CNS relapse of diffuse large B cell Lymphoma: A single centre experience

Abstract

Background and Objective:Central nervous system (CNS) relapse of diffuse large B cell lymphoma (DLBCL) is relatively uncommon and nearly fatal. Two years CNS relapse risk is 0.8% in low, 3.9% in intermediate and 12% in high risk patients. Our aim was to study, the baseline characteristics and outcome in term of median survival of DLBCL patients with CNS relapse.Methods:This is a retrospective analysis. All patients of DLBCL with CNS relapse from 2006 to 2014 were included. Data were collected from computerized Hospital Information System and analyzed for characteristics and median survival.Results:Out of twenty one patients included in the study, 14(66.3%) males and 7(33.7%) were females. On initial diagnosis of DLBCL, median age was 37.4 years (27-47). Ann Arbor stage of I-IV was in 3 (14.3%), 2(9.5%), 4(19%) and 12(57.1%) patients, respectively. Extra-nodal involvement was noted in 16(76.2%), high LDH in 18(85.7%), bone marrow involvement in 8(38.1%) and bulky disease in 5(23.8%) patients. International Prognostic Index (IPI) score was 1 in 4(19%), 2 in 9(42.9%), 3 in 8(38.1%) patients. Extra-nodal sites were gut in 2(9.1%) while 1(4.5%) patient of each of following organs involvement was seen: cervix, gluteal muscle, iliac bone, liver, ovaries, pancreas, parotid gland and testes. Chemotherapy CHOP was given to 16(76.2%) and RCHOP in 5(23.8%) patients. Prophylactic intrathecal methotrexate was given to 10(47.6%) patients. Complete response was in 10 (47.6%), partial response was in 3 (14.3%) and disease progression was in 8 (38.1%) patients. CNS relapse occurred in 17 (81%) patients within six months after completion of therapy. CNS relapse along with systemic disease was in 14(66.6%) patients. Isolated CNS relapse was noted in 7(33.3%) patients. Second line chemotherapy regimens were HDMTX 5(23.8%), HDMTX/TRIO IT 3(14.2%), HDMTX/HDAC 2(9.5%), HCVAD 3(14.2%), ICE 4(19.4%), DHAP 1(4.7%), ICE/HDMTX 1(4.7%), none 2(9.5%). Overall median survival of CNS relapsed patients was 54 days.Conclusion:Patients with DLBCL who had advanced stage, high LDH and extra-nodal involvement at initial presentation are at high risk for CNS relapse. About half of the patients had CNS relapse despite primary CNS prophylaxis. Once relapsed in CNS, these patients have very poor prognosis.

Outcomes of high‑dose methotrexate for CNS prophylaxis in diffuse large B‑cell lymphoma with an intermediate or high CNS‑International Prognostic Index: A single‑center retrospective cohort study

“…Similar risk factors were reported by the UK NCRI R-CHOP-14 vs. 21 trial, where a performance status of 2, elevated lactate dehydrogenase level, IPI, >1 extranodal site of disease and the presence of a 'high-risk' extranodal site were significant risk factors for CNS relapses (17). In the study by Nazir et al (30), an advanced stage, high LDH level and extranodal involvement at the first presentation were significant risk factors for CNS relapse.…”

“…The study found that intrathecal MTX was not optimal for CNS prophylaxis, since CNS relapses occurred in 4 patients, with a 2-year cumulative incidence rate of CNS relapse of 12.5%. In another single-center retrospective study of 21 patients with DLBCL who received CNS prophylaxis by intrathecal and intravenous MTX, half of the patients had CNS relapses, with a poor prognosis and a median survival time of 54 days (30).…”

Construction and Validation of a Novel Nomogram for Predicting the Recurrence of Diffuse Large B Cell Lymphoma Treated with R-CHOP

“… 7 , 21 , 22 In terms of DLBCL, elevated LDH level at initial diagnosis was found to be related to the increased risks of CNS relapse. 23 , 24 Compared with patients with late relapses, patients with early relapses were more likely to have a higher LDH level, higher IPI score and adverse stage (III–IV). 25 In Huang’s study, univariate analysis also indicated that LDH >1000U/L was one of the relapse risk factors of pediatric mature B cell lymphoma.…”