Primary central nervous system lymphoma

Role and application of chemokine CXCL13 in central nervous system lymphoma

Chemokine ligand 13 (CXCL13) and its chemokine receptor 5 (CXCR5) both play significant roles in the tumor microenvironment (TME). CXCL13 in cerebrospinal fluid (CSF) has recently been found to have significant diagnostic and prognostic value in primary and secondary central nervous system (CNS) diffuse large B-cell lymphoma (DLBCL), and the CXCL13-CXCR5 axis has been shown to play an important chemotactic role in the TME of CNS-DLBCL. In this review, we first describe the clinical value of CXCL13 in CSF as a prognostic and diagnostic biomarker for CNS-DLBCL. In addition, this review also discusses the specific mechanisms associated with the CXCL13-CXCR5 axis in tumor immunity of primary diffuse large B cell lymphoma of the central nervous system (PCNS-DLBCL) by reviewing the specific mechanisms of this axis in the immune microenvironment of DLBCL and CNS inflammation, as well as the prospects for the use of CXCL13-CXCR5 axis in immunotherapy in PCNS-DLBCL.

Epileptic seizures in patients with primary central nervous system lymphoma: A systematic review

BACKGROUND

Primary central nervous system lymphoma (PCNSL) accounts for less than 5% of primary brain tumors. Epileptic seizures are a common manifestation of brain tumors; however, literature on the prevalence, characteristics, and oncological implications of seizures in patients with PCNSL is limited, and the management of antiepileptic drugs (AEDs) is unclear. This review aimed to summarize the existing knowledge on seizures in PCNSL, their potential association with surgery, oncological treatment, survival rates, and management of AEDs.

METHODS

A systematic review was performed according to the PRISMA recommendations and included articles published between 1953 and 2023 describing seizures in patients with PCNSL.

RESULTS

The search identified 282 studies, of which 21 were included. Up to 33% of patients with PCNSL developed seizures, mostly at the initial presentation. Little information was found on changes in seizure incidence through the course of the disease, and no details were found on seizure frequency, the percentage of treatment-resistant patients, or the evolution of seizures at remission. Younger age, cortical location, and immunodeficiency have been identified as potential risk factors for seizures, but evidence is very limited. The growing use of vigorous treatments including intensive chemotherapy with autologous stem cell transplantation and immunotherapy with CAR-T cells is associated with a higher incidence of seizures. The association between seizure development and patient mortality in PCNSL remains unknown. There are no data on AED prophylaxis or the use of specific AEDs in PCNSL.

CONCLUSIONS

Further studies are needed to investigate seizures in larger cohorts of PCNSL, to clarify their prevalence, better characterize them, identify risk factors, analyze survival rates, and make recommendations on AED management. We recommend following general practice guidelines for seizures symptomatic of brain tumors and not to prescribe AED prophylaxis in PCNSL.

Analysis of False-negative Findings of the Incomparable Accuracy and Swiftness of Flow Cytometric Diagnosis of Primary Central Nervous System Lymphoma

Primary central nervous system lymphoma (PCNSL), a relatively rare brain tumor, bears a dire prognosis. On occasion, the rapid progression of the tumor makes immediate diagnosis and initiation of therapy imperative. To achieve swift diagnosis, we adopt flow cytometry (FCM) in addition to conventional histopathology. This study aimed to reveal the utility of FCM diagnosis for PCNSL and the cause of false-negative results of FCM diagnosis. We investigated 33 patients with suspected PCNSL on neuroradiological findings and received both FCM and histological diagnosis. The patients' electronic medical records were investigated, and histological findings, results of FCM, and other clinical data were evaluated. Overall, 27 patients (14 males and 13 females) were diagnosed with PCNSL by histological confirmation. The median age at diagnosis was 68 years. FCM analysis showed lymphoma pattern in 24 cases; however, FCM results did not show lymphoma pattern (sensitivity: 88.9%, specificity: 100%) in the other three lymphoma cases (FCM discordant: FCM-D) and six nonlymphomatous tumor cases. Analysis of FCM-D cases showed the infiltration of T lymphocytes or astrocytes into the tumor tissue, indicating tumor microenvironmental reaction; it is assumed that these reactions deceived FCM diagnosis. The survival of FCM-D patients was superior to FCM concordant counterpart, although the difference was not significant (p = 0.459). The diagnosis of PCNSL by FCM is rapid and highly reliable. Some FCM-D cases are PCNSLs with strong tumor microenvironmental reactions.

Primary intramedullary spinal cord lymphoma misdiagnosed as longitudinally extensive transverse myelitis: a case report and literature review

BACKGROUND

Primary intramedullary spinal cord lymphoma (PISCL) is rare and easily misdiagnosed with the lack of typical clinical features and non-specific imaging manifestations.

CASE PRESENTATION

A 49-year-old man was admitted to our hospital because of persistent limbs numbness, pinprick-like pain in the posterior neck and unsteady gaits. He has brisk tendon reflexes and positive Babinski's sign. Magnetic resonance imaging (MRI) of the cervical spine showed an abnormal signal with aberrant reinforcement at medulla oblongata and the level of C1-C7. He was clinically diagnosed as longitudinally extensive transverse myelitis (antibody-negative). Steroid pulse therapy was administered and resulted in reduced symptoms. One month later, his situation was exacerbated compared to the onset. We launched a new cascade of steroid pulse therapy. But it did not improve his symptoms. Finally, the biopsy pathology confirmed PISCL. Chemotherapy, radiotherapy and zanubrutinib were administered and until now about 3 years into treatment the patient is still survival.

CONCLUSIONS

Based on our case and literature review, we recommend that spinal onset patients react ineffectively to standard immunoglobulins or hormonal treatments or experience a relapse after a short time relief should take PISCL into consideration.

Retrospective Evaluation of Cases Undergoing Stereotaxic Brain Biopsy

Objective:  The aim of this study is to evaluate the demographic, radiological and histopathological findings, tumoral biomarkers, and survival rates of patients who underwent a stereotactic brain biopsy and those diagnosed with glioblastoma, metastasis, and lymphoma, and the changes in the diagnosis distribution over the years. Materials and Methods:  The patients who underwent stereotactic biopsy in our clinic between 2012 and 2020 were evaluated retrospectively. Metastasis, glioblastoma, and lymphoma cases were evaluated as three main groups and the others were excluded. P53 gene expression, isocitrate dehydrogenase (IDH) mutation, and Ki-67 values in glioblastoma cases and Bcl-2, Bcl-6 proteins, and Ki-67 values in lymphomas and their relationship with survival were evaluated. Results:  High p53 expression was observed in 27.5% cases diagnosed with glioblastoma. IDH mutation was negative in all glioblastoma cases. Presence of Bcl-2 and Bcl-6 proteins was not associated with survival in lymphomas. Survival rate was significantly higher in cases diagnosed with lymphoma (26.9%) compared to those diagnosed with glioblastoma. A statistically significant increase was determined in patients diagnosed with lymphoma considering the distribution of diseases and incidence and in the distribution of other diagnoses over the years ( p  < 0.05). Conclusion:  As per the distribution of the disease in recent times, it has been observed that there is an increase in lymphoma cases. Histopathology and biomarkers have great importance in the diagnosis and treatment of cerebral lesions. We think that our findings will be supported by studies in which larger patient population and detailed biomarkers will be studied.

Radiotherapy for newly diagnosed primary central nervous system lymphoma: role and perspective

Whole brain radiotherapy (WBRT) has long been a key treatment of newly diagnosed primary central nervous system lymphoma (PCNSL). In the 1990s, the addition of high dose Methotrexate-based induction chemotherapy (HD MTX-based CT) has enabled a drastic improvement in PCNSL patients outcome. However, combined treatment has led to radiation-induced delayed neurotoxicity, especially in older patients. Alternative treatment strategies have been assessed to improve the efficacy and neurotoxicity ratio. Nowadays, in the elderly patients WBRT is widely omitted or deferred, and in younger patients WBRT is challenged by high dose chemotherapy with autologous stem cell transplant (HCT-ASCT) for consolidation treatment after HD MTX-based CT. In this setting, this review is addressed to clinicians with the aim to summarize the role of WBRT in the treatment of newly diagnosed PCNSL and its perspectives.

