttgart, Stuttgart, Germany
| | - H Fricker
- Department of Haematology, Oncology and Stem Cell Transplantation, University Hospital Freiburg, Freiburg, Germany
| | - E Schorb
- Department of Haematology, Oncology and Stem Cell Transplantation, University Hospital Freiburg, Freiburg, Germany
| | - K Fritsch
- Department of Haematology, Oncology and Stem Cell Transplantation, University Hospital Freiburg, Freiburg, Germany
| | - J Finke
- Department of Haematology, Oncology and Stem Cell Transplantation, University Hospital Freiburg, Freiburg, Germany
| | - G Illerhaus
- Department of Haematology/Oncology, Klinikum Stuttgart, Stuttgart, Germany.,Department of Haematology, Oncology and Stem Cell Transplantation, University Hospital Freiburg, Freiburg, Germany
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9
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Primary central nervous system lymphoma: essential points in diagnosis and management. Med Oncol 2017; 34:61. [PMID: 28315229 DOI: 10.1007/s12032-017-0920-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 03/14/2017] [Indexed: 12/19/2022]
Abstract
Primary central nervous system lymphoma (PCNSL) is an extra-nodal non-Hodgkin lymphoma. PCNSL is defined as lymphoma involving the brain, leptomeninges, eyes, or spinal cord without evidence of lymphoma outside the CNS. Treatment includes induction with chemotherapy and consolidation with whole-brain radiotherapy or high-dose chemotherapy supported by autologous stem cell transplantation. High-dose methotrexate is the most important drug in cases with PCNSL, and this drug will be used in combination with small molecules, BTK inhibitors, new monoclonal antibodies, and checkpoint blockers.
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Illerhaus G, Kasenda B, Ihorst G, Egerer G, Lamprecht M, Keller U, Wolf HH, Hirt C, Stilgenbauer S, Binder M, Hau P, Edinger M, Frickhofen N, Bentz M, Möhle R, Röth A, Pfreundschuh M, von Baumgarten L, Deckert M, Hader C, Fricker H, Valk E, Schorb E, Fritsch K, Finke J. High-dose chemotherapy with autologous haemopoietic stem cell transplantation for newly diagnosed primary CNS lymphoma: a prospective, single-arm, phase 2 trial. LANCET HAEMATOLOGY 2016; 3:e388-97. [PMID: 27476790 DOI: 10.1016/s2352-3026(16)30050-3] [Citation(s) in RCA: 111] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 05/19/2016] [Accepted: 05/20/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND High-dose methotrexate-based chemotherapy is standard for primary CNS lymphoma, but most patients relapse. High-dose chemotherapy with autologous stem cell transplantation (HCT-ASCT) is supposed to overcome the blood-brain barrier and eliminate residual disease in the CNS. We aimed to investigate the safety and efficacy of HCT-ASCT in patients with newly diagnosed primary CNS lymphoma. METHODS In this prospective, single-arm, phase 2 trial, we recruited patients aged 18-65 years with newly diagnosed primary CNS lymphoma and immunocompetence, with no limitation on clinical performance status, from 15 hospitals in Germany. Patients received five courses of intravenous rituximab 375 mg/m(2) (7 days before first high-dose methotrexate course and then every 10 days) and four courses of intravenous high-dose methotrexate 8000 mg/m(2) (every 10 days) and then two courses of intravenous rituximab 375 mg/m(2) (day 1), cytarabine 3 g/m(2) (days 2 and 3), and thiotepa 40 mg/m(2) (day 3). 