Advances in treatment of elderly primary central nervous system lymphoma

Abstract

The management of older individuals (≥60 years) with primary central nervous system lymphoma remains a clinical challenge. Identification of optimal therapy and delivering adequate dose intensity are two of the major issues in treating elderly patients. Premorbid performance status and comorbidities influence individualised treatment approaches and geriatric assessment tools are increasingly utilised. Optimal induction treatment remains high-dose methotrexatebased immunochemotherapy, delivery is feasible in the majority of patients and the goal of treatment remains achieving complete remission. Consolidation strategies are also relevant in the elderly, aiming to maximise duration of response and quality of life (QoL). Potential options include high-dose therapy with haematopoietic stem cell consolidation, non-myeloablative chemotherapy and whole-brain radiotherapy. Efficacy of novel agents, such as Bruton tyrosine kinase inhibitors and lenalidomide, have been reported; these represent an alternative for elderly patients unfit for chemotherapy. Prognosis remains poor, improvement of outcomes in this age group is urgently needed.

Management of secondary central nervous system lymphoma

“…All patients with SCNSL should be considered for a short steroid pre-phase. Additionally, patients with impaired PS should be considered for rituximab-methotrexate (MTX ≥3 g/m 2 ) as a first treatment cycle prior to multi-agent chemotherapy 14 or initial dose reductions of cytotoxics such as cytarabine (see treatment recommendations). 2,3 Frailty risk scores such as the Charlson Comorbidity Index (CCI), G8 screening tool and Cumulative Illness Rating Scale may provide an objective measure of fitness and have been shown to discriminate outcomes in primary CNSL (PCNSL).…”

“…All patients with SCNSL should be considered for a short steroid pre‐phase. Additionally, patients with impaired PS should be considered for rituximab‐methotrexate (MTX ≥3 g/m 2 ) as a first treatment cycle prior to multi‐agent chemotherapy 14 or initial dose reductions of cytotoxics such as cytarabine (see treatment recommendations) 2,3 …”

“…2,3 Frailty risk scores such as the Charlson Comorbidity Index (CCI), G8 screening tool and Cumulative Illness Rating Scale may provide an objective measure of fitness and have been shown to discriminate outcomes in primary CNSL (PCNSL). These may guide feasibility of an intensive approach [14][15][16] but have not been specifically validated in SCNSL. 17 Fitness for treatment intensification and autologous stem cell transplantation (ASCT) should be dynamically assessed, as PS commonly improves during effective therapy.…”

“…17 Fitness for treatment intensification and autologous stem cell transplantation (ASCT) should be dynamically assessed, as PS commonly improves during effective therapy. 14…”

“…These may guide feasibility of an intensive approach 14–16 but have not been specifically validated in SCNSL 17 . Fitness for treatment intensification and autologous stem cell transplantation (ASCT) should be dynamically assessed, as PS commonly improves during effective therapy 14 …”