Adam Suleman

Adi Klil Drori

Anca Prica

Jiajia Liu

Lisa K. Hicks

Michael Crump

Neil Berinstein

Robert Kridel

Haematologica

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Methotrexate, cytarabine, thiotepa and rituximab (MATRix) chemoimmunotherapy for primary central nervous system lymphoma: a Toronto experience The MATRix (methotrexate, cytarabine, thiotepa, rituxi-mab) regimen has significantly improved outcomes of pa-tients with primary central nervous system lymphoma (PCNSL). The original trial population, however, was young and fit with few comorbidities. We show that, in a real-world setting, the majority of patients treated with MATRix experienced hematologic toxicity, and 65% of patients de-veloped grade 3 or 4 infectious complications. Dose re-ductions were made in 68% of patients and dose delays occurred in 49% of patients. Survival was comparable to what has been reported in the literature, but the rate of toxicity was higher than previously described. The randomized International Extranodal Lymphoma Study Group trial IELSG32 examined outcomes of MATRix followed by consolidation therapy with either autologous stem cell transplant (ASCT) or whole brain radiation in pa-tients with PCNSL.1 The addition of thiotepa to MATRix had prolonged both overall survival (OS) and progression-free survival (PFS), producing sustained improved outcomes with a 7-year PFS of 50% and an OS of 70%.2 The IELSG32 trial population was a young and fit population, with a median age of 57 years and the majority of patients (67%) had Eastern Cooperative Oncology Group (ECOG) per-formance status 0-1. One retrospective multicenter analy-sis documented poorer outcomes in a population with poorer performance status.3 We therefore set out to examine the use of MATRix as an induction regimen in a real-world clinical setting in Toronto, Canada.  We performed a retrospective review of patients with a di-agnosis of B-cell PCNSL treated at Sunnybrook Health Sciences Centre, Princess Margaret Cancer Centre and St. Michael’s Hospital from October 2017 to March 2020. Ex-clusion criteria included positive serology for human im-munodeficiency virus, or systemic lymphoma. A review of electronic health records was performed to retrieve the pa-tients’ baseline characteristics, medical history, and treat-ment details including dose intensity, timing, and response to therapy. For patients deemed eligible for ASCT, induction with MATRix was given at any of the three hospitals, but ASCT was only performed at one center. As such, patients were often seen for transplant later in their treatment course. The local practice evolved to omit thiotepa from the third cycle to allow for improved stem cell collection off the third or fourth cycle. All other dose adjustments were made at the treating physician’s discretion.  The primary outcome was assessment of adverse events related to treatment. Secondary outcomes included OS and PFS at 2 years, and response to treatment. Response was assessed by magnetic resonance imaging or computed to-mography of the brain using published criteria.4 Descriptive statistics were used to summarize patients’ demographics, treatments and outcomes. The Kaplan-Meier estimator was used to determine the cumulative incidence of OS and PFS at 2 years. Cox regression models were used to investigate the impact of baseline characteristics on outcomes.  A total of 37 patients with a diagnosis of diffuse large B-cell PCNSL were included in this study. The median age of the patients was 58 years (range, 30-69 years). Patients were followed for an average of 16.9 months (range, 3-48 months). The majority of patients received MATRix as first-line therapy (89%). A high number of patients had an ECOG performance status of 2 or more (41%) and 18 pa-tients (49%) had a Charlson Comorbidity Index score of 2 or more. Twenty-four patients (65%) received Pneumocys-tis jiroveci pneumonia prophylaxis throughout treatment with sulfamethoxazole-trimethoprim or atovaquone. Gra-nulocyte colony-stimulating factor was used in all pa-tients for primary prophylaxis.  Dose reductions of any degree were performed in 25 (68%) of the 37 patients during any cycle of MATRix, as shown in Table 1. Treatment was delayed in 18 patients (49%), most often because of infectious complications. Thirty patients (81%) completed all four cycles of MATRix, and 22 patients went on to ASCT. Two (29%) of the seven patients not completing all cycles died before all cycles could be delivered, and the remaining five patients did not complete all four cycles because of toxicity or disease progression while on treatment.  