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Clear Guidelines Needed for CNS Involvement in Lymphoma

Brandon Scalea
Published: Wednesday, Sep 12, 2018

Philip Bierman, MD

Philip Bierman, MD

Although central nervous system (CNS) metastases occur in 1% to 2% of patients with large cell lymphoma, it is imperative to have a standard-of-care approach in place for this small subgroup, said Philip Bierman, MD.

, Bierman discussed the current landscape of CNS involvement in aggressive lymphoma and the research that should be conducted.

OncLive: How prevalent is CNS involvement in lymphoma?

Bierman: It turns out that about 1% to 2% of the time, patients with large cell lymphoma will also have CNS involvement. Sometimes, people call this concurrent CNS and systemic lymphoma. Sometimes, they say it is simultaneous. If you look at patients when they relapse, it often occurs in the first few months after starting treatment.

of high-dose methotrexate.

What are the treatment challenges for these patient populations?

We don't have randomized trials. The main question is, "What's the best regimen?" There is also a question of whether transplantation helps these patients. We don't know that answer, although a lot of people are recommending it. Are there better regimens out there? For example, what [type of benefit would there be if we] combined ibrutinib (Imbruvica) with R-CHOP? What about lenalidomide (Revlimid) with R-CHOP? There is a suggestion that this may decrease the rate of CNS relapse. Most people are saying some sort of anthracycline-based chemotherapy combined with high-dose methotrexate [could be an option].

What is the main takeaway message from this area of research?

This patient population can do well. Not only that, they can be cured. We should treat them according to the guidelines from one of these organizations.

Another question is what to do with people who just have leptomeningeal disease. There are not a lot of prospective trials looking at this. There is some evidence that if people have leptomeningeal disease identified by flow cytometry, then we may be able to eradicate disease in the spinal fluid. For people with more florid disease, they probably require high-dose methotrexate.
Penalver F, Sancho J, Fuente A, et al. Guidelines for diagnosis, prevention and management of central nervous system involvement in diffuse large b-cell lymphoma patients by the Spanish lymphoma group. Haematologica. 2017;102(2):235-245. doi:10.3324/haematol.2016.149120.

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