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AIDS-Related Malignancy
Published in Pat Price, Karol Sikora, Treatment of Cancer, 2020
Mark Bower, Elena Gervasi, Alessia Dalla Pria
In recent years the prognosis for primary cerebral lymphoma in immunocompetent individuals has improved, and this has encouraged clinicians to take a more aggressive approach in HIV-associated PCL. As such we have moved on from whole-brain radiotherapy, due to its poor response durability, the poor survival, and the association with irreversible neurocognitive decline. The current approach, usually reserved for those of better performance status, combines systemic chemotherapy with adequate CNS penetration (usually high-dose methotrexate with or without cytarabine and rituximab) with cART. In some patients who achieve a good response, this approach may be augmented by high-dose chemotherapy and autologous stem cell transplantation. Whole-brain radiotherapy remains a useful palliative treatment modality to control symptoms and should be considered as an alternative approach for patients when the risks of toxicity with high-dose intravenous chemotherapy are considered unacceptable.
Brain metastases
Published in Anju Sahdev, Sarah J. Vinnicombe, Husband & Reznek's Imaging in Oncology, 2020
Anant Subramanian Krishnan, Jane Evanson
The reported incidence of BMs is increasing. A Swedish population study found that the incidence of BMs doubled from 7 people per 100,000 in 1987 to 14 per 100,000 population in 2006 (4). This increase is thought to reflect improved imaging techniques, such as magnetic resonance imaging (MRI) (5), and better patient survival through better management of the primary disease, and metastatic control in other organs (6). Despite improvements in management, long-term survival remains low. A retrospective analysis of 916 patients with brain metastases who underwent whole-brain radiotherapy found the median survival unadjusted for different cancer subtypes was 3.4 months, with an overall survival of 5.6% at 2 years, dropping to 1.8% at 5 years (7).
Panuveitis
Published in Gwyn Samuel Williams, Mark Westcott, Carlos Pavesio, Bushra Thajudeen, Practical Uveitis, 2017
Gwyn Samuel Williams, Mark Westcott
Treatment is organised via the oncologists and has traditionally consisted of chemotherapy, with or without whole brain radiotherapy. There is recent interest in high-dose chemotherapy with autologous stem cell implant. Our role as ophthalmologists is confined to measuring the response. Rarely intravitreal methotrexate can be given for PIOL if the usual treatment has not been successful though this should be in close co-operation with the oncology and the haematology teams. It must also be remembered that intravitreal treatment does not prolong life and is an adjunct to systemic treatment specifically for the aim of stabilising sight, not an alternative, even if there is no apparent brain involvement. The prognosis of primary CNS lymphoma is pretty bleak, with a median survival of between 2.5 and 5 years after diagnosis. Early detection is key and even then, the prognosis, though better, is still quite poor, with most patients still dying of the disease. Having a low index of suspicion in older people presenting with an atypical bilateral uveitis which only transiently responds to steroids is critical.
Specific KIR-HLA genotypes predict outcomes in refractory or relapsed primary central nervous system lymphoma
Published in Hematology, 2023
Zhiguang Lin, Huiwen Xu, Jingjing Ma, Yan Ma, Qing Li, Hui Kang, Mengxue Zhang, Bobin Chen
A total of 31 patients with PCNSL received AT treatment from June 2017 to June 2020 at our institution. One patient whose blood sample was not available was excluded from the study. The analysis included 30 patients (Table 1). Two patients were lost to follow-up when calculating OS. As shown, the median age and ECOG performance status of all patients were 65 years (range 25–79) and 3 (range 1–4), respectively. Eighty percent of patients (24/30) switched to AT therapy due to disease progression after high-dose MTX-based therapy, and the remaining 20% of patients (6/30) received AT therapy as they relapsed after having achieved CR. Based on the medical records, 33.3% of patients (10/30) presented two or more lesions in the brain prior to AT treatment, and 66.7% of them (20/30) had tumors involving deep structures, including the periventricular regions, basal ganglia, corpus callosum, brainstem and cerebellum. The median longest lesion diameter on MR images was 2.3 cm (range: 0.5–5.1). Furthermore, 16.7% of patients (5/30) had lymphoma cells in the cerebrospinal fluid (CSF), and 3.3% (1/30) had lymphoma cells in vitreous fluid. All patients had received a median of 9 g MTX at least once prior to AT treatment. Some patients had previously received other regimens, including idarubicin, rituximab, pemetrexed, and lenalidomide. Other than chemotherapy, 6.7% of patients (2/30) had previously received whole-brain radiotherapy.
Germline genetic variations in methotrexate pathway are associated with pharmacokinetics, outcome, and toxicity in patients with primary central nervous system lymphoma
Published in Expert Review of Clinical Pharmacology, 2023
Zhuo Wu, Ziran Li, Xiaoyan Qiu, Mingkang Zhong, Tianling Ding
The treatments were repeated every 3–4 weeks, and responses were assessed after 3 courses of chemotherapy according to the International Primary CNS Lymphoma Collaborative Group consensus guidelines, which include complete response (CR), partial response (PR), stable disease (SD), and progressive disease (PD) [24]. Once CR was achieved, the same protocol was followed until 6 cycles and patients then received hematopoietic stem cell transplantation as consolidation therapy. On the occurrence of PD, the PFS was calculated and an alternative regimen without MTX was used. Otherwise, the chemotherapy regimen was adjusted using a different drug combined with MTX, such as liposome doxorubicin, cytosine arabinoside, etoposide, or ibrutinib. Patients received whole brain radiotherapy if CR was not achieved. All patients were evaluated using enhanced cranial MRI before each chemotherapy every 3–6 months, or if clinically necessary after treatment completion.
Stereotactic radiosurgery with whole brain radiotherapy combined with bevacizumab in the treatment of brain metastases from NSCLC
Published in International Journal of Neuroscience, 2023
Lu Li, Mei Feng, Peng Xu, Yi Lin Wu, Jun Yin, Yecai Huang, Ming Yu Tan, Lang Jinyi
Whole-brain radiotherapy has been considered the best treatment for brain metastases [26, 27]. With the advancement of radiotherapy technology, stereotactic radiotherapy has been widely used in the treatment of brain metastases based on whole-brain radiotherapy. Several reports have shown that the combination of WBRT with other treatments is beneficial as it increased the local control rate of BM in comparison to the SRS group and reduced the risk of new BM for the group treated with SRS alone in the JROSG 99-1 trial [28]. WBRT also reduced the 2-year recurrence rate of the initial site and field recurrence in the EORTC 22952-26001 trial [29]. A phase III trial of MDACC D00377 [30] reported a significant improvement in intracranial control for the WBRT-SRS treated group in comparison to only the SRS-treated group. However, despite improved intracranial control, all the JROSG 99-1, EORTC 22952-26001 and MDACC trials revealed that the support of WBRT did not enhance survival. This article is the first to report the efficacy and safety of SRS combined with WBRT plus bevacizumab. Compared to SRS, the two groups of OS and LPFS are similar. SRS combined with WBRT plus bevacizumab does not increase toxicity, and the risk of a cerebral hemorrhage, but increases the difficulty to control peritumoral edema.