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CNS lymphoma

  

About Lymphoma > Types of Lymphoma > CNS (Central Nervous System) Lymphoma

Last update: 04/20/2008

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Overview of 
Central Nervous System (CNS) Lymphoma
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Primary central nervous system lymphoma (PCNSL) is a "high-grade non-Hodgkin B-cell neoplasm, usually large cell or immunoblastic type."

Alternative names: Reticulum Cell Sarcoma, Diffuse Histiocytic Lymphoma, and Microglioma

What is lymphoma? Briefly, lymphomas result when DNA damage or changes occurs to an immune cell (a lymphocyte) that alters the behavior of the cells. The damage to DNA results in the abnormal production of proteins that prevents the cells from dying when they should, or causes sustained rapid cell division that produces more of its kind. These malignant cells then may accumulate to form tumors.

Tendencies: Previously a rare tumor accounting for less than 2% of cerebral neoplasms, PCNSL is being seen with increasing frequency in immunocompetent patients, patients with AIDS, and transplant recipients. [2]

Factors influencing prognosis: Age, performance status (PS), LDH serum level, CSF protein concentration, and involvement of deep structures of the brain were independent predictors of survival. A prognostic score including these five parameters seems advisable in distinguishing different risk groups in PCNSL patients. The proposed score and its relevance in therapeutic decision deserve to be validated in further studies."[7]

Secondary CNS: Lymphomas can  sometimes migrate to the central nervous system.  This secondary form of CNS lymphoma is not common, however. 

Primary Central Nervous System Lymphoma: The Memorial Sloan-Kettering Cancer Center Prognostic Model. J Clin Oncol. 2006 Nov 20; PMID: 17116938 
 
"The MSKCC prognostic score is a simple, statistically powerful model with universal applicability to patients with newly diagnosed PCNSL. We recommend that it be adopted for the management of newly diagnosed patients and incorporated into the design of prospective clinical trials."
Resources:
  1. About Primary CNS  - NCI PDQ for Patients | cancerbacup.org.uk  
  2. Primary CNS Lymphoma - emedicine (free login req.) 
    Amy A Pruitt, MD,
  3. HIV-1 Associated Opportunistic Neoplasms: CNS Lymphoma - emedicine
  4. Central Nervous System Lymphoma ~ asheducationbook.org 
    Andrew Lister, Lauren E. Abrey and John T. Sandlund 
     
    "Central nervous system involvement with malignant lymphoma whether primary or secondary is an uncommon but not rare complication observed in the management of patients with hematological malignancy. "
  5. Primary CNS lymphoma of T-cell origin: a descriptive analysis from the international primary CNS lymphoma collaborative group.
    J Clin Oncol. 2005 Apr 1;23(10):2233-9. PMID: 15800313 | Related articles
  6. Imaging of central nervous system lymphomas with iodine-123 labeled rituximab.Eur J Haematol. 2005 Apr;74(4):348-52. PMID: 15777348
  7. Prophylactic intrathecal methotrexate and hydrocortisone reduces central nervous system recurrence and improves survival in aggressive non-Hodgkin lymphoma - http://cat.inist.fr/ 
  8. High-dose methotrexate for primary CNS lymphoma in the elderly - neuro-oncology.dukejournals.org  pdf 
  9. CNS Lymphoma - asheducationbook.org
Treatments
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TOPIC SEARCH: ASCO | PubMed | Medscape | PubMed Novel 

"Due to the unsatisfactory results of whole-brain irradiation alone and to the neurologic toxic effects of chemotherapy and radiation therapy, there is now a major focus on trials with chemotherapy alone. There are now several single-institution reports in which systemic chemotherapy has been employed alone or with osmotic blood-brain barrier disruption. Currently, most regimens are employing high-dose Methotrexate and require hospitalization. For patients who do not respond to chemotherapy alone or with radiation therapy, but are still responsive to salvage chemotherapy with cytarabine and etoposide, intensive chemotherapy with autologous peripheral stem cell transplantation is under evaluation." [5] - cancerweb.ncl.ac.uk 

Outcome report: Intensive Chemotherapy Followed by Hematopoietic Stem-Cell Rescue for Refractory and Recurrent Primary CNS and Intraocular Lymphoma: Societe Francaise de Greffe de Moelle Osseuse-Therapie Cellulaire. J Clin Oncol. 2008 Apr 14; PMID: 18413641  

The respective median progression-free survival (PFS) times after IC + HCR were 11.6 and 41.1 months. The 2-year overall survival probability was 45% in the whole population and 69% among the 27 patients who received IC + HCR. The 2-year PFS probability was 43% among all the patients and 58% in the IC + HCR subpopulation. CONCLUSION: IC + HCR is an effective treatment for refractory and recurrent PCNSL.
Combined immunochemotherapy with reduced whole-brain radiotherapy for newly diagnosed primary CNS lymphoma. J Clin Oncol. 2007 Oct 20;25(30):4730-5. PMID: 17947720