Primary central nervous system lymphoma

Primary central nervous system lymphoma (PCNSL) is a diffuse large B cell lymphoma in which the brain, spinal cord, leptomeninges and/or eyes are exclusive sites of disease. Pathophysiology is incompletely understood, although a central role seems to comprise immunoglobulins binding to self-proteins expressed in the central nervous system (CNS) and alterations of genes involved in B cell receptor, Toll-like receptor and NF-κB signalling. Other factors such as T cells, macrophages or microglia, endothelial cells, chemokines, and interleukins, probably also have important roles. Clinical presentation varies depending on the involved regions of the CNS. Standard of care includes methotrexate-based polychemotherapy followed by age-tailored thiotepa-based conditioned autologous stem cell transplantation and, in patients unsuitable for such treatment, consolidation with whole-brain radiotherapy or single-drug maintenance. Personalized treatment, primary radiotherapy and only supportive care should be considered in unfit, frail patients. Despite available treatments, 15-25% of patients do not respond to chemotherapy and 25-50% relapse after initial response. Relapse rates are higher in older patients, although the prognosis of patients experiencing relapse is poor independent of age. Further research is needed to identify diagnostic biomarkers, treatments with higher efficacy and less neurotoxicity, strategies to improve the penetration of drugs into the CNS, and roles of other therapies such as immunotherapies and adoptive cell therapies.

B-Cell Lymphoma Intramedullary Tumor: Case Report and Systematic Review

Intramedullary tumors represent the major cause of spinal cord injuries, and its symptoms include pain and weakness. Progressive weakness may concomitantly occur in the upper and lower limbs, along with lack of balance, spine tenderness, sensory loss, trophic changes of extremity, hyperreflexia, and clonus. The study protocol was in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A systematic search of the MEDLINE electronic database was performed to identify the studies reporting the clinical features of children and adults who presented with an intramedullary lymphoma. Twenty-one studies were included, reporting 25 cases. Manuscripts were excluded if the full-text article was not available, original data were not reported (e.g., review articles), or if the main disease was not intramedullary lymphoma. A structured data extraction form was employed to standardize the identification and retrieval of data from manuscripts. To enlighten the discussion, a case is also presented. An 82-year-old woman with Fitzpatrick skin type II, diagnosed and treated for non-Hodgkin's lymphoma 7 years ago, was admitted with mental confusion and memory loss for the past 2 months-evolving with recurring falls from her own height. One day before admission, she displayed Brown-Séquard syndrome. An expansive lesion from C2 to C4 in the cervical spinal cord was found and a hypersignal spinal cord adjacent was described at the bulb medullary transition to the C6-C7 level. A primary spinal cord tumor was considered, as well as a melanoma metastasis, due to the lesion's flame pattern. The patient presented a partial recovery of symptoms and a reduction of the spinal cord edema after being empirically treated with corticosteroids, but the lesion maintained its extent. Subsequently, a large diffuse B-cell lymphoma with nongerminal center was found in open body biopsy, infiltrating neural tissue. The main objective of the present study is to report a surgical case treated for a large diffuse B-cell lymphoma, in addition to presenting the results of a systematic review of primary intramedullary spinal cord lymphoma.

Diagnosis and management of rare paediatric Non-Hodgkin lymphoma

Mature B-cell lymphomas, (B- or T-cell) lymphoblastic lymphomas (LBL), and anaplastic large cell lymphoma (ALCL) correspond to about 90% of all non-Hodgkin lymphoma (NHL) cases occurring in children and adolescents. The remaining 10% encompass a complex group of entities characterized by low/very low incidences, paucity of knowledge in terms of underlying biology in comparison to their adult counterparts, and consequent lack of standardization of care, information on clinical therapeutic efficacy and long-term survival. At the Seventh International Symposium on Childhood, Adolescent and Young Adult NHL, organized on October 20-23, 2022, in New York City, New York, US, we had the opportunity to discuss clinical, pathogenetic, diagnostic, and treatment aspects of certain subtypes of rare B- or T-cell NHL and they will be the topic of this review.

Development and validation of a nomogram to predict overall survival and cancer-specific survival in patients with primary intracranial malignant lymphoma: A Retrospective study based on the SEER database

Introduction

Primary intracranial malignant lymphoma (PIML) is a rare form of lymphoma that most often occurs in the brain and has an extremely low 5-year survival rate. Although chemotherapy and radiotherapy are widely used in the clinical management of PIML, the choice of treatment regimen and the actual circumstances of patients remain challenges when assessing survival rates in different patients.

Methods

Considering this, we obtained clinical treatment and survival information from the Surveillance, Epidemiology, and End Results database (SEER) on patients with lymphoma, the primary site of which was the brain, and performed statistical analyses of the demographic characteristics. Survival analyses were performed using the Kaplan-Meier method, and univariate and multivariate Cox proportional hazards regression analyses were performed to identify independent prognostic factors.

Result

We identified age, pathology, the Ann Arbor stage, and treatment as the risk factors affecting patient prognosis. The areas under the curve (AUCs) for overall survival at 1, 3, and 5 years were 0.8, 0.818, and 0.81, respectively. The AUCs for cancer-specific survival at 1, 3, and 5 years were 0.8, 0.79, and 0.79. The prediction ability in the development and verification cohorts was in good agreement with the actual values, while we plotted the clinical decision curves for the model, suggesting that the nomogram can provide benefits for clinical decision-making.

Conclusion

Our model provides a prognostic guide for patients with PIML and a reliable basis for clinicians.

The World Health Organization Classification of Tumors of the Central Nervous System, Fifth Edition, 2021: A Critical Analysis

In 2021 the World Health Organization issued the fifth edition of its classification of the tumors of the central nervous system. This revision made many significant changes in the overall structure of the tumor taxonomy, as well as utilizing to a greatly increased reliance on molecular genetic data to specify the various diagnoses described in the classification, and to add some new tumor types. This represents a trend following the pioneering introduction of certain required genetic alterations for particular diagnoses encoded in the 2016 revision of the preceding fourth edition. In this chapter I describe the major changes and comment on their significance, and highlight some areas which are, at least to me, controversial. The major tumor categories discussed include gliomas, ependymomas, and embryonal tumors, but all tumor types included in the classification are addressed to the extent necessary.

CXCR4, CXCR5 and CD44 May Be Involved in Homing of Lymphoma Cells into the Eye in a Patient Derived Xenograft Homing Mouse Model for Primary Vitreoretinal Lymphoma

Background: Primary vitreoretinal lymphoma (PVRL), a rare malignancy of the eye, is strongly related to primary central nervous system lymphoma (PCNSL). We hypothesized that lymphoma cells disseminate to the CNS and eye tissue via distinct homing receptors. The objective of this study was to test expression of CXCR4, CXCR5, CXCR7 and CD44 homing receptors on CD20 positive B-lymphoma cells on enucleated eyes using a PCNSL xenograft mouse model. Methods: We used indirect immunofluorescence double staining for CD20/CXCR4, CD20/CXCR5, CD20/CXCR7 and CD20/CD44 on enucleated eyes of a PCNSL xenograft mouse model with PVRL phenotype (PCNSL group) in comparison to a secondary CNS lymphoma xenograft mouse model (SCNSL group). Lymphoma infiltration was evaluated with an immunoreactive score (IRS). Results: 11/13 paired eyes of the PCNSL but none of the SCNSL group were infiltrated by CD20-positive cells. Particularly the choroid and to a lesser extent the retina of the PCNSL group were infiltrated by CD20+/CXCR4+, CD20+/CXCR5+, few CD20+/CD44+ but no CD20+/CXCR7+ cells. Expression of CXCR4 (p = 0.0205), CXCR5 (p = 0.0004) and CD44 (p < 0.0001) was significantly increased in the PCNSL compared to the SCNSL group. Conclusions: CD20+ PCNSL lymphoma cells infiltrating the eye co-express distinct homing receptors such as CXCR4 and CXCR5 in a PVRL homing mouse model. These receptors may be involved in PVRL homing into the eye.

