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Primary esophageal lymphoma is a rare malignancy that is difficult to diagnose and treat. While there have been significant advances in understanding the pathogenesis, clinical features, and treatment options, there is a lack of consensus on the most effective treatment approach. This literature review provides a comprehensive overview of the use of available treatment options for primary esophageal lymphoma, including surgery, radiotherapy, and chemotherapy. The review also highlights the current knowledge gaps that need to be addressed through further research. While no single treatment modality has emerged as a clear front-runner, a combination of these treatments may be the most effective approach in managing primary esophageal lymphoma, tailored to the histological subtypes. [ABSTRACT FROM AUTHOR]

The letter to the editor discusses a case of a 33-year-old woman with aggressive primary refractory diffuse large B-cell lymphoma who was treated with nivolumab and axicabtagene ciloleucel (axi-cel). Despite severe toxicities, the patient achieved long-term complete remission, with CAR T cells persisting 6 years after infusion, representing the longest documented persistence of functional CAR T cells in large B-cell lymphoma. The combination of immune checkpoint inhibitors with CAR T cells is proposed to enhance efficacy and overcome resistance, although further studies are needed to clarify its efficacy for specific histologies and optimal dosing and sequencing. [Extracted from the article]

The contemporary landscape of systemic therapy options for hematologic malignancies involving the central nervous system (CNS-HM) is rapidly evolving; a key question is how radiotherapy (RT) can be optimally integrated to improve patient outcomes. Historically, use of RT to treat CNS-HM was defined by broad fields and high doses. While effective, this approach raised concerns of potential neurotoxicity which significantly decreased RT utilization. RT was replaced by high-dose, CNS-penetrant, systemic therapies that offered durable control with lower perceived neurotoxic risk. But, as the therapeutic toolbox for CNS-HM expands, so too does the complexity and diversity of potential clinical scenarios where RT should be considered. In this review, we describe both well-established and emerging opportunities for RT integration, emphasizing how dose selection and field design could balance neurotoxicity risk and disease control. We propose an anatomical framework that captures the diverse utilization of RT for CNS-HM and serves as a practical guide for RT volume and dose design. [ABSTRACT FROM AUTHOR]

Chimeric antigen receptor (CAR) T-cell receptor therapy has transformed outcomes for patients with relapsed and refractory diffuse large B-cell lymphoma (R/R DLBCL). It is currently approved in the third line for all patients and in the second line for early relapsed or primary refractory disease. Although CAR T cell therapy offers the potential for improved outcomes, its use may also include logistical delays related to referral, medical, social, and financial clearance as well as manufacturing time; more than half of patients experience disease recurrence or progression while awaiting CAR T infusion. Bridging radiotherapy, defined as radiation delivered between the decision to pursue CAR T and infusion of CAR T cells, has become an attractive option for patients who would benefit from local disease control or palliation of symptoms. Additionally, patterns of failure analyses have revealed a dominant role of local disease progression, which has fueled investigations on bridging and early salvage radiation to improve long-term outcomes in patients, particularly those with localized or high-risk disease. Several potential mechanisms by which radiation therapy may improve CAR T efficacy have been proposed that include cytoreduction, tumor debulking, neutralization of immunosuppressive hypoxic and acidic tumor microenvironments, and immunologic and pro-apoptotic synergy between radiation and CAR T. Prospective clinical trials and translational work are ongoing and are needed to inform our conceptual understanding of potential mechanisms by which radiation therapy may improve CAR T efficacy and toxicity, identify which patients may be most likely to benefit, and confirm proposed clinical benefits. [ABSTRACT FROM AUTHOR]

Background Few studies address the cost of treating prolactinomas. We performed a cost-utility analysis of surgical versus medical treatment for prolactinomas. Materials and Methods We determined total hospital costs for surgically and medically treated prolactinoma patients. Decision-tree analysis was performed to determine which treatment produced the highest quality-adjusted life years (QALYs). Outcome data were derived from published studies. Results Average total costs for surgical patients were $19,224 ( ± 18,920). Average cost for the first year of bromocriptine or cabergoline treatment was $3,935 and $6,042, with $2,622 and $4,729 for each additional treatment year. For a patient diagnosed with prolactinoma at 40 years of age, surgery has the lowest lifetime cost ($40,473), followed by bromocriptine ($41,601) and cabergoline ($70,696). Surgery also appears to generate high health state utility and thus more QALYs. In sensitivity analyses, surgery appears to be a cost-effective treatment option for prolactinomas across a range of ages, medical/surgical costs, and medical/surgical response rates, except when surgical cure rates are ≤ 30%. Conclusion Our single institution analysis suggests that surgery may be a more cost-effective treatment for prolactinomas than medical management for a range of patient ages, costs, and response rates. Direct empirical comparison of QALYs for different treatment strategies is needed to confirm these findings.