3 weeks after the last course, patients commenced intravenous HCT-ASCT (rituximab 375 mg/m(2) [day 1], carmustine 400 mg/m(2) [day 2], thiotepa 2 × 5 mg/kg [days 3 and 4], and infusion of stem cells [day 7]), irrespective of response status after induction. We restricted radiotherapy to patients without complete response after HCT-ASCT. The primary endpoint was complete response at day 30 after HCT-ASCT in all registered eligible patients who received at least 1 day of study treatment. This trial is registered at ClinicalTrials.gov, number NCT00647049. FINDINGS Between Jan 18, 2007, and May 23, 2011, we recruited 81 patients, of whom two (2%) were excluded, therefore we included 79 (98%) patients in the analysis. All patients started induction treatment; 73 (92%) commenced HCT-ASCT. 61 (77·2% [95% CI 66·1-86·6]) patients achieved a complete response. During induction treatment, the most common grade 3 toxicity was anaemia (37 [47%]) and the most common grade 4 toxicity was thrombocytopenia (50 [63%]). During HCT-ASCT, the most common grade 3 toxicity was fever (50 [68%] of 73) and the most common grade 4 toxicity was leucopenia (68 [93%] of 73). We recorded four (5%) treatment-related deaths (three [4%] during induction and one [1%] 4 weeks after HCT-ASCT). INTERPRETATION HCT-ASCT with thiotepa and carmustine is an effective treatment option in young patients with newly diagnosed primary CNS lymphoma, but further comparative studies are needed. FUNDING University Hospital Freiburg and Amgen.
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Affiliation(s)
- Gerald Illerhaus
- Department of Haematology/Oncology and Palliative Care, Klinikum Stuttgart, Stuttgart, Germany; Department of Hematology, Oncology, and Stem-Cell Transplantation, University Medical Hospital and Faculty of Medicine, Albert-Ludwigs University, Freiburg, Germany.
| | - Benjamin Kasenda
- Department of Haematology/Oncology and Palliative Care, Klinikum Stuttgart, Stuttgart, Germany; Department of Medicine, Royal Marsden Hospital, London, UK
| | - Gabriele Ihorst
- Clinical Trials Unit, University of Freiburg Medical Centre, Freiburg, Germany
| | - Gerlinde Egerer
- Department of Haematology and Oncology, Heidelberg University, Heidelberg, Germany
| | - Monika Lamprecht
- Department of Internal Medicine II, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Ulrich Keller
- III Medical Department, Technische Universität München, Munich, Germany
| | - Hans-Heinrich Wolf
- Department of Haematology and Oncology, University Hospital Halle, Halle, Germany
| | - Carsten Hirt
- Hematology and Oncology, Clinic for Internal Medicine C, University of Greifswald, Greifswald, Germany
| | | | - Mascha Binder
- Department of Internal Medicine II, Oncology, Hematology, and Bone Marrow Transplantation with section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Hau
- Department of Neurology and Wilhelm Sander-NeuroOncology Unit, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Edinger
- Department of Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Norbert Frickhofen
- Department of Haematology and Oncology, HELIOS Dr Horst Schmidt Kliniken, Wiesbaden, Germany
| | - Martin Bentz
- Medizinische Klinik, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Robert Möhle
- Department of Haematology and Oncology, University of Tübingen, Tübingen, Germany
| | - Alexander Röth
- Department of Haematology, Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | | | | | - Martina Deckert
- Institute of Neuropathology, University Hospital of Cologne, Cologne, Germany
| | - Claudia Hader
- Department of Neuroradiology, University Hospital Freiburg, Freiburg, Germany
| | - Heidi Fricker
- Department of Hematology, Oncology, and Stem-Cell Transplantation, University Medical Hospital and Faculty of Medicine, Albert-Ludwigs University, Freiburg, Germany
| | - Elke Valk
- Department of Haematology/Oncology and Palliative Care, Klinikum Stuttgart, Stuttgart, Germany