Drug delivery across the blood-brain barrier for the treatment of pediatric brain tumors - An update

Even though the last decade has seen a surge in the identification of molecular targets and targeted therapies in pediatric brain tumors, the blood brain barrier (BBB) remains a significant challenge in systemic drug delivery. This continues to undermine therapeutic efficacy. Recent efforts have identified several strategies that can facilitate enhanced drug delivery into pediatric brain tumors. These include invasive methods such as intra-arterial, intrathecal, and convection enhanced delivery and non-invasive technologies that allow for transient access across the BBB, including focused ultrasound and nanotechnology. This review discusses current strategies that are being used to enhance delivery of different therapies across the BBB to the tumor site - a major unmet need in pediatric neuro-oncology.

Advanced OCT Analysis of Biopsy-proven Vitreoretinal Lymphoma

PURPOSE

Although diagnosing vitreoretinal lymphoma (VRL) can be challenging, early detection is critical for visual prognosis. We analyzed the spectrum of optical coherence tomography (OCT) findings in patients with biopsy-proven VRL and correlate these features with clinical parameters.

DESIGN

This retrospective cross-sectional study was a multicenter chart review from 13 retina, uveitis, and ocular oncology clinics worldwide from 2008 to 2019. We included patients with a diagnosis of biopsy-proven VRL imaged with OCT at presentation. Ocular information, systemic information, and multimodal retinal imaging findings were collected and studied. The main outcome measure was the characteristics of VRL on OCT.

RESULTS

A total of 182 eyes of 115 patients (63 women, mean age 65 years) were included in this study. The disease was bilateral in 81 patients (70%), and mean baseline visual acuity was 0.2 ± 0.89 logMAR (Snellen equivalent, 20/32). At baseline, 38 patients (33%) presented with isolated ocular involvement, 54 (45%) with associated central nervous system involvement, and 11 (10%) with other systemic lymphomatous involvement; an additional 12 patients (10%) presented with central nervous system and other systemic involvement. On OCT, tumor infiltration was identified in various retinal layers, including lesions in the subretinal pigment epithelium compartment (91% of eyes), the subretinal compartment (43% of eyes), and the intraretinal compartment (7% of eyes). OCT analysis of eyes with VRL identified 3 main regions of retinal infiltration. Subretinal pigment epithelium location, with or without subretinal infiltration, was the most common pattern of involvement and isolated intraretinal infiltration was the least.

Comprehensive Laboratory Diagnostic Workup for Patients with Suspected Intraocular Lymphoma including Flow Cytometry, Molecular Genetics and Cytopathology

Background: Intraocular lymphoma (IOL) presents a real challenge in daily diagnostics. Cyto- and/or histopathology of vitreous body represent the diagnostic cornerstones. Yet, false negative results remain common. Therefore, we analyzed the diagnostic significance of flow cytometry (FC) within the workup algorithm of IOL and compared its sensitivity with the results obtained from routine cytopathology and molecular genetics; Methods: Seven patients undergoing vitrectomy due to suspected IOL were investigated by FC and parallel cytopathology and, if available, digital droplet PCR (ddPCR) for MYD88 L265P; Results: Four out of seven patients were finally diagnosed with IOL. Among the IOL patients, cytopathology confirmed the presence of lymphoma cells in only two cases. In contrast, FC was positive for IOL in all four cases, and FC additionally confirmed the lack of IOL in the remaining patients. In IOL patients diagnosed by FC and with available ddPCR, the diagnosis of IOL was confirmed by the presence of the MYD88 L265P mutation in all three patients; Conclusions: The combination with FC was superior to cytopathology alone in the diagnostic work-up of IOL, and it showed an excellent correlation with ddPCR results. A comprehensive diagnostic panel consisting of cytopathology, FC and molecular genetics should be considered for the work-up of suspected IOL.

Evaluating optical coherence tomography (OCT) findings as potential biomarkers in central nervous system (CNS) lymphoma with or without ocular involvement

BACKGROUND

To evaluate spectral domain optical coherence tomography (SD-OCT) findings as biomarkers in primary central nervous system lymphoma (PCNSL) with or without ocular involvement.

METHODS

This study was a cross-sectional study and patients with a confirmed diagnosis of PCNSL with or without ocular involvement were included. Patient cohort finder tool was used to identify patients with lymphoma using ICD-10 codes (C82-C88), from January 2004 to October 2017. A total of 14,820 patients were identified. Procedure code (92134) for optical coherence tomography (OCT) was then applied to identify patients who had underdone OCT imaging at ophthalmology clinic. Clinic charts of 460 patients with lymphoma and available OCT were reviewed to identify patients with confirmed diagnosis of PCNSL and divided into two groups (Group 1: with and Group 2: without ocular involvement). OCT scans of patients in both study groups were analyzed for the presence of (1) Hyperreflective deposits in choroid, retinal pigment epithelium (RPE), outer and inner retina; (2) RPE thickening; (3) Vitreous debris; (4) Intraretinal fluid; (5) Ellipsoid zone disruption by masked graders. Chi-square was used to analyze the difference between the groups.

RESULTS

Twenty-two eyes (11 patients) with PCNSL were included this study (Group 1: 6 eyes and Group 2: 16 eyes). Mean age of subjects was 65 years. Five patients (45.45%) were female. There was no statistically significant difference between the groups for the presence of hyperreflective deposits in choroid, RPE, outer and inner retina, and presence of RPE thickening, intraretinal fluid, and ellipsoid zone disruption. Vitreous debris was found more commonly in group 1 subjects (83%) than group 2 (31.25%) (p = 0.029). All subjects in both groups showed hyperreflective deposits in the RPE demonstrating RPE infiltration. However, RPE thickening was noted only in 3 patients (Group1: 1 and Group2: 2).

CONCLUSIONS

OCT finding of hyperreflective deposits present in eyes with lymphoma secondary to PCNSL are also observed in eyes with PCNSL without ocular disease. However, the vitreous deposits are more commonly found in eyes with ocular disease. These hyperreflective deposits can serve as biomarkers for early detection of ocular involvement by PCNSL.

Status Quo and Trends of Intra-Arterial Therapy for Brain Tumors: A Bibliometric and Clinical Trials Analysis

Intra-arterial drug delivery circumvents the first-pass effect and is believed to increase both efficacy and tolerability of primary and metastatic brain tumor therapy. The aim of this update is to report on pertinent articles and clinical trials to better understand the research landscape to date and future directions. Elsevier's Scopus and ClinicalTrials.gov databases were reviewed in August 2021 for all possible articles and clinical trials of intra-arterial drug injection as a treatment strategy for brain tumors. Entries were screened against predefined selection criteria and various parameters were summarized. Twenty clinical trials and 271 articles satisfied all inclusion criteria. In terms of articles, 201 (74%) were primarily clinical and 70 (26%) were basic science, published in a total of 120 different journals. Median values were: publication year, 1986 (range, 1962-2021); citation count, 15 (range, 0-607); number of authors, 5 (range, 1-18). Pertaining to clinical trials, 9 (45%) were phase 1 trials, with median expected start and completion years in 2011 (range, 1998-2019) and 2022 (range, 2008-2025), respectively. Only one (5%) trial has reported results to date. Glioma was the most common tumor indication reported in both articles (68%) and trials (75%). There were 215 (79%) articles investigating chemotherapy, while 13 (65%) trials evaluated targeted therapy. Transient blood-brain barrier disruption was the commonest strategy for articles (27%) and trials (60%) to optimize intra-arterial therapy. Articles and trials predominately originated in the United States (50% and 90%, respectively). In this bibliometric and clinical trials analysis, we discuss the current state and trends of intra-arterial therapy for brain tumors. Most articles were clinical, and traditional anti-cancer agents and drug delivery strategies were commonly studied. This was reflected in clinical trials, of which only a single study had reported outcomes. We anticipate future efforts to involve novel therapeutic and procedural strategies based on recent advances in the field.