The majority of patients experienced grade 3 or 4 hema-tologic toxicity during the first cycle of treatment (24.3% grade 3 or 4 anemia, 73.0% grade 3 or 4 thrombocytopenia, 70.3% grade 3 or 4 neutropenia), which often persisted through each cycle of MATRix. Table 2 lists the non-hema-tologic toxicities experienced by patients. Notably, 24 pa-tients (65%) developed infections on treatment, for a total of 33 individual infectious episodes. Eleven of these epi-sodes were from bacteremia, three from viral infections requiring admission, and twelve were other infections in-cluding cellulitis, urinary tract infections, or pneumonia requiring treatment. Seven patients developed severe op-portunistic infections, including blastomycosis pneumonia, herpes simplex virus encephalitis, disseminated varicella  Haematologica | 108 - April 2023   1186LETTER TO THE EDITORzoster virus, Pneumocystis jiroveci pneumonia (2 patients), cytomegalovirus pneumonia and pulmonary aspergillosis. Both episodes of Pneumocystis jiroveci pneumonia oc-curred in patients who were not on prophylaxis, and one occurred in a patient receiving MATRix as second-line therapy. Seven patients (19%) developed episodes of feb-rile neutropenia without any organism being identified. Eight patients (22%) required admission to an intensive care unit  during treatment, with a mean duration of stay of 7.5 days. Six patients (16%) developed a venous throm-boembolic event including a catheter-associated throm-bosis after the third cycle. Two patients developed deep vein thrombosis during the first cycle of treatment, with one episode occurring in a patient receiving MATRix as third-line therapy.  Thirty-five patients (95%) were alive at the end of treat-ment, and 30 patients had magnetic resonance imaging scans available for analysis. A complete response was seen in seven patients (23%) and a partial response in 18 patients (60%). One patient had stable disease and four patients had progressive disease. Of the 25 patients who responded to treatment, 21 went on to have consolidation therapy with ASCT with thiotepa and carmustine conditioning, and four had consolidation with whole brain radiation. Consoli-dation was not administered to ten patients because of disease progression, worsening performance status or in-eligibility as determined by the treating physician.  The 2-year OS for all patients was 74%, and the median OS was not reached (Figure 1). The 2-year OS was 100% for pa-tients who received ASCT and 49% for patients who did not (P<0.01). The 2-year PFS was 54% and the median PFS was not reached. The 2-year PFS was 78% for patients who re-ceived ASCT and 21% for patients who did not (P<0.01). The median PFS was not reached for the 21 patients who re-ceived ASCT, and was 10 months (95% confidence interval: 2.2-17.9 months) for patients who did not. Cox regression analyses found that patients with an ECOG performance status greater than 1 showed a trend toward increased mor-tality, although this was not statistically significant (odds ratio=5.08, 95% confidence interval: 0.80-32.37). MATRix de-livered as second- or third-line therapy was not associated with decreased OS (P=0.99). Six patients (16.2%) died during the study period, four from progression of their PCNSL, and two from infectious complications of treatment.  Number of patients100% dose 75% dose 50% dose or less Omission Cycle 1 (37 patients) Methotrexate  Cytarabine  Thiotepa  Rituximab 33 30 31 34 0 3 1 0 0 2 0 0 4 2 5 3Cycle 2 (36 patients) Methotrexate  Cytarabine  Thiotepa  Rituximab 31 30 30 36 2 5 2 0 1 1 1 0 2 0 3 0Cycle 3 (33 patients) Methotrexate  Cytarabine  Thiotepa  Rituximab 28 25 7 32 3 5 2 0 1 2 2 0 1 1 22* 1Cycle 4 (30 patients) Methotrexate  Cytarabine  Thiotepa  Rituximab 27 22 23 29 2 1 0 0 1 6 1 0 0 1 6 1Table 1. Doses delivered of the components of the MATRix protocol. *Routine omission prior to peripheral blood stem cell collection based on local institutional protocols. Table 2. Non-hematologic toxicities experienced during the delivery of MATRix.ICU: Intensive Care Unit.Frequency  (37 patients)PercentageInfection 24 64.9Febrile neutropenia (no organism identified) 7 18.9Venous thromboembolism 6 16.2ICU admission 8 21.6Acute kidney injury 9 24.3Gastrointestinal injury/upset7 18.9Transaminitis 12 32.4Mucositis 8 21.6Neurotoxicity 10 27.0 Haematologica | 108 - April 2023   1187LETTER TO THE EDITORFigure 1. Survival outcomes of patients who received MATRix chemotherapy for the treatment of primary central nervous system lymphoma. (A) Two-year overall survival (74%) for all patients. (B) Two-year overall survival for patients who underwent autologous stem-cell transplantation (100%) and for patients who did not (49%) (P<0.01). (C) Two-year progression-free survival (54%) for all patients. (D). Two-year progression-free survival for patients who underwent autologous stem-cell transplantation (78%) and for patients who did not (21%) (P<0.01). ASCT: autologous stem-cell transplantation.A BC DThe rate of toxicity in our study was much higher than that in the IELSG32 study. Only 23% of patients in the original trial developed infections, whereas in our non-selected, real-world population, the infection rate was 65%. Although only two patients died directly from an infectious compli-cation, four out of 25 patients with severe infectious com-plications were excluded from consolidation therapy because of their severe deconditioning. The infectious com-plications were more severe than those previously de-scribed3 and included invasive opportunistic infections such as blastomycosis and aspergillosis. In addition, 22% of pa-tients in our cohort required admission to an intensive care unit, for a mean of 7.5 days at some point during treatment; this is a higher percentage than previously reported.1,3 This high likelihood of admission to an intensive care unit raises questions about the tolerability of MATRix, particularly in pa-tients who are less fit.  