Resection of primary central nervous system lymphoma: impact of patient selection on overall survival

Abstract

OBJECTIVEPrimary central nervous system lymphoma (PCNSL) is a rare CNS tumor with a poor prognosis. It is usually diagnosed by needle biopsy and treated mainly with high-dose chemotherapy. Resection is currently not considered a standard treatment option. A possible prolonged survival after resection of PCNSL lesions in selected patients has been suggested, but selection criteria for surgery, especially for solitary lesions, have never been established.METHODSThe authors retrospectively searched their patient database for records of adult patients (≥ 18 years) who were diagnosed and treated for a solitary PCNSL between 2005 and 2019. Patients were divided into groups according to whether they underwent resection or needle biopsy. Statistical analyses were performed in an attempt to identify variables affecting outcome and possible survival advantage and to characterize subgroups of patients who would benefit from resection of their tumor compared with undergoing biopsy only.RESULTSA total of 113 patients with a solitary lesion of PCNSL were identified; 36 patients underwent resection, and 77 had a diagnostic stereotactic biopsy only. The statically significant preoperative risk factors included age ≥ 70 years (adjusted HR 9.61, 95% CI 2.42–38.11; p = 0.001), deep-seated lesions (adjusted HR 3.33, 95% CI 1.13–9.84; p = 0.030), and occipital location (adjusted HR 4.26, 95% CI 1.08–16.78; p = 0.039). Having a postoperative Karnofsky Performance Scale (KPS) score < 80 (adjusted HR 3.21, 95% CI 1.05–9.77; p = 0.040) and surgical site infection (adjusted HR 4.27, 95% CI 1.18–15.47; p = 0.027) were significant postoperative risk factors after the adjustment and selection by means of other possible risk factors. In a subgroup analysis, patients younger than 70 years who underwent resection had a nonsignificant trend toward longer survival than those who underwent needle biopsy (median survival 35.0 months vs 15.2 months, p = 0.149). However, patients with a superficial tumor who underwent resection had significantly longer survival times than those who underwent needle biopsy (median survival 34.3 months vs 8.9 months, p = 0.014). Patients younger than 70 years who had a superficial tumor and underwent resection had significantly prolonged survival, with a median survival of 35.0 months compared with 8.9 months in patients from the same group who underwent needle biopsy (p = 0.007).CONCLUSIONSSpecific subgroups of patients with a solitary PCNSL lesion might gain a survival benefit from resection compared with undergoing only a diagnostic biopsy.

Epidemiologic Characteristics, Prognostic Factors, and Treatment Outcomes in Primary Central Nervous System Lymphoma: A SEER-Based Study

“…Moreover, combining surgical excision and chemotherapy can bring favorable OS and DSS than chemotherapy alone, which suggested that multimodal therapy may be more beneficial. At present, there is insufficient evidence to recommend surgical resection for PCNSL, and several small population retrospective studies indicated that specific subgroups of patients with single lesions and superficial tumors might gain a survival benefit from resection (30,31). Our study also showed the advantages of surgical resection based on a large population.…”

An Update on Neurosurgical Management of Primary CNS Lymphoma in Immunocompetent Patients

“…Yet, patients with single lesions more often underwent resection, and after further statistical adjustment for the number of lesions, only advantage for PFS remained. Other studies came to a similar conclusion reflecting that this might be due to a selection bias for patients with single lesions and patients without the involvement of deep structures ( 55 – 57 ). In contrast, a large retrospective study by Houillier et al.…”

Clinical Features, Diagnosis, and Treatment of Primary Intraventricular Lymphoma: Insights From a Monocentric Case Series

“…As PCNSL has an infiltrative growth pattern, some lesions are multiple and deep, making surgery difficult. Studies have demonstrated that surgical resection did not significantly prolong survival time in patients ( 53 ). As a result, surgical resection was not included in the standard treatment plan and was limited to biopsy.…”