Treatment of Primary CNS Lymphoma: Maximizing Clinical Benefit, Minimizing Neurotoxicity

PURPOSE OF REVIEW

The optimal treatment for newly diagnosed and refractory or relapsed primary central nervous system lymphoma (PCNSL) is not fully defined. We review the epidemiology, clinical presentation, and current management strategies for newly diagnosed PCNSL as well as emerging treatments for refractory and relapsed disease.

RECENT FINDINGS

In recent decades, the incidence of PCNSL has increased in the elderly population. With advancements in chemotherapy for PCNSL, survival has improved. However, outcomes remain inferior when compared with other forms of extranodal lymphoma. Additionally, treatments can be associated with clinically significant neurotoxicities. Despite advances in the treatment of PCNSL, current treatment regimens remain suboptimal in terms of response rates and neurotoxicity. Well-tolerated agents, especially for the elderly, are still needed.

A proposed protocol of intravitreal injection of methotrexate for treatment of primary vitreoretinal lymphoma

PURPOSE

Primary central nervous system lymphoma (PCNSL) is a non-Hodgkin lymphoma involving the brain with possible leptomeningeal and ocular involvement. This study aimed to evaluate the safety and efficacy of modified intravitreal injection regimen of methotrexate (MTX) for therapeutic management of vitreoretinal lymphoma.

MATERIALS AND METHODS

Forty human immunodeficiency virus (HIV)-negative Chinese patients with primary vitreoretinal lymphoma were included in this retrospective noncomparative interventional case series study. Patients were treated with a modified protocol of intravitreal injection of MTX (400 µg/0.1 ml) according to the Intensive-Consolidation-Maintenance regimen. The Intensive phase of once-weekly intravitreal injections for 1 month, followed by the Consolidation phase of one injection every 2 weeks for 1 month, and then the Maintenance phase of once monthly for 1 month, for a total of 7 injections. The primary main outcome measures were clinical response to intravitreal chemotherapy, number of injections for clinical remission, progression-free survival (PFS), overall survival (OS), visual acuity (VA), complications during the study period, and cause of death were investigated.

RESULTS

The duration of follow-up from the commencement of injection of MTX was 12-73 months (median 28, 30.55 ± 14.73 months). A total of 61 eyes of 40 patients were cleared clinically from malignant cells after a median 6.57 ± 3.12 (median 6, range 1-14) times of injection of MTX. A second remission was induced in 3 patients, who were treated with a further course of intravitreal chemotherapy after tumour recurred in their eyes. The median PFS and OS were 20.82 months (95% CI 14.64-27.01) and 29.29 months (95% CI 16.16-42.41), respectively. Complications that occurred during the period of treatment and follow-up included corneal epitheliopathy (3 of 61 eyes) and cataract (6 of 61 eyes). There were no cases of maculopathy, vitreous haemorrhage, optic atrophy, and sterile endophthalmitis. No patient had an irreversible loss of vision that could be attributed to the intravitreal injection of MTX.

CONCLUSIONS

It can be concluded that the modified intravitreal injection regimen of MTX is an effective therapeutic approach in inducing clinical remission of intraocular involvement in PCNSL patients, associated with few complications. However, further study needs to be conducted to indicate whether the proposed approach extends life expectancy.

HIGHLIGHTS

Primary central nervous system lymphoma (PCNSL) can involve the vitreous and retina and is associated with a poor clinical outcome, with a survival rate of less than 3 months in absence of undergoing an effective therapeutic strategy. Methotrexate (MTX) is the most efficient cytotoxic drug for patients with vitreoretinal involvement in primary vitreoretinal lymphoma (PVRL), through intravitreal injection of MTX. In our experience, the modified protocol of intravitreal MTX according to the Intensive-Consolidation-Maintenance regimen, was effective in inducing clinical remission of PVRL with few complications. The accumulating clinical results brought us to propose the consideration of this protocol as a good first-line treatment option for PVRL.

Primary Central Nervous System Lymphoma: A Case of Solitary Brain Lesion

Primary central nervous system lymphoma (PCNSL) is an uncommon variant of extranodal non-Hodgkin’s lymphoma (NHL) that involves the brain, leptomeninges, eyes, or spinal cord without evidence of systemic disease.

This article presents a case of a 63-year-old Caucasian female with high-grade B-cell lymphoma who was found to have a solitary brain lesion and no distant metastasis upon diagnosis. The patient had left-sided weakness and difficulty standing on presentation and was found to have a right frontal lobe mass with surrounding mild vasogenic edema and a small focal area of hemorrhage concerning for high-grade glioma versus lymphoma on MRI. However, pathology results revealed high-grade B-cell lymphoma.

The case reinforces the importance of working up any lesion suspicious for lymphoma/glioma. Diagnosis of high-grade B-cell lymphoma can be difficult based on morphological and cytological appearance due to varying gene expression and presentation at diagnosis. It can closely mimic diffuse B-cell lymphoma. Extensive workup including HIV serology, MRI imaging, evaluation for spinal cord involvement, and lumbar puncture (LP), to rule out cerebrospinal fluid (CSF) involvement, prior to initiating treatment needs to be done. The case also addresses high-grade methotrexate (MTX)-based chemotherapy as a treatment that improves mortality in patients with primary central nervous system (CNS) lymphoma.

Efficacy and safety of intravitreal methotrexate for vitreo-retinal lymphoma - 20 years of experience

Vitreo-retinal lymphoma (VRL) is the most common intraocular lymphoma and is highly associated with central nervous system (CNS) lymphoma (CNSL), both posing a therapeutic challenge. We investigated patients' characteristics, efficacy and safety of intravitreal methotrexate (MTX) injections and their outcomes over 20 years. The records of 129 patients diagnosed between 1997 and 2018 were retrospectively reviewed. Lymphoma involved both the CNS and vitreo-retina (49%), solely the CNS (37%) or solely the vitreo-retina (14%). In all, 45·5% of the patients with CNSL either presented with VRL or developed it after a mean (±SE) of 85·7 (7·3) months. In all, 66·0% of the patients diagnosed with VRL either presented with CNSL or developed it after a mean (±SE) 42·6 (7·6) months. The 81 patients with VRL (134 eyes) received a mean (±SD) of 19 (7) injections; however, only 5 (4) injections were needed to reach complete remission. Local recurrence occurred in two of the 81 patients. Overall, 80·2% of eyes had an initial moderate-severe visual loss, and >50% of them improved. Reversible keratopathy was the most prevalent side-effect. A total of 18·5% developed intraocular pressure (IOP) elevation due to angle neovascularisation after 16 injections, which could be reversed with prompt intravitreal injection of bevacizumab. Intravitreal MTX injections are a safe and effective treatment for VRL. Fewer injections (15) may offer similar results with fewer side-effects.

