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刘加军:原发中枢神经系统淋巴瘤治疗进展(下)

字号+ 作者: 刘加军 来源:医脉通血液科 2021-10-20 我要评论

PCNSL的免疫治疗进展汇总。

原发中枢神经系统淋巴瘤(PCNSL)是指起源于中枢神经系统且具有侵袭性的结外非霍奇金淋巴瘤,病灶原发且仅限于中枢神经系统(大脑、脑膜、眼及其附属器和脊髓)[1]。该病发病率低,仅占颅内肿瘤的4%,占所有结外淋巴瘤的4%-6%,预后差,复发率高,近一半的患者2年内复发[2,3]。PCNSL发病的主要危险因素之一是免疫缺陷,自2000年以来,PCNSL的发病率一直在以每年增加1.6%的速度增长,特别是在免疫功能正常的患者和老年人(>60岁)中[4]。因为血脑屏障的存在,标准淋巴瘤化疗对PCNSL的作用有限,大剂量甲氨蝶呤(HD-MTX)加或不加全脑放射治疗(WBRT)是最有效的治疗方法。尽管PCNSL对初始治疗的缓解率很高,但总体预后仍然很差。随着对PCNSL病理生理的不断深入研究,已经发现B细胞受体通路(BCR)、Toll样受体通路(TLR)、免疫逃避机制、肿瘤免疫微环境受抑制是PCNSL发病中的关键机制。PCNSL的治疗逐渐有了新的方向,靶向治疗和免疫治疗及与之相关的联合用药成为研究热点。本文从外科手术治疗、放疗、化疗、造血干细胞移植、靶向治疗及免疫治疗六个方面系统地回顾了PCNSL的治疗,并总结新型药物现有的临床证据,供广大读者参考。

 

 

在上两期文章中,我们对PCNSL的外科手术治疗、放疗、化疗、造血干细胞移植和靶向治疗进行了总结(详情请戳《刘加军教授谈原发中枢神经系统淋巴瘤治疗进展(上)》、《刘加军教授谈原发中枢神经系统淋巴瘤治疗进展(中)》,今天,我们一起来看看PCNSL的免疫治疗进展吧!

 

 

免疫治疗

 

01
免疫调节剂
 

免疫调节剂(IMiD)可以通过多种作用机制干扰侵袭性淋巴瘤的生长和存活[55],包括改变淋巴瘤细胞微环境和刺激效应细胞,如细胞毒性T细胞和自然杀伤细胞[56,57]。IMiD包括来那度胺和泊马度胺,它们不仅抑制NF-κB的活性,还抑制PI3K/AKT通路,来那度胺维持治疗已被证明可以改善新诊断DLBCL老年患者的PFS。另外,来那度胺和泊马度胺可以透过BBB,成为PCNSL治疗的可观药物。法国的一项多中心单臂研究[65]报道了49例复发难治性PCNSL患者接受来那度胺联合利妥昔单抗治疗,达到至少PR的患者继续接受来那度胺维持治疗,49%的患者表现出临床表现状态逐渐不佳,最佳缓解率为67%,在完成诱导治疗后,缓解率下降到36%,中位PFS为8.1个月,中位OS为19.2个月。基于这些结果,2018版NCCN指南推荐,对于治疗复发难治性PCNSL可包括使用单药来那度胺或联合利妥昔单抗和来那度胺治疗。泊马度胺是第三代IMiD,在一项临床前研究中发现,泊马度胺在2个鼠PCNSL模型中显示出显著的治疗活性。Tun等人[58]研究了25例复发难治性PCNSL和眼部淋巴瘤患者接受泊马度胺治疗的剂量,最大耐受剂量为5mg,持续21天,每28天一个周期(前2个周期每周20mg地塞米松),最终21例可评估患者中有9例(43%)对治疗有反应。

 

 

