Craniotomy and Survival for Primary Central Nervous System Lymphoma

Abstract

Background: Cytoreductive surgery is considered controversial for primary central nervous system lymphoma (PCNSL).

Objective: To investigate survival following craniotomy or biopsy for PCNSL.

Methods: The National Cancer Database-Participant User File (NCDB, n = 8936), Surveillance, Epidemiology, and End Results Program (SEER, n = 4636), and an institutional series (IS, n = 132) were used. We retrospectively investigated the relationship between craniotomy, prognostic factors, and survival for PCNSL using case-control design.

Results: In NCDB, craniotomy was associated with increased median survival over biopsy (19.5 vs 11.0 mo), independent of subsequent radiation and chemotherapy (hazard ratio [HR] 0.80, P < .001). We found a similar trend with survival for craniotomy vs biopsy in the IS (HR 0.68, P = .15). In SEER, gross total resection was associated with increased median survival over biopsy (29 vs 10 mo, HR 0.68, P < .001). The survival benefit associated with craniotomy was greater within recursive partitioning analysis (RPA) class 1 group in NCDB (95.1 vs 29.1 mo, HR 0.66, P < .001), but was smaller for RPA 2-3 (14.9 vs 10.0 mo, HR 0.86, P < .001). A surgical risk category (RC) considering lesion location and number, age, and frailty was developed. Craniotomy was associated with increased survival vs biopsy for patients with low RC (133.4 vs 41.0 mo, HR 0.33, P = .01), but not high RC in the IS.

Conclusion: Craniotomy is associated with increased survival over biopsy for PCNSL in 3 retrospective datasets. Prospective studies are necessary to adequately evaluate this relationship. Such studies should evaluate patients most likely to benefit from cytoreductive surgery, ie, those with favorable RPA and RC.

Keywords: CNS; Lymphoma; Prognosis; Resection; Survival.

FIGURE 1.

Analysis of survival comparing craniotomy vs biopsy for PCNSL patients. A, KM plot comparing survival with craniotomy vs biopsy for all comers in NCDB. B Survival analysis stratified by extent of resection in the SEER database. C, KM plot comparing survival for craniotomy vs biopsy for all comers from the institutional dataset. GTR = gross total resection, STR = subtotal resection. Censored events are represented as hash marks. Log-rank P-values are reported on the graphs.

FIGURE 2.

Effect of craniotomy and chemotherapy on survival in the NCDB. Censored events are represented as hash marks. Log-rank P-values < .001 for all curves.

FIGURE 3.

Survival analysis comparing craniotomy vs biopsy stratified by RPA prognostic categories for PCNSL patients. KM plot comparing survival with craniotomy vs biopsy in RPA class 1 patient in the NCDB A and IS B. KM plot comparing survival with craniotomy vs biopsy for RPA class 2 and 3 patients in the NCDB C and IS D. Censored events are represented as hash marks. Log-rank P-values are reported on the graphs.

FIGURE 4.

Risk category stratification analysis and its effects on survival differences between craniotomy and biopsy for PCNS patients in the institutional database. A, RC stratification of low-RC (score 0-3) vs high-RC (score 4+) shows a significantly longer survival for low-RC on the KM analysis. B, KM plot comparing survival with craniotomy vs biopsy for low-RC patients with PCNSL, and in C, high-RC patients. Censored events are represented as hash marks. Log-rank P-values are reported on the graphs.