There were a significant number of prophylactic or reactive dose reductions, and yet the rate of infections was still high. Although fewer patients achieved a complete response, ef-ficacy was not impacted compared to the IELSG32 trial in this early analysis. High efficacy despite dose reductions was also seen in the study by Schorb et al., in which dose reduc-tions during the first cycle also did not have an impact on PFS or OS.3 Dose reductions in the IELSG32 trial were not re-ported. Further studies exploring alternative dosing that could maintain efficacy with less toxicity would be of value.  In their real-world experience, Schorb et al. found that 2-year OS and PFS were significantly affected by both age and ECOG performance status.3 The demographics of the populations in our study and that by Schorb et al. were similar with a median age of 58 years and 62 years, re-spectively, and a performance status of >2 in 40% of pa-tients in our study versus 51% in that by Schorb  et al.3 OS was not significantly affected in either trial, but newer sec-ond-line treatments such as ibrutinib and lenalidomide may enhance survival compared to that in the original IELSG32 trial.5-7 In conclusion, this is one of the first studies to look at the use of MATRix in a real-world setting with a varied pa- Haematologica | 108 - April 2023   1188LETTER TO THE EDITORtient population. There were no restrictions to inclusion based on performance status or age, allowing for a di-verse cohort. We highlight infectious complications with a focus on opportunistic infections. Efficacy was main-tained even with a significant number of dose reductions. Reducing infections by carefully selecting patients and providing prophylaxis against infections should be con-sidered. Authors Adam Suleman,1 Jiajia Liu,1 Lisa K. Hicks,1,2 Adi Klil Drori,3° Michael Crump,1,4 Robert Kridel,1,4 Anca Prica1,4# and Neil Berinstein1,5#   1Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; 2Division of Medical Oncology and Hematology, St. Michael’s Hospital, Toronto, Ontario, Canada; 3AbbVie, Inc., North Chicago, IL, USA; 4Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada and 5Sunnybrook Health Sciences Centre, Odette Cancer Centre, Toronto, Ontario, Canada    #AP and NB contributed equally as co-senior authors.  °AbbVie had no role in this study and solely reflects this author’s current affiliation. Correspondence:  A. SULEMAN - asule095@uottawa.ca   https://doi.org/10.3324/haematol.2022.282014  Received: August 29, 2022. Accepted: November 23, 2022. Early view: December 1, 2022.  ©2023 Ferrata Storti Foundation Published under a CC BY-NC license   Disclosures No conflicts of interest to disclose. AKD is currently affiliated with AbbVie, but this company had no role in the study.  Contributions AS and AKD collected data for the manuscript. JL, AP and NB conceptualized the manuscript. AS, JL, LKH, AKD, MC, RK, AP and NB all contributed to writing the manuscript.  Data-sharing statement The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.References   1. Ferreri AJM, Cwynarski K, Pulczynski E, et al. Chemoimmunotherapy with methotrexate, cytarabine, thiotepa, and rituximab (MATRix regimen) in patients with primary CNS lymphoma: results of the first randomisation of the International Extranodal Lymphoma Study Group-32 (IELSG32) phase 2 trial. Lancet Haematol. 2016;3(5):e217-e227.   2. Ferreri AJM, Cwynarski K, Pulczynski E, et al. Long-term efficacy, safety and neurotolerability of MATRix regimen followed by autologous transplant in primary CNS lymphoma: 7-year results of the IELSG32 randomized trial. Leukemia. 2022;36(7):1870-1878.   3. Schorb E, Fox CP, Kasenda B, et al. Induction therapy with the MATRix regimen in patients with newly diagnosed primary diffuse large B-cell lymphoma of the central nervous system – an international study of feasibility and efficacy in routine clinical practice. Br J Haematol. 2020;189(5):879-887.   4. Abrey LE, Batchelor TT, Ferreri AJM, et al. Report of an international workshop to standardize baseline evaluation and response criteria for primary CNS lymphoma. J Clin Oncol. 2005;23(22):5034-5043.   5. Ghesquieres H, Chevrier M, Laadhari M, et al. Lenalidomide in combination with intravenous rituximab (REVRI) in relapsed/refractory primary CNS lymphoma or primary intraocular lymphoma: a multicenter prospective “proof of concept” phase II study of the French Oculo-Cerebral lymphoma (LOC) Network and the Lymphoma Study Association (LYSA). Ann Oncol. 2019;30(4):621-628.   6. Choquet S, Houillier C, Bijou F, et al. Ibrutinib monotherapy in relapse or refractory primary CNS lymphoma (PCNSL) and primary vitreo-retinal lymphoma (PVRL). Result of the interim analysis of the iLOC phase II study from the LYSA and the French LOC Network. Blood. 2016;128(22):784.    7. Grommes C, Nayak L, Tun HW, Batchelor TT. Introduction of novel agents in the treatment of primary CNS lymphoma. Neuro Oncol. 2019;21(3):306-313. Haematologica | 108 - April 2023   1189LETTER TO THE EDITOR

Methotrexate, cytarabine, thiotepa and rituximab (MATRix) chemoimmunotherapy for primary central nervous system lymphoma: a Toronto experience

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Methotrexate, cytarabine, thiotepa and rituximab (MATRix) chemoimmunotherapy for primary central nervous system lymphoma: a Toronto experience

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