Primary Central Nervous System Lymphoma: A Critical Review of the Role of Surgery for Resection

Abstract

Background Primary central nervous system lymphomas (PCNSL) are rare CNS tumors that carry a poor prognosis, with most patients suffering recurrence. Progress has been made in the treatment of this pathology, notably with the widespread use of systemic high dose methotrexate. However, unlike most other malignant CNS neoplasms, surgery for cytoreduction is not routinely performed for this disease, mainly as a result of negative experiences decades ago. Since these studies were published, the availability of intraoperative monitoring, MR imaging and neuro-navigation as well as surgical adjuncts such as fluorescence- guided resection have greatly improved the safety of intracranial procedures. More recent data is suggestive of a potential survival benefit for resection of single PCNSL lesions when patients are subsequently treated with modern regimen high-dose methotrexate, yet this evidence is limited, and should be interpreted conservatively. Methods and findings A systematic review of the literature was performed to identify trials evaluating surgical options for the treatment of PCNSL. Conclusion In this review, we provide a critical overview of the evidence favoring and discouraging resection for PCNSL. This literature suffers from several biases and limitations that must be considered in the context of the extrapolation of this literature into clinical decision-making.

Assessing the Safety of Craniotomy for Resection of Primary Central Nervous System Lymphoma: A Nationwide Inpatient Sample Analysis

“…Previously published high complication rates associated with craniotomy for PCNSL ( 8 , 9 ) have contributed to the wide acceptance of diagnostic biopsy as the first-line surgical option followed by high-dose methotrexate, with or without radiation ( 7 ). The role of craniotomy for surgical resection of PCNSL in the era of modern neurosurgical techniques requires a fresh mindset, as most data on the safety and efficacy of resection precede modern neurosurgical techniques and high-dose systemic methotrexate, and thus might be outdated ( 21 ). Recently, a few studies demonstrated a potentially beneficial impact on survival with cytoreduction in PCNSL ( 16 , 17 ).…”

“…Therefore, to understand the safety of craniotomy for PCNSL using modern surgical techniques, institutional series might complement our study, as these could offer more granularity and thus information on the transience or permanence of complications. The NIS also offers no information on the location of the tumor, a parameter that is relevant especially with regards to PCNSL, as these tumors often develop in eloquent areas, or areas that are difficult to access (i.e., deep brain structures), thus increasing the risk of postoperative complications ( 8 , 11 , 21 ). Additionally, the dataset does not provide certain specifications about the patients (clinical history, neurological status, general status, etc.)…”

Craniotomy and Survival for Primary Central Nervous System Lymphoma

“…5 Surgery for cytoreduction is not standard for PCNSL, though it is occasionally performed for symptomatic relief of severe mass effect or if the lesion mimics other pathology on imaging studies. 5,6 This treatment paradigm contrasts with the management of other intra-axial tumors including brain metastasis and diffusely infiltrative gliomas, where surgery contributes to oncologic control and is associated with a survival advantage. [7][8][9][10][11][12] Cytoreductive surgery was excluded from first-line management of PCNSL largely due to results from studies concluding resection offered no benefit and potentially worsened outcomes.…”

Primary central nervous system lymphoma and 5-aminolevulinic acid

“…New advances in surgical technology and adjuvant treatments have led to more aggressive approaches reconsidering the role of surgical resection in PCNSL. [2,6,12,14] Bellinzona et al [2] could not demonstrate a clear benefit from surgery in all patients with PCNSL, but they suggested that it might be a subgroup of patients with large single space-occupying lesions and deteriorating neurological status who might benefit from it. Weller et al [12] performed a secondary analysis of the German PCNSL Study Group-1 trial, and, considering that there were no significant differences in the baselines characteristic of both study groups such as age and Karnofsky performance status, they concluded that progression-free survival and overall survival were significantly shorter in biopsied patients compared to patients with subtotal or gross total resection (GTR).…”

“…[1,3] However, these conclusions must be taken cautiously since most of these studies were done previous to the development of modern surgical techniques, chemotherapy and imaging. [14] Figure 1: e images a, b, and c correspond to the patient 1. e images d, e, and f correspond to the patient 2.…”