Introduction: Resection for Primary Central Nervous System Lymphoma (PCNSL) has been considered high-risk and not beneficial. We investigated survival following craniotomy in 3 modern and complementary datasets.
Methods: The National Cancer Database-Participant User File (NCDB-PUF, n=9,435), Surveillance, Epidemiology, and End Results Program (SEER, n=5,615), and an institutional series (IS) (n=132) were used. We identified prognostic scales and investigated their effects on survival and the relationship between craniotomy and survival for PCNSL.
Results: In NCDB-PUF, craniotomy was associated with increased survival over biopsy (23.2 vs. 11.6 months) adjusted for radiation and chemotherapy on multi-variable analysis (HR 0.71, p<0.001), with a similar trend in IS (HR 0.68, p = 0.15). In SEER, gross total resection (GTR) was associated with increased survival over biopsy (29 vs. 10 months, HR 0.68, p < 0.001), as was subtotal resection (HR 0.73, p = 0.001). The survival benefit associated with craniotomy was more pronounced within Recursive Partitioning Analysis (RPA) class 1 group in NCDB-PUF (106.8 v. 32.9 months, HR 0.64, p<0.001), whereas the survival benefit was smaller for RPA 2-3 (17.7 vs. 10.3 months, HR 0.81, P<0.001). We created a surgical risk category (RC) considering lesion location, age, and frailty. RC was predictive of survival in IS (HR 0.44, p=0.003). Craniotomy was associated with increased survival over biopsy for patients with low-RC (133.4 vs. 37.2 months, HR 0.46, p=0.040), but not with high-RC in IS.
Conclusions: Craniotomy is associated with increased survival over biopsy for PCNSL. Prospective studies are necessary to investigate causality, control potential confounders, and address biases to adequately evaluate the therapeutic role of cytoreduction. Such studies should stratify patients by prognostic factors.
Patient Care: This research provides strong evidence to the growing body of literature supporting the role of cytoreductive surgery in the treatment of patients with PCNSL.
Learning Objectives: By the conclusion of this session, participants should be able to: (1) understand the historical therapy for PCNSL, (2) explain the discrepancy in the role of cytoreduction for this disease compared to other intracranial tumors, and (3) understand the need for re-evaluation of established treatment modalities in the setting of new technical and technological advancements.