Diagnostic delay and outcome in immunocompetent patients with primary central nervous system lymphoma in Spain: a multicentric study.

INTRODUCTION: To assess the management of immunocompetent patients with primary central nervous system lymphomas (PCNSL) in Spain. METHODS: Retrospective analysis of 327 immunocompetent patients with histologically confirmed PCNSL diagnosed between 2005 and 2014 in 27 Spanish hospitals. RESULTS: Median age was 64 years (range: 19-84; 33% ≥ 70 years), 54% were men, and 59% had a performance status (PS) ≥ 2 at diagnosis. Median delay to diagnosis was 47 days (IQR 24-81). Diagnostic delay > 47 days was associated with PS ≥ 2 (OR 1.99; 95% CI 1.13-3.50; p = 0.016) and treatment with corticosteroids (OR 2.47; 95% CI 1.14-5.40; p = 0.023), and it did not improve over the years. Patients treated with corticosteroids (62%) had a higher risk of additional biopsies (11.7% vs 4.0%, p = 0.04) but corticosteroids withdrawal before surgery did not reduce this risk and increased the diagnostic delay (64 vs 40 days, p = 0.04). Median overall survival (OS) was 8.9 months [95% CI 5.9-11.7] for the whole series, including 52 (16%) patients that were not treated, and 14.1 months (95%CI 7.7-20.5) for the 240 (73.4%) patients that received high-dose methotrexate (HD-MTX)-based chemotherapy. Median OS was shorter in patients ≥ 70 years (4.1 vs. 13.4 months; p < 0.0001). Multivariate analysis identified age ≥ 65 years, PS ≥ 2, no treatment, and cognitive/psychiatric symptoms at diagnosis as independent predictors of short survival. CONCLUSIONS: Corticosteroids withdrawal before surgery does not decrease the risk of a negative biopsy but delays diagnosis. In this community-based study, only 73.4% of patients could receive HD-MTX-based chemotherapy and OS remains poor, particularly in elderly patients ≥ 70 years.

[Use of steroids in neuro-oncology]. / Uso de esteroides en neurooncologia.

Corticosteroids are widely used in routine clinical practice in neuro-oncology. However, despite their widespread use, there is no established consensus on their indications, dosages and dosage schedule. This article reviews the mechanism of action of corticosteroids, their indications for use, side effects and the appropriate management, dosage and duration of therapy, as well as the role of new treatments currently being use to treat cerebral oedema. The most widely used corticosteroid in neuro-oncology is dexamethasone, probably due to its low mineralocorticoid effect and its long half-life. Its effect on cerebral oedema is fundamental in the symptomatic control of patients with brain tumours. It is recommended to start treatment only in symptomatic patients, in doses of 4-8 mg/24 h, always seeking the minimum effective dosage. Side effects associated with corticosteroid use are common and have a negative impact on patients' quality of life.

TITLE: Uso de esteroides en neurooncologia.Los corticoides se utilizan ampliamente en la practica clinica habitual en neurooncologia. Sin embargo, pese a lo extendido de su uso, no existe un consenso establecido sobre sus indicaciones, dosis y posologia. En este articulo se realiza una revision bibliografica del mecanismo de accion de los corticoides, sus indicaciones de uso, efectos secundarios y manejo adecuado, dosis y duracion de la terapia, asi como el papel de nuevos tratamientos actuales para el edema cerebral. El corticoide con un uso mas extendido en neurooncologia es la dexametasona, probablemente por su escaso efecto mineralocorticoide y por su elevada vida media. Su efecto sobre el edema cerebral es fundamental en el control sintomatico de los pacientes con tumores cerebrales. Se recomienda iniciar tratamiento unicamente en pacientes sintomaticos, en dosis de 4-8 mg/24 h, buscando siempre la minima dosis eficaz. Los efectos secundarios asociados al uso de corticoides son frecuentes e impactan negativamente en la calidad de vida de los pacientes.