Systemic high-dose MTX and BTK inhibitors in vitreoretinal lymphoma: efficacy and survival analysis

INTRODUCTION Vitreoretinal lymphoma (VRL) is a rare subtype of central nervous system lymphoma (CNSL) that predominantly comprises B-cell lymphomas. Because of its clinical resemblance to uveitis and transient response to glucocorticoid therapy, the diagnosis of VRL is often delayed.1 Although initial manifestations appear indolent, the disease can lead to irreversible vision loss or central nervous system (CNS) relapse, resulting in a poor prognosis.2 Based on the site of initial malignant lymphocyte infiltration, primary VRL (PVRL) originates in the vitreous or retina without CNS or systemic involvement, whereas secondary VRL (SVRL) arises from CNSL or systemic lymphoma.3 As the most common form of intraocular lymphoma, VRL poses substantial therapeutic challenges because of its anatomical constraints and the high risk of CNS progression, a key determinant of long-term survival outcomes.4 The therapeutic management of VRL remains controversial because no universally accepted standard of care has been established. Local therapies, including intravitreal methotrexate (IVT-MTX) injections and radiotherapy, are commonly used to control intraocular disease; however, these modalities fail to prevent CNS dissemination, the primary driver of disease-related mortality.4 Systemic therapies, particularly high-dose methotrexate (HD-MTX)–based regimens, have been investigated to reduce CNS progression by eradicating occult systemic or CNS-infiltrating tumor cells.5 Retrospective studies suggest that HD-MTX decreases the rate of CNS progression in VRL, although its efficacy and toxicity profiles require further validation in VRL-specific cohorts.5 Bruton’s tyrosine kinase (BTK), a non-receptor kinase critical for B-cell receptor signaling, plays a central role in the pathogenesis of B-cell lymphomas.6 BTK inhibitors (BTKis), such as ibrutinib, have demonstrated efficacy in CNSL. Soussain et al and our institution reported that BTKi monotherapy achieves high response rates in VRL, potentially owing to the pharmacological and physiological similarities between the blood-brain and blood-retinal barriers.7–9 Nevertheless, clinical evidence for BTKi use specifically in VRL remains limited, and large-scale studies evaluating the combination of systemic HD-MTX and BTKi are lacking. Because VRL is rare, most reports are limited by small sample sizes and single-center designs. We conducted a retrospective analysis of 56 patients with VRL treated at 2 centers in China to provide more robust evidence. We aimed to assess the impact of therapeutic approaches, including IVT-MTX, HD-MTX–based systemic therapy, and BTKis, on outcomes such as progression-free survival (PFS), overall survival (OS), and CNS progression. We intend for these findings to inform clinical decision-making by clarifying the role of systemic prophylaxis in the multidisciplinary management of this malignancy. 2. METHODS We analyzed 56 patients diagnosed with VRL between August 2019 and July 2025, including 51 patients from Beijing Tongren Hospital, Capital Medical University, and 5 patients from Union Hospital, Tongji Medical College, Huazhong University of Science and Technology. The cohort included 47 patients with PVRL, 2 with primary CNSL (PCNSL) who later developed ocular involvement, and 7 with concurrent PCNSL and VRL at diagnosis. Treatment approaches were heterogeneous and often overlapping. Eighteen patients received IVT-MTX alone. Twenty-nine received HD-MTX–based systemic therapy, potentially combined with a CD20 monoclonal antibody or a BTKi. Thirty patients received a BTKi. Of the 30 patients treated with a BTKi, 22 received it in combination with HD-MTX for CNS prophylaxis, 7 received a BTKi without HD-MTX, and 1 received a BTKi with other chemotherapeutic agents. Primary endpoints were treatment response, PFS, OS, and the incidence of CNS progression. Secondary endpoints included ocular relapse, brain relapse, ocular-free survival (OFS), and brain-free survival (BFS). At diagnosis, all patients underwent comprehensive systemic evaluation, including brain magnetic resonance imaging (MRI), whole-body positron emission tomography/computed tomography (PET-CT), diagnostic vitrectomy, and measurement of interleukin-10 (IL-10) and interleukin-6 (IL-6) levels in the vitreous or aqueous humor. Ophthalmic examinations were performed using a slit-lamp biomicroscope. Lumbar puncture was performed for cerebrospinal fluid (CSF) analysis, including cell count, protein and glucose concentrations, cytology, and flow cytometry. Based on these findings, CNS involvement was confirmed, determining the final diagnostic