Therapy (Prophylaxis) for CNS Involvement
Adapted from James O. Armitage, Mayo
Clin Proc. 2012
My Treatment Approach to Patients With Diffuse Large B-Cell Lymphoma
"It is clear that most
patients with diffuse large B-cell lymphoma are at a low risk
of CNS metastasis."
Patients thought to be at higher risk for
developing CNS involvement may receive prophylactic therapy to
attempt to reduce its frequency.
Relapse in the CNS (Central
Nervous System) following treatment for DLBCL is one of most
CNS relapse can involve the
meninges (membranes that envelope the central nervous system),
or the brain.
This is a serious complication,
but some patients who develop CNS metastasis after apparently
successful treatment for systemic DLBCL can be rescued with
autologous stem cell transplant.
The most common treatment are intrathecal methotrexate
with or without cytarabine with or without additional intravenous
Incidence / risk of this
Two large series of patients treated using this approach found
an incidence of CNS relapse between 1% and 2%.
However, in 2 large series of patients in which CNS prophylaxis
was not routinely given, the incidence of CNS relapse was
2.2% and 2.8% - [not much higher].
In a recent report the incidence of CNS relapse in patients who
received rituximab with CHOP was significantly lower than that
in patients who received CHOP alone (6.4% vs 9.7%), and the
results were even more striking for patients who achieved a
complete remission (5.8% vs 2.2%), suggesting that use of
Rituxan might reduce the incidence.
Similar results were reported at the University of Nebraska
with a CNS relapse rate of 3.6% with CHOP and
2.2% with CHOP-R (P=.05).
The value of prophylaxis
treatment might be marginal.
Factors associated with CNS
relapse include specific sites of involvement
bone, and bone marrow
Other factors associated with increased risk of CNS relapse:
high serum lactate dehydrogenase,
low serum albumin,
age younger than 60 years, and
more extensive disease.
CNS prophylaxis is often given
with each cycle of CHOP-R to patients who present with
testicular involvement, and
involvement of the bone marrow by large cell lymphoma
OR when DLBCL presents in unusual extranodal sites such as
adrenal gland, kidney, and bone.
It appears that some patients
destined to develop meningeal metastasis have cells present in
the spinal fluid at diagnosis that can be detected by flow
cytometry. Such tests might be one way to identify
patients who should have aggressive “prophylactic” therapy.