Challenges in the Treatment of Newly Diagnosed and Recurrent Primary Central Nervous System Lymphoma

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  • 1 The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland;
  • 2 Department of Neurology, Mayo Clinic, Phoenix, Arizona;
  • 3 Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York; and
  • 4 Center for CNS Lymphoma, Dana-Farber Cancer Institute, Boston, Massachusetts.
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Primary central nervous system lymphomas (PCNSLs) are rare cancers of the central nervous system (CNS) and are predominantly diffuse large B-cell lymphomas of the activated B-cell (ABC) subtype. They typically present in the sixth and seventh decade of life, with the highest incidence among patients aged >75 years. Although many different regimens have demonstrated efficacy in newly diagnosed and relapsed or refractory PCNSL, there have been few randomized prospective trials, and most recommendations and treatment decisions are based on single-arm phase II trials or even retrospective studies. High-dose methotrexate (HD-MTX; 3–8 g/m2) is the backbone of preferred standard induction regimens. Various effective regimens with different toxicity profiles can be considered that combine other chemotherapies and/or rituximab with HD-MTX, but there is currently no consensus for a single preferred regimen. There is controversy about the role of various consolidation therapies for patients who respond to HD-MTX–based induction therapy. For patients with relapsed or refractory PCNSL who previously experienced response to HD-MTX, repeat treatment with HD-MTX–based therapy can be considered depending on the timing of recurrence. Other more novel and less toxic regimens have been developed that show efficacy in recurrent disease, including ibrutinib, or lenalidomide ± rituximab. There is uniform agreement to delay or avoid whole-brain radiation therapy due to concerns for significant neurotoxicity if a reasonable systemic treatment option exists. This article aims to provide a clinically practical approach to PCNSL, including special considerations for older patients and those with impaired renal function. The benefits and risks of HD-MTX or high-dose chemotherapy with autologous stem cell transplantation versus other, better tolerated strategies are also discussed. In all settings, the preferred treatment is always enrollment in a clinical trial if one is available.

Submitted August 30, 2020; accepted for publication October 7, 2020.

Disclosures: The authors have disclosed that they have no financial interests, arrangements, or affiliations with the manufacturers of any products discussed in this article or their competitors.

Funding: Dr. Nayak is supported by the Leukemia and Lymphoma Society Scholar in Clinical Research Award (LLS Grant ID: 2322-19).

Correspondence: Matthias Holdhoff, MD, PhD, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, 201 North Broadway, 9th Floor, Mailbox 3, Baltimore, MD 21287. Email: mholdho1@jhmi.edu; andLakshmi Nayak, MD, Center for CNS Lymphoma, Dana Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215. Email: Lakshmi_Nayak@dfci.harvard.edu
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