Presumptive Primary Cerebral T-Cell Lymphoma in a White-Tailed Deer (Odocoileus virginianus)

Primary central nervous system (CNS) lymphomas are rare in humans and even more uncommon in animals. We report the clinical, pathological and immunohistochemical features of a presumptive primary cerebral T-cell lymphoma (PCTCL) in an aged female white-tailed deer (Odocoileus virginianus) that had chronic progressive neurological disease characterized by ataxia, claudication and eventual circling. The animal was euthanized due to poor prognosis. Grossly, a 2.5 cm dark red, friable nodule effaced the cortical neuroparenchyma of the left anterior cingulate cortex (LACC). Microscopically, the meningeal vasculature and adjacent grey and white matter cortical neuroparenchyma of the LACC were infiltrated by a poorly demarcated, unencapsulated and densely cellular round cell neoplasm with a consistent angiocentric pattern. The neoplasm was associated with extensive regions of haemorrhage and liquefactive necrosis. Neoplastic cells immunolabelled for CD3 antigen and had high proliferative activity, as indicated by Ki-67 labelling. Based on the cytohistomorphological and immunohistochemical features and absence of metastasis, a diagnosis of PCTCL was determined. This case indicates that PCTCL should be considered in the differential diagnosis of neurological disease and intracranial, intra-axial CNS masses in deer.

Primary central nervous system lymphoma - ocular variant: an interdisciplinary review on management

Primary central nervous system lymphoma-ophthalmic variant (PCNSL-O) is an ocular subset of PCNSL predominantly involving subretinal pigment epithelium space, retina, and vitreous. The ophthalmic manifestations can precede, occur simultaneously, or follow other compartments of the CNS. Clinical trials have resulted in a significantly improved outcome in PCNSL patients over the past 2 decades, with a higher proportion of patients receiving frontline high dose methotrexate-based polychemotherapy regimens with curative intent; however, the current management of PCNSL-O remains controversial owing to lack of prospective data. The goals of PCNSL-O treatment are both to achieve local (ocular) control and to prevent tumor-specific mortality from further CNS involvement. Despite achieving high rates of ocular control with intravitreal agents like methotrexate and rituximab, the overall survival is poor, as 65-85% of patients eventually succumb to CNS disease. Few studies define the role of systemic chemotherapy with/without local treatment as a first line induction treatment for PCNSL-O considering limiting factors such as ocular penetration of systemically administered drugs and treatment related neurotoxicity. Also, the role of adjuvant treatment for PCNSL-O to prevent CNS progression and to improve overall survival is unknown. In this systematic review of the literature, we analyze treatment outcomes of various regimens (local, systemic, and combination) in terms of local control, CNS progression, and overall survival.

Blood Coagulation Factor Fibrinogen in Tumor Pathogenesis of Central Nervous System B-Cell Lymphoma

Central nervous system (CNS) lymphoma is an extranodal non-Hodgkin B-cell lymphoma characterized by malignant lymph tissue arising in the brain or spinal cord, associated with inflammation and blood-brain barrier (BBB) disruption. Although BBB disruption is known to occur in patients with CNS lymphoma, a direct link between these two has not been shown. Herein, abundant deposition of the blood coagulation protein fibrinogen around B-cell lymphoma was detected in CNS lymphoma patients and in the CNS parenchyma in an orthotopic mouse model. Functional enrichment analysis of unbiased cerebrospinal fluid proteomics of CNS B-cell lymphoma patients showed that coagulation protein networks were highly connected with tumor-associated biological signaling pathways. In vivo two-photon imaging demonstrated that lymphoma growth was associated with BBB disruption, and in vitro experiments identified a role for fibrinogen in promoting lymphoma cell adhesion. Overall, these results identify perivascular lymphoma clustering at sites of fibrinogen deposition, and suggest that fibrinogen may be a target for pharmacologic intervention in metastatic B-cell lymphoma associated with BBB disruption.

Molecular Subtypes and Genomic Profile of Primary Central Nervous System Lymphoma

Primary central nervous system lymphomas (PCNSL) are aggressive non-Hodgkin lymphomas affecting the central nervous system (CNS). Although immunophenotyping studies suggested an uniform activated B-cell (ABC) origin, more recently a spectrum of ABC and germinal center B-cell (GC) cases has been proposed, with the molecular subtypes of PCNSL still being a matter of debate. With the emergence of novel therapies demonstrating different efficacy between the ABC and GC patient groups, precise assignment of molecular subtype is becoming indispensable. To determine the molecular subtype of 77 PCNSL and 17 secondary CNS lymphoma patients, we used the NanoString Lymphoma Subtyping Test (LST), a gene expression-based assay representing a more accurate technique of subtyping compared with standard immunohistochemical (IHC) algorithms. Mutational landscapes of 14 target genes were determined using ultra-deep next-generation sequencing. Using the LST-assay, a significantly lower proportion (80% vs 95%) of PCNSL cases displayed ABC phenotype compared with the IHC-based characterization. The most frequently mutated genes included MYD88, PIM1, and KMT2D. In summary, we successfully applied the LST-assay for molecular classification of PCNSL, reporting higher proportion of cases with GC phenotype compared with IHC analyses, leading to a more precise patient stratification potentially applicable in the diagnostic algorithm of PCNSL.

Recent Topics on The Mechanisms of Immunosuppressive Therapy-Related Neurotoxicities

Although transplantation procedures have been developed for patients with end-stage hepatic insufficiency or other diseases, allograft rejection still threatens patient health and lifespan. Over the last few decades, the emergence of immunosuppressive agents such as calcineurin inhibitors (CNIs) and mammalian target of rapamycin (mTOR) inhibitors have strikingly increased graft survival. Unfortunately, immunosuppressive agent-related neurotoxicity commonly occurs in clinical practice, with the majority of neurotoxicity cases caused by CNIs. The possible mechanisms through which CNIs cause neurotoxicity include increasing the permeability or injury of the blood–brain barrier, alterations of mitochondrial function, and alterations in the electrophysiological state. Other immunosuppressants can also induce neuropsychiatric complications. For example, mTOR inhibitors induce seizures, mycophenolate mofetil induces depression and headaches, methotrexate affects the central nervous system, the mouse monoclonal immunoglobulin G2 antibody (used against the cluster of differentiation 3) also induces headaches, and patients using corticosteroids usually experience cognitive alteration. Therapeutic drug monitoring, individual therapy based on pharmacogenetics, and early recognition of symptoms help reduce neurotoxic events considerably. Once neurotoxicity occurs, a reduction in the drug dosage, switching to other immunosuppressants, combination therapy with drugs used to treat the neuropsychiatric manifestation, or blood purification therapy have proven to be effective against neurotoxicity. In this review, we summarize recent topics on the mechanisms of immunosuppressive drug-related neurotoxicity. In addition, information about the neuroprotective effects of several immunosuppressants is also discussed.

Treatment outcome and prognostic factors in PCNSL

Objectives

Standard treatment with a thiotepa-based regimen in countries with a limited resource is less feasible. Aims of the study were to evaluate the treatment outcome, and identify the prognostic factors in patients with primary central nervous system lymphoma (PCNSL).

Methods

We conducted a retrospective study of 43 patients diagnosed with PCNSL, DLBCL subtype, who were treated with either HDMTX-based regimen, whole brain radiotherapy (WBRT), or both between 2010 and 2017.

Results

There were 43 patients with a median age of 65 years (range 34–89 years). Protein expression of CD10, Bcl6, MUM1, Bcl2 and MYC were found in 19, 86, 91, 91 and 23%, respectively. Both germinal center B cell (GCB) and double-expressor (MYC+/Bcl2+) lymphomas were found in 21%. Multiple brain lesions and maximum tumor diameter (MTD) ≥5 cm were seen in 27 and 10 patients, respectively. Chemotherapy combined with WBRT, chemotherapy and WBRT were given to 20, 14 and 9 patients, respectively. Overall complete remission (CR) rate was 55.8%. Those receiving a combined-modality therapy had a higher CR rate than those treated with either chemotherapy (75% versus 36%, p = 0.036) or WBRT (75% versus 44%, p = 0.109). Median follow-up time was 17 months, and a 7-year overall survival (OS) was 40%. Features associated with a prolonged OS were an ECOG score ≤ 2 (p = 0.001), multiple brain lesions (p = 0.010), multiple area of brain involvement (p = 0.023), MTD < 5 cm (p = 0.004), GCB subtype (p = 0.003) and positive CD10 staining (p = 0.007). Expression of Bcl2 protein was associated with a significantly worse OS in the non-GCB DLBCL patients.

