Autologous Stem Cell Transplantation (ASCT) As Upfront Treatment in Primary Central Nervous System Lymphoma (PCNSL): A Systematic Review and Comparative Analysis in Clinical Trials Setting
Notice bibliographique
Résumé
Abstract Purpose PCNSL standard treatment encompass 2 phases: induction and consolidation. Induction consists of high-dose methotrexate-based polychemotherapy for most patients and consolidation is still to be defined. ASCT is an effective treatment and despite the advancements in this technique for other disease sites, its role in PCNSL remains unclear. This systematic review aims to evaluate toxicity and outcomes of ASCT as upfront treatment in PNCSL. Material and Methods In accordance to PRISMA guidelines, a systematic review of the literature was conducted on studies reporting ASCT in PCNSL. EMBASE, MEDLINE and Cochrane databases were systematically searched for relevant studies until May 2016. All clinical trials (CT) evaluating the role of ASCT as up front treatment for PCNSL (excluding recurrence or salvage) were included. Studies were classified into 2 groups for statistical analysis: (1) Regimens containing thiotepa (either on induction or intensification regimen or conditioning regimen; (2) Regimens without thiotepa. Dichotomous outcomes were summarized as risk ratios (RRs). The size effect of the intervention for time-to-event outcomes was calculated by the pooled hazard ratio (HR), followed by the confidence interval (CI) of 95%. For determining derivative of expected events, the Z-Score for two-tailed p-value was calculated based on relative risk of each study. Results From 1803 references, 7 articles (6 phase 2; 1 pilot trial) from 2006 to 2016 were selected, comprising a total of 181 patients. For up front treatment of PCNSL with ASCT regimens containing thiotepa plus or minus WBRT: total of 128 patients were identified in 5 studies. Patient's median age was 54,5 (range, 54 to 57), KPS ranged from 70 to 90, WBRT was allowed in 3 studies and a median of 81% of the patients completes the ASCT protocol. Median complete response rate (CRR) was 69% (range, 54 to 81%), 2-years progression free survival (2PFS) 69% (range, 54 to 81%) and 2-years overall survival (2OS) 84% ranging from 83 to 91% in a median follow-up time of 15 to 63 months. Median neurotoxicity rates (NR) and treatment related mortality (TRM) were 3% (0 to 33%) and 3% (0 to 13%), respectively. (2) Up front ASCT regimens without thiotepa plus or minus WBRT: total of 53 patients were identified in 2 studies. Patient's median age was 52,5 (range, 52 to 53), KPS ranged from 70 to 80, WBRT was allowed in 1 study and a median of 59% of the patients completes the ASCT protocol. Median CRR was 31% (range, 18 to 44%), 2PFS 44% (range, 25 to 62%), 2OS of 65% ranging from 60 to 70% in a median follow-up time of 28 to 34 months. Median NR and TRM were 4% (0 to 8%) and 4%, respectively. Regimens containing thiotepa were associated with better 2OS (RR 0.46; IC95 0.27 to 0.80; P=0.006; Z=2.76) and increased 2PFS (RR 0.52; IC95 0.37 to 0.74; P=0.0002; Z=3.69). The addition of WBRT wasn't associated with better 2OS (RR 0.94; IC95 0.53 to 1.67; P=0.082; Z=0.22) Conclusions Up front ASCT in the management of PCNSL is associated with high CRR and excellent 2OS and 2PFS when thiotepa is added to the regimen. Close to 200 patients treated in CT settings with up front ASCT for PCNSL were found in the literature and at least 4 different treatment scenarios were described. An important rate (>10%) of TRM was seen in two studies however ASCT was seem to be safe in most of the publications. Disclosures No relevant conflicts of interest to declare.
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Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,009 | 0,027 |
| Méta-épidémiologie (sens strict) | 0,002 | 0,001 |
| Méta-épidémiologie (sens large) | 0,013 | 0,013 |
| Bibliométrie | 0,007 | 0,008 |
| Études des sciences et des technologies | 0,001 | 0,001 |
| Communication savante | 0,002 | 0,002 |
| Science ouverte | 0,002 | 0,001 |
| Intégrité de la recherche | 0,002 | 0,001 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,004 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».