| | - Elisabeth Schorb
- Department of Hematology, Oncology, and Stem-Cell Transplantation, University Medical Hospital and Faculty of Medicine, Albert-Ludwigs University, Freiburg, Germany
| | - Kristina Fritsch
- Department of Hematology, Oncology, and Stem-Cell Transplantation, University Medical Hospital and Faculty of Medicine, Albert-Ludwigs University, Freiburg, Germany
| | - Jürgen Finke
- Department of Hematology, Oncology, and Stem-Cell Transplantation, University Medical Hospital and Faculty of Medicine, Albert-Ludwigs University, Freiburg, Germany
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Schorb E, Finke J, Ferreri AJM, Ihorst G, Mikesch K, Kasenda B, Fritsch K, Fricker H, Burger E, Grishina O, Valk E, Zucca E, Illerhaus G. High-dose chemotherapy and autologous stem cell transplant compared with conventional chemotherapy for consolidation in newly diagnosed primary CNS lymphoma--a randomized phase III trial (MATRix). BMC Cancer 2016; 16:282. [PMID: 27098429 PMCID: PMC4839072 DOI: 10.1186/s12885-016-2311-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 04/12/2016] [Indexed: 02/08/2023] Open
Abstract
Background Primary central nervous system lymphoma (PCNSL) is a highly aggressive Non-Hodgkin lymphoma (NHL) with rising incidence over the past 30 years in immunocompetent patients. Although outcomes have improved, PCNSL is still associated with inferior prognosis compared to systemic NHL. Many questions regarding the optimal therapeutic approach remain unanswered. Methods/Design This is a randomized, open-label, international phase III trial with two parallel arms. We will recruit 250 patients with newly diagnosed PCNSL from approximately 35 centers within the networks of the German Cooperative PCNSL study group and the International Extranodal Lymphoma Study Group. All enrolled patients will undergo induction chemotherapy consisting of 4 cycles of rituximab 375 mg/m2/d (days 0 & 5), methotrexate 3.5 g/m2 (d1), cytarabine 2 × 2 g/m2/d (d2-3), and thiotepa 30 mg/m2 (d4) every 21 days. All patients will undergo stem-cell harvest after the second cycle. After 4 cycles of induction chemotherapy, patients achieving partial or complete response will be centrally randomized to 2 different consolidation treatments: (A) conventional-dose immuno chemotherapy with rituximab 375 mg/m2 (d0), dexamethasone 40 mg/d (d1-3), etoposide 100 mg/m2/d (d1-3), ifosfamide 1500 mg/m2/d (d1-3) and carboplatin 300 mg/m2 (d1) (R-DeVIC) or (B) high-dose chemotherapy with BCNU (or busulfan) and thiotepa followed by autologous stem cell transplantation (HCT-ASCT). The objective is to demonstrate superiority of HCT-ASCT compared to R-DeVIC with respect to progression-free survival (PFS, primary endpoint). Secondary endpoints include overall survival (OS), treatment response and treatment-related morbidities. Minimal follow-up after treatment completion is 24 months. Discussion The rationale for consolidation treatment in PCNSL is to eliminate residual lymphoma cells and to decrease the risk for relapse. This can be achieved by agents crossing the blood brain barrier either applied at conventional doses or at high doses requiring autologous stem cell support. HCT-ASCT has been shown to be feasible and highly effective in patients with newly-diagnosed PCNSL. However, it is unclear whether HCT-ASCT is really superior compared to conventional-dose chemotherapy after an intensified antimetabolites-based immunochemotherapy in patients with newly-diagnosed PCNSL. To answer this question, we designed this investigator initiated randomized phase III trial. Trial registration German clinical trials registry DRKS00005503 registered 22 April 2014 and ClinicalTrials.gov NCT02531841 registered 24 August 2015. Electronic supplementary material The online version of this article (doi:10.1186/s12885-016-2311-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elisabeth Schorb