BackgroundGlioblastoma patients can develop hydrocephalus, either obstructive, typically at diagnosis as a result of mass effect, or communicating, usually later in the disease.ObjectiveTo characterize the indications and efficacy of ventriculoperitoneal (VP) shunting for patients with glioblastoma-associated hydrocephalus.MethodsRetrospective review was conducted of 841 glioblastoma patients diagnosed from 2004 to 2014, 64 (8%) of whom underwent VP shunting for symptomatic hydrocephalus, to analyze symptoms and outcomes after shunting. Overall survival and postshunt survival were analyzed with Kaplan-Meier methods, with predictors evaluated by use of Cox proportional hazards.ResultsOf the 64 patients who underwent shunting, 42 (66%) had communicating hydrocephalus (CH) and 22 (34%) had obstructive hydrocephalus (OH). CH patients underwent more preshunt craniotomies than those with noncommunicating hydrocephalus, with a mean of 2.3 and 0.7 surgeries, respectively ( P < .001). Ventricular entry during craniotomy occurred in 52% of CH patients vs 59% of those with OH ( P = .8). After shunting, 61% of all patients achieved symptomatic improvement, which was not associated with hydrocephalus variant ( P > .99). Hydrocephalus symptom improvement rates were as follows: headache, 77%; lethargy, 61%; and altered cognition or memory, 54%. Symptomatic improvement was more likely in patients who were younger at shunt placement (hazard ratio, 0.96; P = .045). Symptomatic improvement, shorter time between glioblastoma diagnosis and shunt placement, and CH rather than OH led to improved postshunt survival (hazard ratio = 0.24-0.99; P = .01-.04).ConclusionVP shunting improves symptoms in most glioblastoma patients with suspected CH or OH, specifically younger patients. Symptomatic improvement, shorter duration between glioblastoma diagnosis and shunt placement, and CH rather than OH improve postshunt survival.

BackgroundThe role of stereotactic radiosurgery (SRS) for recurrent glioblastoma and the radionecrosis risk in this setting remain unclear.ObjectiveTo perform a large retrospective study to help inform proper indications, efficacy, and anticipated complications of SRS for recurrent glioblastoma.MethodsWe retrospectively analyzed patients who underwent Gamma Knife SRS between 1991 and 2013. We used the partitioning deletion/substitution/addition algorithm to identify potential predictor covariate cut points and Kaplan-Meier and proportional hazards modeling to identify factors associated with post-SRS and postdiagnosis survival.ResultsOne hundred seventy-four glioblastoma patients (median age, 54.1 years) underwent SRS a median of 8.7 months after initial diagnosis. Seventy-five percent had 1 treatment target (range, 1-6), and median target volume and prescriptions were 7.0 cm 3 (range, 0.3-39.0 cm 3 ) and 16.0 Gy (range, 10-22 Gy), respectively. Median overall survival was 10.6 months after SRS and 19.1 months after diagnosis. Kaplan-Meier and multivariable modeling revealed that younger age at SRS, higher prescription dose, and longer interval between original surgery and SRS are significantly associated with improved post-SRS survival. Forty-six patients (26%) underwent salvage craniotomy after SRS, with 63% showing radionecrosis or mixed tumor/necrosis vs 35% showing purely recurrent tumor. The necrosis/mixed group had lower mean isodose prescription compared with the tumor group (16.2 vs 17.8 Gy; P = .003) and larger mean treatment volume (10.0 vs 5.4 cm 3 ; P = .009).ConclusionGamma Knife may benefit a subset of focally recurrent patients, particularly those who are younger with smaller recurrences. Higher prescriptions are associated with improved post-SRS survival and do not seem to have greater risk of symptomatic treatment effect.

