Primary central nervous system lymphoma: The role of consolidation treatment after a complete response to high‐dose methotrexate‐based chemotherapy

Abstract

BACKGROUND.The most effective treatment for a new diagnosis of primary central nervous system lymphoma is high‐dose methotrexate (MTX)‐based chemotherapy followed by whole‐brain radiation therapy (WBRT). However, this combined modality treatment carries an increased risk of delayed neurotoxicity. For patients who achieve a complete response (CR) after induction that uses high‐dose MTX‐based chemotherapy, it is not clear if consolidation treatment is necessary. Therefore, a retrospective study was conducted to assess the impact of consolidation treatment after a CR to initial induction chemotherapy on disease control and survival.METHODS.The authors retrospectively analyzed 122 patients who achieved a CR after initial MTX‐based chemotherapy. The benefit of consolidation WBRT, high‐dose cytarabine (HDAC), or both on failure‐free (FFS) and overall survival (OS) was assessed.RESULTS.With a median follow‐up of 60 months, FFS was longer in patients who received WBRT plus HDAC as consolidation treatment (P = .03 by univariate analysis); there was no difference in OS observed among patients who received no consolidation treatment, HDAC alone, WBRT plus HDAC, or WBRT alone. Age and Karnofsky performance scale (KPS) were the only independent prognostic factors. Patients who received WBRT alone or in combination with HDAC had higher rates of neurotoxicity.CONCLUSIONS.Consolidation treatment with WBRT, HDAC, or both does not appear to improve survival in patients who achieved a CR with induction MTX‐based therapy. Age, KPS, and risk of delayed neurotoxicity must be considered in the choice of consolidation regimens. Cancer 2008. © 2008 American Cancer Society.

Early whole brain radiotherapy in primary CNS lymphoma: negative impact on quality of life in the randomized G-PCNSL-SG1 trial

“…Nevertheless, clear differences between the treatment groups were evident in year 2 after randomization. The higher rates of cognitive dysfunction observed with early WBRT are consistent with previous non-randomized observational studies showing a high rate of cognitive deficits and/or impaired QoL after HD-MTX followed by WBRT (Correa et al 2004;Harder et al 2004;Herrlinger et al 2005;Correa et al 2012;Ekenel et al 2008), while neither QoL impairment nor neuropsychological deficits were found in 21 longterm survivors treated with chemotherapy alone (Juergens et al 2010). Also, a non-randomized analysis of cognitive functioning and QoL in PCNSL long-term survivors treated with our without WBRT suggests that the addition of WBRT increases the risk of neurotoxicity (Doolittle et al 2013).…”

The role of autologous stem cell transplantation in primary central nervous system lymphoma

“…Similarly, a growing inclination to avoid radiotherapy in patients achieving complete remission (CR) after induction chemotherapy has been applied also to PCNSL. 11 This choice is strongly motivated by the previously mentioned association between WBRT and risk of severe neurotoxicity. 5 However, WBRT withdrawal should be considered with caution as the situation is completely different in PCNSL, where the quality of response after chemotherapy is suboptimal compared with DLBCL patients treated with rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone (R-CHOP).…”

Primary CNS Lymphoma in Immunocompetent Patients

“…In two multicenter retrospective analyses no differences were noted regarding disease-free survival or OS times between patients in CR receiving WBRT as consolidation treatment and those receiving WBRT at the time of relapse [68,69]. In the MSKCC experience, consolidation treatment with WBRT produced a longer failure-free survival time but not OS time in CR patients after MTX-based therapy and produced higher rates of neurotoxicity [70].…”