- Department of Hematology/Oncology, Freiburg University Medical Center, Freiburg, Germany
| | - Juergen Finke
- Department of Hematology/Oncology, Freiburg University Medical Center, Freiburg, Germany
| | - Andrés J M Ferreri
- Unit of Lymphoid Malignancies, Head Division of OncoHematological Medicine, Department of OncoHematology, San Raffaele Scientific Institute, Milan, Italy
| | - Gabriele Ihorst
- Clinical Trials Unit, Freiburg University Medical Center, Freiburg, Germany
| | - Kristina Mikesch
- Clinic of Hematology, Oncology and Palliative Care, Klinikum Stuttgart, Kriegsbergstr.60, Stuttgart, 70174, Germany
| | - Benjamin Kasenda
- Clinic of Hematology, Oncology and Palliative Care, Klinikum Stuttgart, Kriegsbergstr.60, Stuttgart, 70174, Germany
| | - Kristina Fritsch
- Department of Hematology/Oncology, Freiburg University Medical Center, Freiburg, Germany
| | - Heidi Fricker
- Department of Hematology/Oncology, Freiburg University Medical Center, Freiburg, Germany
| | - Elvira Burger
- Clinical Trials Unit, Freiburg University Medical Center, Freiburg, Germany
| | - Olga Grishina
- Clinical Trials Unit, Freiburg University Medical Center, Freiburg, Germany
| | - Elke Valk
- Clinic of Hematology, Oncology and Palliative Care, Klinikum Stuttgart, Kriegsbergstr.60, Stuttgart, 70174, Germany
| | - Emanuele Zucca
- Oncology Institute of Southern Switzerland, San Giovanni Hospital, Bellinzona, Switzerland
| | - Gerald Illerhaus
- Clinic of Hematology, Oncology and Palliative Care, Klinikum Stuttgart, Kriegsbergstr.60, Stuttgart, 70174, Germany.
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Korfel A, Schlegel U. [Primary CNS lymphoma. Progress in the diagnostics and therapy]. DER NERVENARZT 2015; 86:710-2, 714-5. [PMID: 26013534 DOI: 10.1007/s00115-014-4227-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Some important knowledge has recently been gained on primary central nervous system lymphomas (PCNSL) despite its rarity. GOAL This article summarizes the most relevant progress in the diagnostics and therapy of PCNSL and discusses future directions. MATERIAL AND METHODS Reference articles in the English language literature were studied with respect to future approaches in PCNSL. RESULTS New diagnostic methods in cerebrospinal fluid have been developed to facilitate lymphoma diagnosis; however, their value still has to be validated. A better immunohistological and molecular characterization of PCNSL will probably result in identification of new therapeutic targets. The only phase III trial for PCNSL completed so far did not demonstrate a survival advantage with whole brain irradiation after high-dose methotrexate (HDMTX)-based chemotherapy as compared to chemotherapy alone. The optimal primary chemotherapy has not yet been established due to a lack of results from randomized trials. Non-comparative studies suggest a superiority of combined polychemotherapy over HDMTX monotherapy. Future therapeutic developments are directed towards consolidation of HDMTX-based induction chemotherapy with noncross-resistant conventional chemotherapy or high-dose chemotherapy with autologous stem cell transplantation. An important goal of all therapies for PCNSL is to avoid delayed neurotoxicity. DISCUSSION Further improvement of diagnostics and well-designed comparative studies, including new drugs when possible are still needed to define the optimal management of this still frequently prognostically unfavorable disease.
