Secondary infiltration of the central nervous system in patients with diffuse large B-cell lymphoma

Abstract

ObjectiveTo investigate the incidence and risk factors of infiltration of the central nervous system after the initial treatment of diffuse large B-cell lymphoma in patients treated at Santa Casa de Misericórdia de São Paulo. MethodsA total of 133 patients treated for diffuse large B-cell lymphoma from January 2001 to April 2008 were retrospectively analyzed in respect to the incidence and risk factors of secondary central nervous system involvement of lymphoma. Intrathecal prophylaxis was not a standard procedure for patients considered to be at risk. This analysis includes patients whether they received rituximab as first-line treatment or not. ResultsNine of 133 (6.7%) patients developed central nervous system disease after a mean observation time of 29 months. The median time to relapse or progression was 7.9 months after diagnosis and all but one patient died despite the treatment administered. Twenty-six (19.5%) patients of this cohort received rituximab as first-line treatment and nine (7.1%) received intrathecal chemoprophylaxis. Of the nine patients that relapsed, seven (77.7%) had parenchymal central nervous system involvement; seven (77.7%) had stage III or IV disease; one (11.1%) had bone marrow involvement; two (22.2%) had received intrathecal chemoprophylaxis; and 3 (33.3%) had taken rituximab. In a multivariate analysis, the risk factors for this infiltration were being male, previous use of intrathecal chemotherapy and patients that were refractory to initial treatment. ConclusionCentral nervous system infiltration in this cohort is similar to that of previous reports in the literature. As this was a small cohort with a rare event, only three risk factors were important for this infiltration

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

“…Most relapses occur with a median duration of less than one year from the time of initial diagnosis. 3 - 6 There is association of increased risk for developing CNS relapse in patients with elevated LDH, ≥2 extranodal sites and involvement of specific extranodal sites (testes, paranasal sinus, breast and bone marrow) on initial presentation. 7 - 9 There is a validated prognostic model to predict the risk of CNS relapse utilizing five clinical factors (age > 60 years, LDH > normal, stage III or IV, ECOG PS >1, and involvement of the kidney or adrenal gland) thus recommending for CNS prophylaxis therapy.…”

Central nervous system prophylaxis in diffuse large B‐cell lymphoma

“…The available evidence is from retrospective data with all its caveats, including limited number of patients, no control groups, inconsistent dosing, and most importantly, administration of other systemic agents, such as high‐dose systemic MTX (HD‐MTX), that penetrate the CNS, and selection bias in who received IT CNS prophylaxis and who did not. Many experts believe that IT chemoprophylaxis is not relevant in the rituximab era, especially considering that parenchymal CNS involvement is becoming more common, in which case HD‐MTX may be more beneficial . Future randomized studies may help clarify these controversial findings and objectively establish an appropriate strategy for optimizing the potential benefits of IT CNS prophylaxis in preventing CNS relapse in DLBCL.…”

“…The incidence of CNS relapse in DLBCL is approximately 5%, with a median duration of less than 1 year from time of initial diagnosis to CNS relapse (4,5). This observation suggests that occult CNS involvement goes undetected during initial workup.…”

Predictors of central nervous system involvement in diffuse large B-cell lymphoma: a divining rod is wanted

“…In this issue of the Revista Brasileira de Hematologia e Hemoterapia, da Rocha et al report their efforts to identify reliable variables predicting CNS recurrence in a retrospective series of 133 patients with DLBCL diagnosed between 2001 and 2008 (5) . Accordingly, male gender, previous use of intrathecal chemotherapy and refractory response to the initial treatment were independent risk factors for CNS infiltration.…”

“…The key question is still what should we do to improve the sensitivity of prognostic variables and scores? As proposed by da Rocha et al (5) , this must be done through the study of grouped risk factors and a more sensitive assessment of hidden disease in the CNS. To reduce study populations to a specific lymphoma category, or to a single extranodal lymphoma, treated with a uniform strategy, excluding any form of CNS prophylaxis, and prospective data collection may be suitable strategies to improve the reliability of conclusions.…”