The addition of rituximab to MPV increased the risk of significant neutropenia requiring routine growth factor support. Additional cycles of R-MPV nearly doubled the CR rate. Reduced-dose WBRT was not associated with neurocognitive decline, and disease control to date is excellent.
Primary CNS lymphoma treated with combined intra-arterial ACNU and radiotherapy - http://www.springerlink.com/content/a61h2x70813j4521/ 

The intra-arterial administration of ACNU combined with radiation therapy yielded a high response rate at acceptable toxicity levels in younger patients with PCNSL. However, late neurotoxicity was a serious complication in patients above 60 years of age.
Management of central nervous system lymphomas using monoclonal antibodies: challenges and opportunities.
Clin Cancer Res. 2005 Oct 1;11(19 Pt 2):7151s-7157s. Review. PMID: 16203815 
Case report of a patient with primary central nervous system lymphoma treated with radioimmunotherapy. Clin Lymphoma Myeloma. 2006 Nov;7(3):236-8. 
PMID: 17229341 
Salvage therapy for primary central nervous system lymphoma with (90)Y-Ibritumomab and Temozolomide. J Neurooncol. 2007 Jul;83(3):291-3. Epub 2007 Jan 24. PMID: 17245621 

Aggressive initial treatment of Primary Central Nervous System Lymphoma (PCNSL) has achieved prolonged survival and occasional cures. However, some patients do not respond to initial therapy and others relapse after an initial remission. The optimal salvage regimen is not known and many different strategies have been proposed. In this report we describe the efficacy of a combination of (90)Y-Ibritumomab Tiuxetan (Zevalin) and Temozolamide as a maintenance therapy for recurrent PCNS Lymphoma in two patients that are both alive and in complete remission after 9 and 10 months respectively. This combination merits further study and provides a reasonable therapeutic alternative for older patients with progressive PCNSL.
Phase II Trial of the Bonn Polychemotherapy Protocol with Deferred Radiotherapy in Patients with Primary Central Nervous System Lymphoma. - ASH 2006

Conclusions: Primary chemotherapy based on high-dose MTX and ara-C is highly efficient in PCNSL. A substantial fraction of patients < 60 years can obviously be cured with this regimen.
CNS Lymphoma:  High-Dose Chemotherapy With Autologous Stem-Cell Transplantation and Hyperfractionated Radiotherapy As First-Line Treatment of Primary CNS Lymphoma. 
J Clin Oncol. 2006 Jul 24; PMID: 16864853 

With a median follow-up of 63 months (range, 4 months to 84 months), 5-year overall survival probability is 69% for all patients and 87% for the 23 patients receiving HDT plus ASCT. The 5-year probability of relapse-related death is 21% for all patients (n = 30) and 8.7% for patients treated with HDT plus ASCT (n = 23). CONCLUSION: Sequential systemic methotrexate and AraC and thiotepa followed by HDT plus ASCT and hyperfractionated WBRT is very effective with little toxicity as initial therapy for PCNSL.
Intraventricular application of rituximab as a treatment option in patients with CNS lymphoma and leptomeningeal disease. - ASCO 
Phase I Study of Intraventricular Administration of Rituximab in Patients With Recurrent CNS and Intraocular Lymphoma - http://jco.ascopubs.org/cgi/content

The maximum tolerated dose was determined to be 25 mg and rapid craniospinal axis distribution was demonstrated. Cytologic responses were detected in six patients; four patients exhibited complete response. 

Two patients experienced improvement in intraocular NHL and one exhibited resolution of parenchymal NHL. High RNA levels of Pim-2 and FoxP1 in meningeal lymphoma cells were associated with disease refractory to rituximab monotherapy.

Conclusion: These results suggest that intrathecal rituximab (10 to 25 mg) is feasible and effective in NHL involving the CNS.
Safety and efficacy of a multicenter study using intraarterial chemotherapy in conjunction with osmotic opening of the blood-brain barrier for the treatment of patients with malignant brain tumors. Cancer. 2000 Feb 1;88(3):637-47. PMID: 10649259 | Related articles
Enhanced chemotherapy delivery by intraarterial infusion and blood-brain barrier disruption in malignant brain tumors: the Sherbrooke experience. Cancer. 2005 Jun 15;103(12):2606-15. PMID: 15880378 | Related articles
Due to the difficulties in treating PCNSL (as of 2004), we think it reasonable as described above  to specifically ask your treating physician about  investigational treatments.  
 