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Affiliation(s)
- A Korfel
- Medizinische Klinik mit Schwerpunkt Hämatologie, Onkologie und Tumorimmunologie, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Deutschland,
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Treatment outcome of relapsed/refractory primary central nervous system diffuse large B-cell lymphoma: a single-center experience of autologous stem cell transplantation. Int J Hematol 2013; 98:346-54. [PMID: 23868695 DOI: 10.1007/s12185-013-1403-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 07/11/2013] [Accepted: 07/11/2013] [Indexed: 10/26/2022]
Abstract
No salvage treatment strategy has been established for relapsed or refractory primary central nervous system lymphoma (PCNSL). We compared treatment outcomes of patients who underwent salvage chemotherapy with or without autologous stem cell transplantation (ASCT). We retrospectively analyzed PCNSL patients who were histologically diagnosed with diffuse large B-cell lymphoma. All patients relapsed after high-dose methotrexate (MTX)-based chemotherapy, or were refractory to high-dose MTX. Patients were treated with salvage chemotherapy, such as ICE/D (ifosfamide, carboplatin, etoposide, and dexamethasone) or high-dose MTX. High-dose chemotherapy containing thiotepa and busulfan followed by ASCT was performed if patients were eligible for ASCT after salvage treatment. Forty-five patients (35 relapsed and 10 refractory) received ICE/D or high-dose MTX. Despite the important difference that ICE/D was used predominantly for early relapsed or refractory patients, the two salvage treatments produced similar overall response rates [84.4 % (38/45) for ICE/D and 81.3 % (13/16) for high-dose MTX re-treatment]. Eighteen patients underwent ASCT, whereas 27 patients received salvage chemotherapy alone. The median progression-free survival of patients who underwent ASCT (19.5 months) was significantly better than that of patients who did not receive ASCT (6.7 months, P = 0.023). Multivariate analysis showed that refractoriness to initial treatment and no ASCT were significantly associated with poor survival outcome. Our study suggested that the combination of ifosfamide, carboplatin, etoposide, and dexamethasone may represent a feasible salvage treatment option for relapsed or refractory PCNSL, and that high-dose chemotherapy containing thiotepa and busulfan followed by ASCT may be effective for patients with a favorable toxicity profile.
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The combination of 13N-ammonia and 18F-FDG in predicting primary central nervous system lymphomas in immunocompetent patients. Clin Nucl Med 2013; 38:98-102. [PMID: 23334122 DOI: 10.1097/rlu.0b013e318279b6cc] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Accurate identification of primary central nervous system lymphoma (PCNSL) and its differentiation from other brain tumors remain difficult but are essential for treatment. In this study, we investigated whether (13)N-ammonia combined with (18)F-FDG could distinguish PCNSL from solid gliomas effectively. METHODS Ten consecutive patients with final diagnosis of PCNSL (5 female and 5 male patients; mean [SD] age, 59.10 [12.47] years; range, 43-74 years) and another fifteen consecutive patients with solid glioma lesions (5 female and 10 male patients; mean [SD] age, 46.73 [19.61] years; range, 14-72 years) were included in this study. PET/CT imaging was performed for all of them with both (18)F-FDG and (13)N-ammonia as tracers. Tumor-to-gray matter (T/G) ratios were calculated for the evaluation of tumor uptake. Both Student t test and discriminant analysis were recruited to assess the differential efficacy of these 2 tracers. RESULTS The T/G ratios of (18)F-FDG in PCNSL lesions were higher than in solid gliomas (3.26 [1.18] vs 1.56 [0.41], P < 0.001), whereas the T/G ratios of (13)N-ammonia in PCNSL lesions were lower than in solid gliomas significantly (1.38 [0.20] vs 2.11 [0.69], P < 0.001). All the lesions of PCNSL displayed higher T/G ratios of (18)F-FDG than (13)N-ammonia, whereas 14 (77.8%) of 18 glioma lesions showed contrary results. Tumor classification by means of canonical discriminant analysis yielded an overall accuracy of 96.9%, and only one glioma lesion was misclassified into the PCNSL group. CONCLUSIONS PCNSLs and solid gliomas have different metabolic profiles on N-ammonia and F-FDG imaging. The combination of these 2 tracers can distinguish these 2 clinical entities effectively and make an accurate prediction of PCNSL.
