Clinical Report: Surgical Resection vs Biopsy in Primary CNS Lymphoma Management
Overview
This systematic review and meta-analysis compared overall survival (OS) and progression-free survival (PFS) in patients with primary central nervous system lymphoma (PCNSL) undergoing surgical resection versus biopsy alone. The analysis included studies from 2001 to 2022 and assessed the impact of surgical intervention on survival outcomes and secondary clinical parameters.
Background
Primary central nervous system lymphoma (PCNSL) is an aggressive brain tumor predominantly affecting elderly and immunocompromised patients. Diagnosis relies on MRI followed by biopsy for histopathological confirmation. While chemotherapy, especially high-dose methotrexate-based regimens, remains the first-line treatment, the role of surgical resection has been controversial, with traditional views discouraging surgery except in cases of life-threatening mass effect. Recent studies have challenged this dogma, prompting a need for systematic evaluation of resection versus biopsy outcomes.
PCNSL accounts for approximately 6.7% of CNS tumors with an incidence of 0.45 per 100,000 person-years.
Most PCNSLs are diffuse large B-cell lymphomas, commonly presenting as single supratentorial lesions.
High-dose methotrexate-based chemotherapy is the recommended first-line treatment after biopsy confirmation.
Historical contraindication of surgical resection is being reconsidered due to emerging evidence suggesting potential survival benefits in select patients.
The meta-analysis followed PRISMA guidelines, including studies comparing resection and biopsy with hazard ratios for OS and PFS as primary outcomes.
Quality assessment using the Newcastle–Ottawa Scale ensured inclusion of high-quality studies (NOS ≥ 6).
Clinical Implications
Clinicians should consider that while biopsy remains the standard for diagnosis, surgical resection may offer survival advantages in selected PCNSL patients, particularly those with accessible lesions causing mass effect. Treatment decisions should be individualized, balancing potential benefits of resection against risks and patient-specific factors. Further high-quality prospective studies are warranted to refine surgical indications.
Conclusion
This meta-analysis highlights the evolving role of surgical resection in PCNSL management, suggesting potential survival benefits over biopsy alone in certain cases. These findings support a nuanced approach to surgical decision-making in PCNSL treatment.
References
Weller et al. 2012 -- Rethinking surgical resection in PCNSL
PRISMA Guidelines 2009 -- Preferred reporting items for systematic reviews and meta-analyses
Newcastle–Ottawa Scale 2011 -- Quality assessment tool for nonrandomized studies