02
免疫检查点抑制剂
 

在PCNSL中可以经常发现9p24.1/PD-L1/PD-L2拷贝数改变和易位,这表明PCNSL中存在免疫逃避的遗传基础[59]。在系统性霍奇金淋巴瘤中,Reed-Sternberg细胞上的9p24.1拷贝增加和PD-L1表达增加与纳武利尤单抗治疗的疗效相关[60]。这一原则是否也适用于PCNSL尚不清楚。在临床前研究中,抗PD1单克隆抗体的免疫检查点抑制对CNS淋巴瘤具有显著的治疗活性[61]。目前尚没有来自前瞻性研究的临床证据。一项回顾性病例系列研究[62]报告了5例接受单药纳武利尤单抗治疗的复发难治性PCNSL患者,其中4例患者获得CR,1例患者获得PR。但在开始纳武利尤单抗之前,1例患者接受了WBRT,另一例患者接受了局灶性放疗。目前关于PD-1单抗治疗PCNSL的临床试验正在开展,包括一项多中心临床试验研究纳武利尤单抗单药治疗PCNSL和睾丸淋巴瘤(NCT02857426)。另一项使用帕博丽珠单抗的单中心试验(NCT02779101)正在进一步研究PCNSL中免疫逃避和PD-1阻断的相关性。其他临床试验计划将检查点抑制剂与靶向药物(如伊布替尼或IMiD)结合使用。

 

 

03
CAR-T细胞治疗
 

嵌合抗原受体(CAR)T细胞疗法已被批准用于治疗复发难治性DLBCL。已经有研究发现CAR-T细胞可穿透中枢神经系统,并在继发性中枢神经系统淋巴瘤患者中观察到治疗反应[63]。目前,CAR-T细胞治疗复发/难治性CD19+ PCNSL的Ⅰ期临床试验正在进行(NCT04443829)。

 

 

 

总结

几十年来,对PCNSL的病理生理学认识局限,主要是由于该病发病罕见,病理组织获取困难且有限,相关的临床试验开展困难等。随着对PCNSL的逐渐深入认识,放疗、手术、以HD-MTX为基础的联合化疗成为PCNSL可行的治疗手段,PCNSL的一线治疗方案不断被优化,但治疗效果仍不容乐观,且对于复发难治性PCNSL更是棘手。此外基于PCNSL的高度侵袭性及发病率逐渐增加,探索更加可行有效的治疗方式、提高生存率、延长生存期十分必要。最近通过使用数据库进行大规模基因组学研究取得了新进展,发现了PCNSL的新驱动因素,提供了以小分子抑制剂和免疫检查点抑制剂为目标的研究对象。根据目前针对PCNSL的新药研究,伊布替尼和来那度胺是仅有的表现出有临床意义新型药物,其他新型药物的临床研究也正在积极开展。总之,对PCNSL治疗的探索仍需要更多的临床试验和前瞻性研究,化疗、靶向治疗、免疫治疗的多药联合治疗为PCNSL提供了可观的治疗前景。

 

 

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刘加军 教授

  • 教授、主任医师、博士生导师

  • 中山大学附属第三医院血液内科主任

  • 欧洲肿瘤协会抗癌分会会员

  • 中国免疫协会会员

  • 广东省医疗行业协会常委

  • 广东省血液学会会员等

  • 主研方向:白血病细胞凋亡信号转导机制、造血干细胞移植、血液肿瘤的分子靶向治疗、基因治疗及新型抗肿瘤药物的机制研究等。

  • 医疗专长:从事内科血液学临床医疗工作20多年。多年来从事白血病细胞凋亡信号转导机制及血液肿瘤的分子靶向治疗研究。对各种贫血、出血性疾病及血液肿瘤有熟练的诊治能力。诊疗疾病包括血液病造血干细胞移植、白血病化疗、恶性淋巴瘤和多发性骨髓瘤等恶性血液疾病的个体化治疗方案选择、各种原因不明的贫血、不明原因的长期发热以及淋巴结肿大的鉴别诊断和治疗等。

 

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