classification. Treatment regimens were individualized. In patients receiving systemic therapy, HD-MTX was administered with leucovorin rescue, often in combination with rituximab. IVT-MTX was typically administered twice weekly for 4 weeks, followed by weekly injections for 4 additional weeks, and then monthly for 3 months. Ophthalmic evaluations were performed at 2 weeks and at 1, 2, and 5 months, alongside serial brain MRI monitoring. Treatment response was assessed based on ophthalmic and neuroimaging findings. Complete response (CR) was defined as the complete disappearance of intraocular lymphoma on ophthalmic examination and the absence of CNS disease on MRI. OS was calculated from the date of diagnosis to the date of death or last follow-up. PFS was calculated as the time from diagnosis to disease relapse or progression (irrespective of site) or death from any cause. Ocular relapse was defined as the reappearance of disease or emergence of new lesions in the anterior chamber, vitreous, or retina after achieving a CR or partial response (PR) to first-line therapy. Brain relapse was defined as the detection of CNSL confirmed by CT, Fluorodeoxyglucose PET/CT, or MRI, or by pathological assessment, following an initial response. CNS progression was defined as any new CNS involvement occurring during the course of VRL treatment. BFS and OFS were measured as the time from diagnosis to brain and ocular relapse, respectively. Patients who were alive and event-free were censored at the last follow-up visit. Survival curves were generated using the Kaplan–Meier method, and the cumulative incidence of CNS progression was estimated. Risk factors for OS were analyzed using Cox proportional hazards regression. Age, sex, bilaterality, systemic therapy, BTKi treatment, corticosteroid use, ocular relapse, and CNS/systemic relapse were evaluated. Variables were categorized using predefined reference levels. Univariate analyses were conducted for all variables, and those with a p value 1.0 was observed in the vitreous fluid, aqueous humor, and CSF of 7, 27, and 27 patients, respectively. Monoclonal B cells were detected by CSF flow cytometry in 4 cases. One patient with normal renal function showed elevated serum ß2-microglobulin levels. Patient characteristics and first-line treatment protocols are summarized in Table 1. Table 1 - Patients characteristics and initial treatments. Patient demographics Number of patients (%) Age, median (range), y 56 (35–79) Sex Male 25 (44.6) Female 31 (55.4) Bilaterality Yes 29 (51.8) No 27 (48.2) Diagnosis level Cytologic diagnosis 25 (44.6) Cytokine (IL-10/IL-6 ratio) + clinical evidence 31 (55.4) Median time to diagnosis (range), d 11 (0–524) Disease involvement Eye 47 (83.9) CNS 2 (3.6) Eye and CNS 7 (12.5) Median best corrected visual acuity of affected eyes at diagnosis (13 eyes received intraocular MTX) 0.3 (0.01–1) Vitreous haze at diagnosis (17 patients) 13 (76.5) Lumbar puncture performed 45 (80.4) IL-10 and IL-6 cytokines in the aqueous humor (39 eyes) IL-10 level (pg/mL): median (range) 197.9 (1–26,803.4) Elevated IL-10 (>30 pg/mL) 30 (76.9) IL-10/IL-6 ratio (>1) 33 (84.6) Initial treatment IVT-MTX only 17 (30.4) HD-MTX–based chemotherapy only 13 (23.2) BTKi only 2 (3.6) IVT-MTX and BTKi 5 (8.9) IVT-MTX and HD-MTX–based chemotherapy 16 (28.6) IVT-MTX and other chemotherapy 1 (1.8) Other therapy 2 (3.6) Intravitreal injection of MTX treatment course 8 (0–41) HD-MTX treatment course 4 (3–6) Total treatment course 6 (1–17) Follow-up period, median (range), d 593 (5–2183) BTKi = Bruton’s tyrosine kinase inhibitor, CNS = central nervous system, HD-MTX =high-dose intravenous methotrexate, IL = interleukin, IVT-MTX = intravitreal methotrexate. 3.2. Tumor response and survival Five patients were not evaluable for treatment response: 3 because of missing data, 1 who sought treatment elsewhere, and 1 who could not be assessed because of COVID-19. Among the 51 evaluable patients, 35 (68.6%) achieved CR, 15 (29.4%) attained PR, and 1 (2.0%) had progressive disease (PD) with systemic progression. Following IVT-MTX monotherapy, vision improved in 8 of 13 treated eyes (61.5%), with a median visual acuity of 0.6 (range, 0.05–1.0). One eye experienced visual deterioration caused by cataract formation. After completion of first-line therapy, among 41 evaluable patients, 26 (63.4%) achieved CR, 11 (26.8%) attained PR, and 3 (7.3%) had PD. Survival data were available for 53 patients, with a median follow-up of 593 days (3 were lost to follow-up). The median PFS (mPFS) was 800 days (95% CI: 486–NR) (Fig. 1, Part 1). The 1-, 2-, and 5-year PFS rates were 76.3%, 51.8%, and 12.6%, respectively. Patients who received HD-MTX–based systemic therapy demonstrated