Discussion

The factors affecting treatment outcomes in PCNSL were cell of origin of DLBCL, lesion characteristics, patients’ status and treatment regimen.

Primary vitreoretinal lymphoma: prevalence, impact, and management challenges

Primary vitreoretinal lymphoma (PVRL) is a rare and potentially fatal intraocular malignancy. More than half of PVRL cases eventually involve the central nervous system (CNS). PVRL frequently masquerades as chronic uveitis. Advanced imaging tests, such as optical coherence tomography and fundus autofluorescence, have been applied in the diagnosis of PVRL. Histology and immunohistochemistry, in combination with molecular tests and IL-10 analysis, have been demonstrated as reliable in diagnosing PVRL. Mortality is high in patients with PVRL associated with CNS involvement, and relapses are common. The use of systemic chemotherapy in addition to the local therapies has proved to extend the mean survival time of these patients. Local therapies, including intravitreal injections of methotrexate and/or rituximab and low-dose radiotherapy to the eye, have been shown to be extremely effective in controlling intraocular lymphoma.

An unusual case report of primary vitreoretinal lymphoma

Background

Primary vitreoretinal lymphoma (PVRL) is a rare ocular condition and its diagnosis remains a challenge. The clinical presentation is variable and it can masquerade as chronic intermediate or posterior uveitis. We report an unusual case of primary central nervous system lymphoma (PCNSL) presenting as migrating retinal lesions with unique shapes. The diagnostic challenges are described and the clinical features of intraocular lymphoma are reviewed.

Case presentation

A 53 year-old gentleman presented with unilateral visual disturbance and a wide area of retinal whitening with sharp borders temporal to the macula, corresponding to hyper-reflective subretinal changes on optical coherence tomography (OCT). The lesion resolved spontaneously after 6 weeks but was replaced by multiple punctate sub-retinal and sub-retinal pigment epithelial lesions. The second eye was involved 4 months later and there were new areas of hyper-reflective changes in both eyes, which migrated nasally within a week, with no evidence of scarring in the previous sites. The diagnosis of diffuse B-cell lymphoma was made on brain biopsy when the patient subsequently presented with acute confusion and magnetic resonance imaging brain scan showed a frontal lesion. Following systemic chemotherapy, the sub-retinal changes resolved with complete restoration of retinal architecture and improvement in visual acuity.

Conclusion

We report an unusual case of PVRL presenting as migrating retinal lesions with unique shapes. PVRL is a great imitator and a high index of clinical suspicion is required in unexplained ocular lesions to prevent a delay in diagnosis.

Flow cytometry shows added value in diagnosing lymphoma in brain biopsies

Background

To assess the sensitivity, specificity and turnaround time of flow cytometric analysis on brain biopsies compared to histology plus immunohistochemistry analysis in tumors with clinical suspicion of lymphoma.

Methods

All brain biopsies performed between 2010 and 2015 at our institution and analyzed by both immunohistochemistry and flow cytometry were included in this retrospective study. Immunohistochemistry was considered the gold standard.

Results

In a total of 77 biopsies from 71 patients, 49 lymphomas were diagnosed by immunohistochemistry, flow cytometry results were concordant in 71 biopsies (92.2%). We found a specificity and sensitivity of flow cytometry of 100% and 87.8%, respectively. The time between the biopsy and reporting the result (turnaround time) was significantly shorter for flow cytometry, compared to immunohistochemistry (median: 1 vs. 5 days).

Conclusions

Flow cytometry has a high specificity and can confirm the diagnosis of a lymphoma significantly faster than immunohistochemistry. This allows for rapid initiation of treatment in this highly aggressive tumor. However, since its sensitivity is less than 100%, we recommend to perform histology plus immunohistochemistry in parallel to flow cytometry. © 2018 The Authors. Cytometry Part B: Clinical Cytometry published by Wiley Periodicals, Inc. on behalf of International Clinical Cytometry Society

Primary central nervous system histiocytic sarcoma: A case report and review of literature

RATIONALE

Primary central nervous system histiocytic sarcoma (PCNSHS) is a rare lymphohematopoietic tumor with a histiocytic cell origin. To our knowledge, only 28 cases have been published in English and 2 cases in Chinese.

PATIENT CONCERNS

A 49-year-old Asian female presented to the hospital with a 2 month history of hypomnesia, odynophagia, and gait disorder. Physical examination demonstrated decreased lower extremity muscle strength. The patient denied a history of malignancy.

DIAGNOSES

Radiology demonstrated a lesion in parietal lobe with uniformenhancement. Histologic analysis showed pleomorphic tumor cells with a loose arrangement, effacing the normal brain tissue. The tumor cells exhibited abundant eosinophilic cytoplasm, highly atypical nuclei and predominant nucleoli. Immunohistochemistry revealed positive immunoreactivity for CD45, lysozyme, CD68, and CD163, and negative for pan-cytokeratin (CK), epithelial membrane antigen (EMA), glial fibrillary acidic protein (GFAP), CD3, CD20, CD1a, CD79a, CD138, oligodendrocyte transcription factor (olig2), CD15, melan-A, CD30, CD21, CD35, Human Melanoma Black-45 (HMB45), and anaplastic lymphoma kinase-1 (ALK-1). The diagnosis of PCNSHS was rendered.

INTERVENTIONS

The patient underwent complete surgical resection and adjuvant radiotherapy.

OUTCOMES

Follow-up information shows the patient died 8 months following the initial diagnosis.

LESSONS

PCNSHS is extremely rare with an aggressive clinical course. Immunohistiochemistry is necessary to make this diagnosis and to exclude other primary intracranial and lymphohematopoietic tumors. Further research is required to improve the outcome of patients with PCNSHS.

Primary cauda equina lymphoma diagnosed by nerve biopsy: A case report and literature review

Primary cauda equina lymphoma (CEL) is a rare malignant tumor among various neoplasms that affects the cauda equina nerve roots. The present case report described the case of a 65-year-old man who presented with cauda equina syndrome with progressive motor palsy in the legs and gait disturbance over the last 5 months. Magnetic resonance (MR) images showed enlargement of the cauda equina occupying the dural sac from the L1-S1 level with isointensity to the spinal cord signal on both T1- and T2-weighted imaging. Enhancement of the cauda equina was seen on contrast MR images. On F-18 2-fluoro-2-deoxy-glucose positron emission tomography examination, diffuse accumulation of 2-fluoro-2-deoxy-glucose was observed in the cauda equina with a maximum standardized uptake value of 4.9. Based on elevation of soluble interleukin 2 receptor in cerebrospinal fluid and a biopsy of the enlarging cauda equina, a diagnosis of CEL of the diffuse large B-cell type was made. The present case report provided a detailed case discussion and a review of the available literature on this rare entity, focusing on clinical characteristics and imaging of primary CEL.

Primary Cerebral Lymphoma: A Retrospective Study in 22 Immunocompetent Patients

Aims and background

Primary CNS lymphomas are uncommon tumors in immunocompetent patients. We describe the radiological features that should orient towards performing a biopsy and analyze the results in our series of patients.

Methods

We reviewed 22 immunocompetent patients with primary central nervous system lymphoma admitted in our Institute between 1977 and 1997. The follow-up period ranged from 2 months (patient deceased) to 69 months. Fourteen patients underwent surgical removal of the tumor and the remainder a biopsy. All patients received radiotherapy and 8 patients radiotherapy plus chemotherapy.