Central neurocytomas are uncommon intraventricular neoplasms whose optimal management remains controversial due to their rarity. We assessed outcomes for a historical cohort of neurocytoma patients and evaluated effects of tumor atypia, size, resection extent, and adjuvant radiotherapy. Progression-free survival (PFS) was measured by Kaplan-Meier and Cox proportional hazards methods. A total of 28 patients (15 males, 13 females) were treated between 1995 and 2014, with a median age at diagnosis of 26 years (range 5-61). Median follow-up was 62.2 months and 3 patients were lost to follow-up postoperatively. Thirteen patients experienced recurrent/progressive disease and 2-year PFS was 75% (95% CI 53-88%). Two-year PFS was 48% for MIB-1 labeling >4% versus 90% for ≤4% (HR 5.4, CI 2.2-27.8, p = 0.0026). Nine patients (32%) had gross total resections (GTR) and 19 (68%) had subtotal resections (STR). PFS for >80% resection was 83 versus 67% for ≤80% resection (HR 0.67, CI 0.23-2.0, p = 0.47). Three STR patients (16%) received adjuvant radiation which significantly improved overall PFS (p = 0.049). Estimated 5-year PFS was 67% for STR with radiotherapy versus 53% for STR without radiotherapy. Salvage therapy regimens were diverse and resulted in stable disease for 54% of patients and additional progression for 38 %. Two patients with neuropathology-confirmed atypical neurocytomas died at 4.3 and 113.4 months after initial surgery. For central neurocytomas, MIB-1 labeling index >4% is predictive of poorer outcome and our data suggest that adjuvant radiotherapy after STR may improve PFS. Most patients requiring salvage therapy will be stabilized and multiple modalities can be effectively utilized.

Intractable focal epilepsy is a devastating disorder with profound effects on cognition and quality of life. Epilepsy surgery can lead to seizure freedom in patients with focal epilepsy; however, sometimes it fails due to an incomplete delineation of the epileptogenic zone. Brain networks in epilepsy can be studied with resting-state functional connectivity analysis, yet previous investigations using functional magnetic resonance imaging or electrocorticography have produced inconsistent results. Magnetoencephalography allows non-invasive whole-brain recordings, and can be used to study both long-range network disturbances in focal epilepsy and regional connectivity at the epileptogenic zone. In magnetoencephalography recordings from presurgical epilepsy patients, we examined: (i) global functional connectivity maps in patients versus controls; and (ii) regional functional connectivity maps at the region of resection, compared to the homotopic non-epileptogenic region in the contralateral hemisphere. Sixty-one patients were studied, including 30 with mesial temporal lobe epilepsy and 31 with focal neocortical epilepsy. Compared with a group of 31 controls, patients with epilepsy had decreased resting-state functional connectivity in widespread regions, including perisylvian, posterior temporo-parietal, and orbitofrontal cortices (P < 0.01, t-test). Decreased mean global connectivity was related to longer duration of epilepsy and higher frequency of consciousness-impairing seizures (P < 0.01, linear regression). Furthermore, patients with increased regional connectivity within the resection site (n = 24) were more likely to achieve seizure postoperative seizure freedom (87.5% with Engel I outcome) than those with neutral (n = 15, 64.3% seizure free) or decreased (n = 23, 47.8% seizure free) regional connectivity (P < 0.02, chi-square). Widespread global decreases in functional connectivity are observed in patients with focal epilepsy, and may reflect deleterious long-term effects of recurrent seizures. Furthermore, enhanced regional functional connectivity at the area of resection may help predict seizure outcome and aid surgical planning.

ObjectiveThe efficacy of epilepsy surgery depends critically upon successful localization of the epileptogenic zone. Magnetoencephalography (MEG) enables noninvasive detection of interictal spike activity in epilepsy, which can then be localized in three dimensions using magnetic source imaging (MSI) techniques. However, the clinical value of MEG in the presurgical epilepsy evaluation is not fully understood, as studies to date are limited by either a lack of long-term seizure outcomes or small sample size.MethodsWe performed a retrospective cohort study of patients with focal epilepsy who received MEG for interictal spike mapping followed by surgical resection at our institution.ResultsWe studied 132 surgical patients, with mean postoperative follow-up of 3.6 years (minimum 1 year). Dipole source modeling was successful in 103 patients (78%), whereas no interictal spikes were seen in others. Among patients with successful dipole modeling, MEG findings were concordant with and specific to the following: (1) the region of resection in 66% of patients, (2) invasive electrocorticography (ECoG) findings in 67% of individuals, and (3) the magnetic resonance imaging (MRI) abnormality in 74% of cases. MEG showed discordant lateralization in ~5% of cases. After surgery, 70% of all patients achieved seizure freedom (Engel class I outcome). Whereas 85% of patients with concordant and specific MEG findings became seizure-free, this outcome was achieved by only 37% of individuals with MEG findings that were nonspecific to or discordant with the region of resection (χ(2) = 26.4, p < 0.001). MEG reliability was comparable in patients with or without localized scalp electroencephalography (EEG), and overall, localizing MEG findings predicted seizure freedom with an odds ratio of 5.11 (95% confidence interval [CI] 2.23-11.8).SignificanceMEG is a valuable tool for noninvasive interictal spike mapping in epilepsy surgery, including patients with nonlocalized findings receiving long-term EEG monitoring, and localization of the epileptogenic zone using MEG is associated with improved seizure outcomes.