significantly longer PFS than those who did not (p = 0.003; Fig. 1, Part 2). The mPFS was 1287 days (95% CI, 800 days–not reached) in the HD-MTX group and 376 days (95% CI, 334–820 days) in the non–HD-MTX group. Two patients treated with BTKi monotherapy achieved CR and PR, with PFS durations of 367 and 261 days, respectively; both later developed CNS progression. Across the full cohort, BTKi therapy did not significantly improve PFS (p = 0.170), and no benefit was observed when BTKis were combined with either HD-MTX (p = 0.950; Fig. 1, Part 3) or IVT-MTX (p = 0.640; Fig. 1, Part 4). Similarly, among patients receiving HD-MTX, no significant difference in PFS was observed between those who received IVT-MTX and those who did not (p = 0.290). Other clinical factors, including age, sex, bilaterality, and prior corticosteroid use, had no significant effect on PFS. Patients with SVRL demonstrated a trend toward longer PFS than those with PVRL (p = 0.087), although this did not translate into a statistically significant difference in OS (p = 0.340). This PFS trend may be explained by the more intensive combination regimens used in SVRL cases. Subgroup analysis of patients with PVRL revealed that HD-MTX use was associated with significantly longer mPFS than non-use (1287 vs 376 days; p = 0.019). In contrast, BTK inhibition did not confer a significant PFS benefit in this subgroup (p = 0.470). The median OS was not reached, with a projected 5-year OS rate of 47.9% (95% CI: 0.191–1). In Cox regression analysis, univariate models indicated that older age and disease relapse were nominally associated with worse OS (HR >1), whereas systemic therapy and female sex were associated with improved OS (HR 0.050), likely reflecting limited statistical power. Summary results are illustrated in Figure 1, Parts 5–6.Figure 1.: Survival outcomes and treatment effects in patients with primary vitreoretinal lymphoma. Part 1: Kaplan–Meier curve of PFS for the entire cohort; Part 2: Comparison of PFS between patients receiving HD-MTX–based systemic therapy and those who did not; Part 3: Comparison of PFS with vs without BTKi therapy in patients receiving HD-MTX–based regimens; Part 4: Comparison of PFS with vs without BTKi therapy in patients receiving IVT-MTX–based regimens; Part 5: Forest plot of univariate analysis for OS; Part 6: Forest plot of multivariate analysis for OS. BTKi = Bruton’s tyrosine kinase inhibitor, CNS = central nervous system, HD-MTX = high-dose methotrexate, IVT-MTX = intravitreal methotrexate, mPFS = median progression-free survival, OS = overall survival, PFS = progression-free survival.3.3. Toxicity and relapse Among 38 patients who developed treatment-related toxicities, 14 (36.8%) had grade I to II myelotoxicity, and 2 (5.3%) had grade III to IV events. Hematologic toxicities included neutropenia (31.6%), thrombocytopenia (18.4%), and anemia (34.2%). Non-hematologic events included transaminase elevation (21.1%) and creatinine elevation (15.8%). Of 39 patients receiving IVT-MTX, ocular toxicities included keratitis (n = 4), cataract (n = 5), elevated intraocular pressure (n = 1), and optic disc edema (n = 1). No ocular complications were related to anterior chamber paracentesis, and no systemic chemotherapy-related ocular toxicity occurred. No treatment-related deaths or therapy discontinuations occurred because of adverse events. During follow-up, 25 of 53 patients (47.2%) relapsed, involving the CNS (n = 20), ocular (n = 5), and systemic (n = 2) sites. Specifically, 18 patients had CNS-only relapse, 3 had ocular-only, 1 had systemic-only, 2 had concurrent ocular and CNS relapse, and 1 had ocular and CNS involvement. Among 47 patients with PVRL, 19 (40.4%) experienced CNS progression. The incidence of CNS progression was significantly lower in patients who received HD-MTX than in those who did not (17.2% vs 62.5%; p = 0.001). The median BFS was significantly longer in the HD-MTX group (1341 days; 95% CI, 885 days–not reached) than in the non–HD-MTX group (401 days; 95% CI, 367 days–not reached) (p = 0.006). Ocular relapse was less frequent than brain relapse, and the median OFS was not reached. Among 29 HD-MTX–treated patients, relapse occurred in 3 of 7 (42.9%) who did not receive a BTKi vs 2 of 22 (9.1%) who did (p = 0.074). None of the 3 patients receiving first-line HD-MTX plus a BTKi followed by hematopoietic stem cell transplantation relapsed; their longest PFS to date is 705 days. 3.4. Treatment of the relapses In the second-line setting, 20 of 25 relapsed patients (80%) received HD-MTX–based chemotherapy. Among them, 18 received a CD20 monoclonal antibody (rituximab or zuberitamab), and 16 were additionally treated with a BTKi (orelabrutinib or zanubrutinib). Among