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Mappa S, Marturano E, Licata G, Frezzato M, Frungillo N, Ilariucci F, Stelitano C, Ferrari A, Sorarù M, Vianello F, Baldini L, Proserpio I, Foppoli M, Assanelli A, Reni M, Caligaris-Cappio F, Ferreri AJM. Salvage chemoimmunotherapy with rituximab, ifosfamide and etoposide (R-IE regimen) in patients with primary CNS lymphoma relapsed or refractory to high-dose methotrexate-based chemotherapy. Hematol Oncol 2012; 31:143-50. [PMID: 23161567 DOI: 10.1002/hon.2037] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 10/03/2012] [Accepted: 10/05/2012] [Indexed: 11/11/2022]
Abstract
Despite a high proportion of patients with primary CNS lymphoma (PCNSL) experiences failure after/during first-line treatment, a few studies focused on salvage therapy are available, often with disappointing results. Herein, we report feasibility and activity of a combination of rituximab, ifosfamide and etoposide (R-IE regimen) in a multicentre series of patients with PCNSL relapsed or refractory to high-dose methotrexate-based chemotherapy. We considered consecutive HIV-negative patients ≤75 years old with failed PCNSL treated with R-IE regimen (rituximab 375 mg/m(2) , day 0; ifosfamide 2 g/m(2) /day, days1-3; etoposide 250 mg/m(2) , day 1; four courses). Twenty-two patients (median age 60 years; range 39-72; male/female ratio: 1:4) received R-IE as second-line (n = 18) or third-line (n = 4) treatment. Eleven patients had refractory PCNSL, and 11 had relapsing disease. Twelve patients had been previously irradiated. Sixty (68%) of the 88 planned courses were actually delivered; only one patient interrupted R-IE because of toxicity. Grade 4 hematological toxicity was manageable; a single case of grade 4 non-hematological toxicity (transient hepatotoxicity) was recorded. Response was complete in six patients and partial in three (overall response rate = 41%; 95%CI: 21-61%). Seven patients were successfully referred to autologous peripheral blood stem cell collection; four responders were consolidated with high-dose chemotherapy supported by autologous stem cell transplant. At a median follow-up of 24 months, eight responders did not experience relapse, two of them died of neurological impairment while in remission. Six patients are alive, with a 2-year survival after relapse of 25 ± 9%. We concluded that R-IE is a feasible and active combination for patients with relapsed/refractory PCNSL. This regimen allows stem cell collection and successful consolidation with high-dose chemotherapy and autologous transplant.
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Affiliation(s)
- Silvia Mappa
- Unit of Lymphoid Malignancies, Division of Onco-Hematological Medicine, Department of Onco-Hematology, San Raffaele Scientific Institute, Milan, Italy
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Current world literature. Curr Opin Oncol 2012; 24:756-68. [PMID: 23079785 DOI: 10.1097/cco.0b013e32835a4c91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Prodduturi P, Bierman PJ. Current and emerging pharmacotherapies for primary CNS lymphoma. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2012; 6:219-31. [PMID: 22654527 PMCID: PMC3362327 DOI: 10.4137/cmo.s7752] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Primary central nervous system lymphoma (PCNSL) constitutes a rare group of extranodal non-Hodgkin's lymphoma (NHL) primarily of B cell origin. It occurs in both immuno-competent and immune-compromised patients. High dose m ethotrexate (HD-MTX) based chemotherapy is the standard therapy. Chemotherapy with whole brain radiation therapy (WBRT) improves response rates and survival compared with WBRT alone. However, due to the increased risk for neurotoxicity with WBRT, recent studies have focused on using chemotherapy alone. Methotrexate based multi-agent chemotherapy without WBRT is associated with similar t reatment rates and survival compared with regimens that include WBRT although controlled trials have not been performed. Because of the low incidence of this disease, it is difficult to conduct randomized controlled trials. In this article we have discussed about the past, present and emerging treatment options in patients with PCNSL.
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Affiliation(s)
- Prathima Prodduturi
- University of Nebraska Medical Center, Division of Hematology and Oncology, Omaha, NE, USA 68198-7680
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