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

Abstract

Object 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. Methods 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. Results 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, Δ 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. Conclusions 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.

Craniotomy and Survival for Primary Central Nervous System Lymphoma

“…While 1 study reports that over 80% of patients have deep lesions, 50 another series found that 70% of patients with PCNSL presenting for neurosurgical evaluation have lobar lesions, 23 and thus potentially resectable tumors. Our findings add to the growing body of evidence that using modern neurosurgical techniques, craniotomy for PCNSL is not only safe, 32 but may also be associated with prolonged survival, particularly for those patients in favorable prognostic categories. However, given the methodological limitations of this and prior studies, current evidence falls short of demonstrating causality.…”

“…Number of lesions and lesion location have been previously shown to be independently predictive of surgical complications. 32 Lesions involving brainstem, basal ganglia, corpus callosum, or periventricular areas were classified as deep. Departing from the prognostic system of Ferreri et al, 33 we classified the cerebellum as superficial despite worse prognosis because of its relative surgical accessibility.…”

“…34 Frailty affects complication rates after intracranial surgery. 32,36 The modified frailty index was developed from the Canadian Study on Health and Aging 37,38 with increasing frailty score associated with poorer outcomes across many surgical procedures, [39][40][41] including craniotomy for glioblastoma resection. 36 This index gives 1 point for each variable present: difficulty with activities of daily living; history of diabetes mellitus; lung or respiratory disease; congestive heart failure; myocardial infarction; other cardiac disease; arterial hypertension; clouding, delirium, or cognitive impairment; history of transient ischemic attack; history of stroke; and peripheral vascular disease.…”

The role of surgical resection in primary central nervous system lymphoma: a single-center retrospective analysis of 70 patients

“…However, Bellinzona et al [ 15 ] demonstrated that surgery might have a role in a selected subset of patients presenting with large single space occupying lesions and deteriorating neurological status. Cloney et al [ 17 ] suggested that the overall complication rate of resection for PCNSL is comparable to rates for other CNS malignancies and believed that resection is safe for selected patients. In our series of 70 patients, 42 underwent stereotactic biopsy, and 28 underwent surgical resection.…”

“…Resection for PCNSL patients has been discouraged and traditionally limited due to an unacceptable morbidity for the procedure according to the literature from the 1970s to 1990s. However, with the development of modern surgical techniques, especially neuronavigation, fluorescein for tumour visualization and intraoperative neurophysiologic monitoring, which have improved the safety and accuracy of surgery, the postsurgical complication rates for PCNSL have decreased to 0–20%, as the recent literature has reported [ 10 , 14 , 17 ]. For example, Cloney et al [ 17 ] reported that the complication rate of the resection group (17.2%) was lower than that of the biopsy group (28.2%) through the analysis of 129 patients with PCNSL between 2000 and 2015, and they deemed resection safe for selected patients.…”