evaluable second-line patients, 12 achieved CR, 3 achieved PR, 2 had stable disease (SD), and 3 had PD. Five were not evaluable or were pending assessment. Seven patients proceeded to third-line therapy (1 PR, 3 PD, others pending evaluation), and 1 patient received fourth-line Chimeric Antigen Receptor T-Cell Immunotherapy, achieving PR. Multivariate logistic regression identified systemic therapy as an independent protective factor against CNS or systemic relapse (OR = 0.109, 95% CI: 0.018–0.490; p = 0.007). For ocular relapse, systemic therapy also showed a protective trend (OR = 0.130; p = 0.119). In contrast, corticosteroid use was identified as a significant risk factor for CNS or systemic relapse (OR = 8.573, 95% CI: 1.465–75.455; p = 0.030). No other clinical variables—including age, sex, bilaterality, BTKi use, or primary site—were significantly associated with relapse outcomes. 4. DISCUSSION Our retrospective analysis of 56 patients reaffirms the pivotal role of systemic HD-MTX–based therapy in improving PFS and reducing CNS progression, consistent with the broader literature and our previous meta-analyses. In the present cohort, HD-MTX was associated with significantly prolonged median PFS (p = 0.003) and a markedly lower CNS progression rate (17.2% vs 62.5%; p = 0.001). These results align with those of our earlier systematic review that highlighted the importance of systemic therapy in extending PFS and OS, particularly in preventing CNS relapse, the leading cause of mortality in patients with VRL.11 Although IVT-MTX remains the cornerstone of local disease control, our data suggest that it is insufficient as a standalone strategy to prevent CNS infiltration. This with the findings that local therapy was associated with high rates of intraocular and CNS has also been demonstrated that although IVT-MTX, and local could intraocular lymphoma these treatments to prevent CNS In contrast, the of systemic HD-MTX to a potentially by eradicating systemic or CNS disease that is at diagnosis. its to control intraocular disease to be less In our cohort, a of patients experienced ocular relapse systemic therapy, the findings of the HD-MTX–based chemotherapy was associated with a high ocular relapse rate This that although HD-MTX the intravitreal levels may be insufficient to vitreoretinal this observed that combined local and systemic therapy was associated with improved ocular control, the role of systemic prophylaxis and local disease Our cohort achieved a median OS, with a projected 5-year OS rate of This may be to 2 the of CNS progression HD-MTX, and the of at relapse. In our all patients who experienced relapse received systemic therapy. These second-line regimens included HD-MTX–based chemotherapy combined with other such as BTKis, or A of patients underwent hematopoietic cell This treatment the importance of therapy to long-term BTKi therapy, our data did not a significant PFS benefit with monotherapy, consistent with our earlier that reported a lower CR rate for BTKis than for combination studies BTKis the efficacy of HD-MTX using a particularly for Our study also identified HD-MTX–based systemic therapy as an independent protective factor against CNS/systemic relapse (OR = 0.109, p = the that systemic treatment is critical for VRL our data suggest a in CNS relapse rates with the HD-MTX and BTKi combination with HD-MTX a benefit not in the PFS This the of combination therapy a protective against progression. prior corticosteroid use was associated with an increased risk of CNS relapse, may diagnosis or disease the for and definitive treatment. The observed in our cohort was with no treatment-related deaths or Ocular adverse events related to IVT-MTX were consistent with those reported in previous and systemic toxicities were predominantly This can be to and management during HD-MTX including level and leucovorin our data the of systemic HD-MTX into VRL therapeutic Our study has retrospective small sample and the of treatment regimens the to definitive the follow-up may have been insufficient to relapses or long-term the of treatments Nevertheless, our findings are by clinical data that provide into VRL In this study the importance of systemic HD-MTX therapy for improving PFS and reducing CNS progression in patients with Although HD-MTX may not prevent ocular relapse, its combination with local therapy and such as BTKis, a strategy to disease These results the of systemic therapy into the first-line management of VRL, particularly for patients with primary ocular disease who are at high risk of CNS relapse. are to these findings and for this malignancy. received from Science and and the the and performed data and the and to study data and approved the final