Results

Two of the 14 patients treated by surgical removal of the tumor died. There was no mortality related to biopsy procedures. Patients treated with radiotherapy had 1-year, 2-year and 5-year survival rates of 66%, 41.6% and 16.6%, compared to 87.5%, 62.5% and 50%, respectively, for patients who received radiotherapy and chemotherapy.

Conclusions

At present, there is no definite treatment for these highly malignant brain tumors. The most favorable results seem related to biopsy followed by radiotherapy plus chemotherapy versus surgical removal, which is related to a high risk of severe postoperative deficit for both the deep location and infiltrating nature of these lesions.

Primary Central Nervous System Lymphomas: Clinicopathologic and Immunohistochemical Analysis of 30 Cases

Aims and background

Primary Central Nervous System lymphomas are attracting mounting interest because of their increasing incidence in an immunocompetent population and as sporadic tumors. A new lymphoma classification has been proposed, based on new morphologic entities and on advanced immunonologic and molecular techniques.

Methods and Results

The study concerns the clinical and pathologic characterization of 30 cases of primary central nervous system non-Hodgkin's lymphomas in non-HIV patients using a wide monoclonal antibodies panel. Comparative evaluation of effectiveness and reliability between surgery and stereotactic biopsies was made according to Kiel and Real lymphoma classifications. There were 24 high-grade and only 3 low-grade lymphomas. Three stereotactic biopsies were not diagnostic.

Conclusions

Stereotactic procedures were confirmed as the most immediate and least aggressive approach to CNS tumors, but inadequate sampling caused a deadlock to a full lymphoma diagnosis, which requires immunohistochemical and sometimes also molecular studies. However, it should be stressed that morphologic criteria (tumor cell cytology and neoplastic cuffing of the vascular walls) maintain their diagnostic effectiveness.

Primary central nervous system lymphoma at the cerebellopontine angle mimicking a trigeminal schwannoma: A unique case report and literature review

Primary central nervous system lymphoma (PCNSL) is an uncommon extranodal manifestation of non-Hodgkin's lymphoma with those presenting at the cerebellopontine angle (CPA) being rare presentations with limited reported cases in the literature. We report a 60-year old female presenting with PCNSL of the left CPA radiologically mimicking a trigeminal schwannoma with corresponding clinical signs. Imaging showed a left CPA lesion that was biopsied and confirmed as diffuse large B-cell lymphoma. Given its rarity, PCNSL should be considered in the differential diagnosis for all CPA tumours.

Incidence and outcomes of primary central nervous system lymphoma in solid organ transplant recipients

Primary central nervous system lymphoma (PCNSL) risk is greatly increased in immunosuppressed human immunodeficiency virus-infected people. Using data from the US transplant registry linked with 17 cancer registries (1987-2014), we studied PCNSL and systemic non-Hodgkin lymphoma (NHL) in 288 029 solid organ transplant recipients. Transplant recipients had elevated incidence for PCNSL compared with the general population (standardized incidence ratio = 65.1; N = 168), and this elevation was stronger than for systemic NHL (standardized incidence ratio=11.5; N = 2043). Compared to kidney recipients, PCNSL incidence was lower in liver recipients (adjusted incidence rate ratio [aIRR] = 0.52), similar in heart and/or lung recipients, and higher in other/multiple organ recipients (aIRR = 2.45). PCNSL incidence was higher in Asians/Pacific Islanders than non-Hispanic whites (aIRR = 2.09); after induction immunosuppression with alemtuzumab (aIRR = 3.12), monoclonal antibodies (aIRR = 1.83), or polyclonal antibodies (aIRR = 2.03); in recipients who were Epstein-Barr virus-seronegative at the time of transplant and at risk of primary infection (aIRR = 1.95); and within the first 1.5 years after transplant. Compared to other recipients, those with PCNSL had increased risk of death (adjusted hazard ratio [aHR] = 11.79) or graft failure/retransplantation (aHR = 3.24). Recipients with PCNSL also had higher mortality than those with systemic NHL (aHR = 1.48). In conclusion, PCNSL risk is highly elevated among transplant recipients, and it carries a poor prognosis.

Proteomic changes in cerebrospinal fluid from primary central nervous system lymphoma patients are associated with protein ectodomain shedding

Primary central nervous system lymphomas (PCNSLs) are mature B-cell lymphomas confined to the central nervous system (CNS). Blood-brain barrier (BBB) dysfunction drastically alters the cerebrospinal fluid (CSF) proteome in PCNSL patients. To reveal the interaction of PCNSL tumors with CNS structures and the vasculature, we conducted a whole-proteome analysis of CSF from PCNSL patients (n = 17 at initial diagnosis) and tumor-free controls (n = 10) using label-free quantitative mass spectrometry. We identified 601 proteins in the CSF proteome using a one-step approach without further prefractionation, and quantified 438 proteins in detail using the Hi-N method. An immunoassay revealed that 70% of the patients in our unselected PCNSL patient cohort had BBB dysfunction. Correlation analysis indicated that 127 (30%) of the quantified proteins were likely increased in PCSNL patients due to BBB dysfunction. After the exclusion of these proteins, 66 were found to differ in abundance (fold-change > 2.0, p < 0.05) between PCNSL and control CSF proteomes, and most of those were associated with the CNS. These data also provide the first evidence that proteomic changes in CSF from PCNSL patients are mainly associated with protein ectodomain shedding, and that shedding of human leukocyte antigen class 2 proteins is a mechanism of tumor-cell immune evasion.

18F-FDG PET/CT in primary brain lymphoma

The actual role of 18F-FDG PET/CT in evaluating primary brain lymphoma is still an open issue. Brain lymphoma usually show elevated 18F-FDG uptake, often higher than other brain tumors or inflammatory processes, but the metabolic behavior of this lymphoma is not still understood. Our aim was to investigate the particular metabolic behavior of this lymphoma. Forty six patients (21 female, 25 male) with histologically-confirmed brain lymphoma who underwent 18F-FDG PET/CT from vertex to the mid-thigh for initial staging were retrospectively evaluated. The PET images were analyzed visually and semi-quantitatively by measuring the maximum standardized uptake value (SUVmax), lesion-to-liver SUVmax ratio, lesion-to-blood pool SUVmax ratio and the tumor to normal brain uptake ratio (T/N ratio) and compared with epidemiological (age, sex, HIV infection) and morphological (tumor size, MRI appearance) characteristics. Thirty-eight patients (83%) had positive 18F-FDG PET/CT (average SUVmax was 15.6 ± 9.2; lesion-to-liver SUVmax ratio 5.8 ± 2.8; lesion-to-blood pool SUVmax ratio 7.1 ± 3.8, T/N ratio 3.1 ± 1.7) at the corresponding brain lesion; the remaining 8 (17%) were not 18F-FDG avid. 18F-FDG avidity was significantly associated with morphological appearance and tumor size and not correlated with other features. 18F-FDG PET/CT detected extracranial disease in two cases (4%) with negative bone marrow biopsies and CT. In conclusion, brain lymphomas are 18F-FDG avid in 83% of cases showing high 18F-FDG uptake and 18F-FDG avidity is correlated with tumor size and morphological appearance of the lesion. PET/CT helped to recognize extracranial disease in two patients.

Spinal cord involvement in primary CNS lymphoma

LETM is a common syndrome and the diagnosis of CNS lymphoma is not usually considered in the list of differentials. Primary CNS lymphoma can present as longitudinally extensive transverse myelopathy. Failure to suspect and evaluate leads to delay in diagnosis and treatment. PCNSL may be non contrast enhancing on gadolinium enhanced MRI. CSF analysis should be done preferably before starting corticosteroids as it is usual practice in treatment of transverse myelitis, as steroids may lead to transient improvement and mask the correct diagnosis. Repeated CSF examinations may be needed to clinch the diagnosis.

