First-Line Treatment and Outcome of Elderly Patients with Primary Central Nervous System Lymphoma (PCNSL) – A Systematic Review and Individual Patient Data Meta-Analysis
Menée à partir des données de 13 études incluant au total 405 patients atteints d'un lymphome primitif du système nerveux central et à partir des données de 378 autres patients (âge : de 60 à 90 ans ; durée médiane de suivi : 40 mois), cette méta-analyse évalue l'efficacité, du point de vue de la survie, et la toxicité de différents traitement de première ligne (méthotrexate, radiothérapie du cerveau entier, agents alkylants)
Background : To investigate prognosis and effects of first-line therapy in elderly primary central nervous system lymphoma (PCNSL) patients. Patients and Methods : A systematic review of studies about first-line therapy in immunocompetent patients≥60 years with PCNSL until 2014 and a meta-analysis of individual patient data from eligible studies and international collaborators were performed. Results : We identified 20 eligible studies; from 13 studies we obtained individual data of 405 patients, which were pooled with data of 378 additional patients (N=783). Median age and Karnofsky Performance Score (KPS) was 68 years (range: 60 - 90) and 60% (range: 10% - 100%), respectively. Treatments varied greatly, 573 (73%) patients received high-dose methotrexate (HD-MTX)-based therapy. 276 patients received whole brain radiotherapy (median 36 Gy, range 28.5 - 70). KPS≥70% was the strongest prognostic factor for mortality (hazard ratio [HR] 0.50, 95% CI 0.41 - 0.62). After a median follow-up of 40 months, HD-MTX based therapy was associated with improved survival (HR 0.70, 95% CI 0.53 – 0.93). There was no difference between HD-MTX plus oral chemotherapy and more aggressive HD-MTX based therapies (HR 1.39, 95% CI 0.90 - 2.15). Radiotherapy was associated with an improved survival, but correlated with an increased risk for neurological side effects (odds ratio 5.23, 95% CI 2.33 - 11.74). Conclusions : Elderly PCNSL patients benefit from HD-MTX based therapy, especially if combined with oral alkylating agents. More aggressive HD-MTX protocols do not seem to improve outcome. WBRT may improve outcome, but is associated with increased risk for neurological side effects. Prospective trials for elderly PCNSL patients are warranted.