      See Studies for CNS in ClinicalTrials.gov  
      Contact investigators listed in protocols.  
      Arrange to have the investigator talk with your treating physician.
Salvage chemotherapy with temozolomide in primary CNS lymphomas: preliminary results of a phase II trial. Eur J Cancer. 2004 Jul;40(11):1682-8. PMID: 15251157
Primary cerebral lymphoma: a retrospective study in 22 immunocompetent patients.
Tumori. 2004 May-Jun;90(3):294-8. PMID: 15315308
Treatment of Primary CNS Lymphoma With Methotrexate and Deferred Radiotherapy: A Report of NABTT 96-07. J Clin Oncol. 2003 Mar 15;21(6):1044-9. PMID: 12637469 - PubMed
What's New in Primary Central Nervous System Lymphoma, An interview with Virginia Stark-Vance, M.D. -dfw-neuronetwork.com 
Treatment of Primary CNS Lymphoma With Methotrexate and Deferred Radiotherapy: A Report of NABTT 96-07 Tracy Batchelor, Kathryn Carson, Alison O’Neill, Stuart A. Grossman, Jane Alavi, Pamela New, Fred Hochberg, Regina Priet - jco.org 
"These results indicate that high-dose methotrexate is associated with modest toxicity and a radiographic response proportion (74%) comparable to more toxic regimens. "
Clinical Trials
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Studies for CNS in ClinicalTrials.gov
ClinicalTrials.gov (easy and comprehensive) searches by:
Lymphoma subtype
Treatment type
State or Country
Other criteria such as age, stage, phase, refractory
Resources & 
Research News
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  1. Ocular presentation of primary central nervous system lymphoma: diagnosis and treatment. Br J Haematol. 2004 Jul;126(2):202-8. PMID: 15238140
  2. Methotrexate Induction Therapy Followed by High-Dose Chemotherapy ... 
    Doctor's Guide  ... followed by high-dose chemotherapy with autologous stem-cell rescue may be a feasible treatment approach for primary central nervous system
    (CNS) lymphoma ... - docguide.com  (press release)
  3. Primary Central Nervous System Lymphoma: Results of a Pilot and Phase II Study of Systemic and Intraventricular Chemotherapy With Deferred Radiotherapy. J Clin Oncol. 2003 Nov 3 PMID: 14597744 | More
  4. Importance of radiotherapy in the outcome of patients with primary CNS lymphoma: an analysis of the CHOD/BVAM regimen followed by two different radiotherapy treatments. J Clin Oncol. 2002 Jan 1;20(1):231-6. PMID: 11773174  - PubMed
  5. Results of intensive chemotherapy followed by hematopoietic stem-cell rescue in 22 patients with refractory or recurrent primary CNS lymphoma or intraocular lymphoma. Bull Cancer. 2004 Feb;91(2):189-92. French  PMID: 15047459
  6. Primary CNS lymphoma of T-cell origin: a descriptive analysis from the international primary CNS lymphoma collaborative group. J Clin Oncol. 2005 Apr 1;23(10):2233-9. PMID: 15800313
  7. Prognostic scoring system for primary CNS lymphomas: the International Extranodal Lymphoma Study Group experience. J Clin Oncol. 2003 Jan 15;21(2):266-72. PMID: 12525518
  8. Initial response to glucocorticoids: an important prognostic factor in patients with primary CNS lymphoma (PCNSL) - ASCO 2002
  9. Immunochemotherapy with rituximab and temozolomide for central nervous system lymphomas. Cancer. 2004 Jul 1;101(1):139-45.
    PMID: 15221999 | Related articles
  10. Trends in survival from primary central nervous system lymphoma, 1975-1999. Cancer. 2005 Oct 20; PMID: 16240449
  11. Prospective trial on topotecan salvage therapy in primary CNS lymphoma - annonc.oxfordjournals.org  

    The response rate was 33% with five complete (CR) and four partial remissions (PR). The median follow-up was 37.7 months. All complete responders had sustained remissions lasting for 9 to 28 months. The median event-free survival (EFS) was 2.0 months (9.1 months in responders), the overall survival (OAS) was 8.4 months. CTC grade 3–4 leukopenia occurred in 26% and thrombocytopenia in 11% of the patients. Eight of 12 patients alive without cerebral lymphoma ≥ six months after topotecan exhibited deficits attributable to late neurotoxicity.
  12. CNS outcomes predicted by gene expression: Retrospective analysis of P-STAT6 expression as a predictive marker in primary nervous system lymphoma patients assigned to high-dose methotrexate - ASCO 2007 
  13. Feasibility study: Study of radiolabeled indium-111 and Zevalin in primary central nervous system lymphoma. Cancer. 2007 Oct 11; PMID: 17932895 
  14. Brain parenchyma involvement as isolated central nervous system (CNS) relapse of systemic non-Hodgkin lymphoma: an International Primary CNS Lymphoma Collaborative Group report.
    Blood. 2007 Oct 25; PMID: 17962515 

    Our results suggest systemic methotrexate is the optimal treatment for isolated CNS relapse involving the brain parenchyma. Long-term survival is possible in some patients.
  15. Outcomes CNS Lymphoma : Methotrexate May Cure up to 20% of Patients With CNS lymphoma

    "In this small, multicenter study we found that at almost 7 years of follow-up, 5 of the original 25 patients were still in remission after treatment with high-dose methotrexate alone and that toxicity was modest," principal investigator Tracy Batchelor, MD, told Medscape Neurology & Neurosurgery. 

    The study is published in the January 29 issue of Neurology.
 
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For all medical concerns,  you should always consult your doctor. 
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