Intraocular lymphoma

Intraocular lymphoma (IOL) is a rare lymphocytic malignancy which contains two main distinct forms. Primary intraocular lymphoma (PIOL) is mainly a sub-type of primary central nervous system lymphoma (PCNSL). Alternatively, IOL can originate from outside the central nervous system (CNS) by metastasizing to the eye. These tumors are known as secondary intraocular lymphoma (SIOL). The IOL can arise in the retina, uvea, vitreous, Bruch's membrane and optic nerve. There are predominantly of B-cell origin; however there are also rare T-cell variants. Diagnosis remains challenging for ophthalmologists and pathologists, due to its ability to masquerade as noninfectious or infectious uveitis, white dot syndromes, or occasionally as other metastatic cancers. Laboratory tests include flow cytometry, immunocytochemistry, interleukin detection (IL-10: IL-6, ratio >1), and polymerase chain reaction (PCR) amplification. Methotrexate-based systemic chemotherapy with external beam radiotherapy and intravitreal chemotherapy with methotrexate are useful for controlling the disease, but the prognosis remains poor. Therefore, it is important to make an early diagnose and treatment. This review is focused on the clinical manifestations, diagnosis, treatment and prognosis of the IOL.

Radiation therapy for older patients with brain tumors

The incidence of brain tumors in the elderly population has increased over the last few decades. Current treatment includes surgery, radiotherapy and chemotherapy, but the optimal management of older patients with brain tumors remains a matter of debate, since aggressive radiation treatments in this population may be associated with high risks of neurological toxicity and deterioration of quality of life. For such patients, a careful clinical status assessment is mandatory both for clinical decision making and for designing randomized trials to adequately evaluate the optimal combination of radiotherapy and chemotherapy.

Several randomized studies have demonstrated the efficacy and safety of chemotherapy for patients with glioblastoma or lymphoma; however, the use of radiotherapy given in association with chemotherapy or as salvage therapy remains an effective treatment option associated with survival benefit. Stereotactic techniques are increasingly used for the treatment of patients with brain metastases and benign tumors, including pituitary adenomas, meningiomas and acoustic neuromas. Although no randomized trials have proven the superiority of SRS over other radiation techniques in older patients with brain metastases or benign brain tumors, data extracted from recent randomized studies and large retrospective series suggest that SRS is an effective approach in such patients associated with survival advantages and toxicity profile similar to those observed in young adults. Future trials need to investigate the optimal radiation techniques and dose/fractionation schedules in older patients with brain tumors with regard to clinical outcomes, neurocognitive function, and quality of life.

The Challenge of Primary Central Nervous System Lymphoma

Primary central nervous system (CNS) lymphoma is a challenging subtypes of aggressive non-Hodgkin lymphoma. Emerging clinical data suggest that optimized outcomes are achieved with dose-intensive CNS-penetrant chemotherapy and avoiding whole brain radiotherapy. Anti-CD20 antibody-based immunotherapy as a component of high-dose methotrexate-based induction programs may contribute to improved outcomes. An accumulation of insights into the molecular and cellular basis of disease pathogenesis is providing a foundation for the generation of molecular tools to facilitate diagnosis as well as a roadmap for integration of targeted therapy within the developing therapeutic armamentarium for this challenging brain tumor.

SLE and Non-Hodgkin's Lymphoma: A Case Series and Review of the Literature

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disorder punctuated by varied multiorgan complications all along the course of its natural history. Lymphoma represents a relatively well-recognized malignant phenomenon associated with lupus. The cause and effect relationships of lymphoma in SLE have been subject to extensive scrutiny with several studies reporting on clinic-pathologic characteristics and risk factors predicting lymphoma development in SLE. However, the pathogenic role of immunosuppressives in SLE-related lymphoma still remains unclear, and indices to help guide diagnosis, prognostication, therapy, and posttreatment monitoring are yet to be established. In this review, we describe 3 SLE patients who developed non-Hodgkin's lymphoma at different time points of their disease. Through a careful dissection of the aforementioned cases, we intend to apprise readers of the currently available literature surrounding risk factors, management, and prognosis in SLE-related lymphoma. We will also review and discuss the implications of immunosuppressives in SLE-related lymphoma and the role of mycophenolate mofetil in SLE-related primary CNS lymphoma development.

The safety of resection for primary central nervous system lymphoma: a single institution retrospective analysis

Surgical resection is not the standard of care for primary central nervous system lymphoma (PCNSL), as historical studies have demonstrated unfavorable complication rates and limited benefits. Some recent studies suggest that resection may provide a therapeutic benefit, yet the safety of these procedures has not been systematically investigated in the setting of modern neurosurgery. We examined the safety of surgical resection for PCNSL. We retrospectively analyzed all patients with PCNSL treated at Columbia University Medical Center between 2000 and 2015 to assess complications rates following biopsy or resection using the Glioma Outcomes Project system. We identified predictors of complications and selection for resection. Well-validated scales were used to quantify patients' baseline clinical characteristics, including functional status, comorbid disease burden, and cardiac risk. The overall complication rate was 17.2% after resection, and 28.2% after biopsy. Cardiac risk (p = 0.047, OR 1.72 [1.01, 2.95]), and comorbid diagnoses (p = 0.004, OR 3.05 [1.42, 6.57]) predicted complications on multivariable regression. Patients who underwent resection had better KPS scores (median 70 v. 80, p = 0.0068, ∆ 10 [0.0, 10.00]), and were less likely to have multiple (46.5% v. 27.6%, p = 0.030, OR 1.42 [1.05, 1.92]) or deep lesions (70.4% v. 39.7%, p = 0.001, OR 1.83 [1.26, 2.65]). Age (p = 0.048, OR 0.75 per 10-year increase [0.56, 1.00]) and deep lesions (p = 0.003, OR 0.29 [0.13, 0.65]) influenced selection for resection on multivariable regression. Surgical resection of PCNSL is safe for select patients, with complication rates comparable to rates for other intracranial neoplasms. Whether there is a clinical benefit to resection cannot be concluded.

Clinicopathological Features and Outcomes in Primary Central Nervous System Lymphoma: A 10-year Experience

Context

Primary central nervous system lymphoma (PCNSL) is a variant of extranodal lymphoma, accounting for 4% of primary central nervous system tumors. PCNSL was more common in immunocompetent individuals. International Extranodal Lymphoma Study Group (IELSG) scoring was used for prognostication. High-dose methotrexate regimens along with radiotherapy improved outcomes in PCNSL.

Aims

The aim of this study is to analyze the clinical and pathological features, progression-free survival (PFS), and overall survival (OS) in patients with PCNSL.

Materials and Methods

Data of patients with PCNSL between 2005 and 2016 were retrospectively analyzed. Outcome was analyzed in patients who received chemotherapy. GraphPad Prism software for Windows Version 6 was used to plot the Kaplan-Meier curves for PFS and OS. Log-rank test was used to calculate P values. P < 0.05 was considered as statistically significant.

Results

A total of 42 patients were available for analysis. Of these, 34 patients who received chemotherapy were evaluable for outcome parameters. The median age at presentation was 46 years (range, 10-75) with male-to-female ratio of 2.2:1. Only 2 (4.7%) patients were HIV positive. Diffuse large B-cell lymphoma (DLBCL) was the most common histology seen in 41 (97.6%) patients. Using IELSG risk scoring, scores of 8 (19%), 19 (45.2%), and 15 (35.8%) were stratified into low, intermediate, and high risk. The median PFS and OS were 11 months (range, 2-72) and 15.9 months (2.4-80.4), respectively. The median OS was 36.2 months (range, 8.8-72), 15.6 months (2-36), and 6.1 months (2.6-12.7) in low-, intermediate-, and high-risk groups, respectively, which was statistically significant (P = 0.0002).

Conclusions

Immunocompetent patients with PCNSL outnumber immunocompromised patients. DLBCL was the most common histology, and IELSG risk stratification significantly predicts the outcome in PCNSL.