Results of a large population-based study of patients with primary CNS lymphoma diagnosed between 2011 and 2016 showed a higher proportion of patients 60 years and older compared with reports from studies conducted 1 to 2 decades earlier.  The findings from this study were published in Neurology.

Primary CNS lymphoma is a rare, aggressive form of non-Hodgkin lymphoma that can involve the brain, spine, leptomeninges, and eyes. It is characterized by the absence of systemic disease, and a poor prognosis.

A number of advances in the treatment of patients with this disease have been made over the past 3 decades. These have included replacement of conventional whole-brain radiotherapy (WBRT) alone with combined modality therapy including high-dose methotrexate-based chemotherapy followed by WBRT consolidation, which was shown to prolong time to recurrence in these patients. Alternatively, the use of first-line, high-dose chemotherapy followed by autologous stem cell transplantation (ASCT) consolidation is an approach designed to circumvent WBRT-associated toxicity.

In addition, studies of the safety and efficacy of combining first-line high-dose methotrexate with other drugs, such as high-dose cytarabine or rituximab, have shown promising results, although concerns related to toxicity, particularly in older patients, remain with some of these approaches.  

This retrospective study included patient-, disease-, and treatment-related data for all adult, HIV-negative patients with primary CNS lymphoma diagnosed between 2011 and 2016 who were included in the French oculo-cerebral lymphoma network, a prospective, nationwide database.

Of the 1002 patients included in this analysis, the median patient age was 68 years (range, 18-91 years), and the median Karnofsky Performance Status (KPS) was 60. Patients at least 60 years old and at least 70 years old comprised 72% and 43% of the study population, respectively.

These data “are in line with epidemiologic studies reporting a continuously increasing rate in the elderly over the last decades,” the study authors commented.

More than 90% of patients were treated with high-dose methotrexate chemotherapy, including more than 80% of patients aged 80 years or older, although the dose was more likely to be lower in the latter population.

Consolidation therapy with WBRT or ASCT was received by 15% and 6% of patients, respectively, although the majority of these patients were younger than 60, with only 11% of patients aged 60 years or older receiving consolidation therapy.

The objective response rate (ORR) to first-line treatment was significantly higher in younger patients compared with older patients (73% vs 54%; P <.001), and ORRs for the overall population and the population treated with consolidation therapy were 59% and 92%, respectively.

At a median follow-up of 44.4 months, the median overall survival (OS) for the overall population was 25.3 months. Although the rates of 1-, 2-, and 5-year OS for the overall population were 62%, 51%, and 38%, the 5-year OS rate for those treated with first-line high-dose chemotherapy followed by ASCT was 76%.

One-quarter of patients included in the study died within 6 months of primary CNS lymphoma diagnosis, and these patients were more likely to be older (P <.001) and to have a worse KPS at diagnosis (P <.001). Cause of death in this group was determined to be multifactorial in 44% of cases, and included impaired neurologic status due to lymphoma, complications (eg, infections), and/or treatment-related side effects.

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Median OS in patients 60 years or older at diagnosis of primary CNS lymphoma was 15.4 months compared with 28.4 months in those younger than 60 years (P <.001).

On multivariate analysis, prognostic factors associated with longer OS included age younger than 60 years (P <.001), KPS of 70 or higher at diagnosis (P <.001), female sex (P =.03), and response to first-line induction chemotherapy (P <.001).

The finding that “age represents not only the strongest prognostic factor of the disease, but also a major risk factor for severe treatment-related neurotoxicity,” prompted the study authors to conclude that these results “should stimulate specific studies devoted to the elderly [with primary CNS lymphoma] to optimize the therapeutic management of this growing vulnerable population.”

Reference

Houillier C, Soussain C, Ghesquières H, et al. Management and outcome of primary CNS lymphoma in the modern era: an LOC network study [published online January 6, 2020]. Neurology. doi: 10.1212/WNL.0000000000008900

This article originally appeared on Oncology Nurse Advisor