Consolidation Therapy in Primary Central Nervous System Lymphoma
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Neuro-oncology (G Lesser, Section Editor)
Consolidation Therapy in Primary Central Nervous System Lymphoma Peter Kim, MD, MS Antonio Omuro, MD* Address * Yale Brain Tumor Center, Yale Cancer Center and Department of Neurology, LLCI 920, Yale School of Medicine, 15 York Street, New Haven, CT, 06510, USA Email: [email protected]
* Springer Science+Business Media, LLC, part of Springer Nature 2020
This article is part of the Topical collection on Neuro-oncology Keywords Primary CNS lymphoma I Consolidation therapy I Whole-brain radiotherapy I Conditioning chemotherapy I Autologous stem cell transplant I Non-myeloablative chemotherapy
Opinion statement Primary central nervous system lymphoma is a complex disease with no agreed-upon standard-of-care therapy. Induction therapy involves multiagent chemotherapy based on high-dose methotrexate, with several regimens available. We have a preference for a regimen using rituximab, methotrexate (3.5 g/m2), procarbazine, and vincristine (R-MPV) for initial induction therapy, given the favorable balance between toxicities and very high response rates (80–90%), which allow for decreasing disease burden and increasing the effectiveness of consolidation treatments. However, in the absence of consolidation therapies, R-MPV is not an effective regimen to achieve long-term remission. Based on high rates of long-term remission, our first choice for consolidation therapy is high-dose chemotherapy with autologous stem-cell transplant using thiotepa, busulfan, and cyclophosphamide as a myeloablative regimen, with a curative intent. This typically applies to patients with a favorable performance status at the end of induction, typically with ECOG performance status of 2 or better, adequate organ function, and age younger than 70. Patients with a high transplant-related mortality risk may still be considered for milder myeloablative regimens such as carmustine/thiotepa. For patients who are not transplant candidates, we typically offer consolidation with reduced dose whole-brain radiation therapy (WBRT) (23.4 Gy), which seems to be associated with lower risks of neurotoxicity as compared with higher doses of radiation. For patients who are not transplant candidates and that do not accept the risk of cognitive decline from the radiotherapy, we typically offer consolidation high-dose cytarabine, provided the patient understands the high risk of relapse. For these patients, a clinical trial is strongly recommended.
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Curr. Treat. Options in Oncol.
(2020) 21:74
Introduction Treatment of primary central nervous system lymphoma (PCNSL) has evolved significantly in the past 4 decades. In the 1980s, initial treatment attempts were made with focal radiotherapy alone, achieving a 2-year overall survival (OS) of 16% and 5-year OS of 4% [1]. Subsequent evaluation and modulation of radiation therapy, with the standardization of WBRT,, improved outcomes marginally to an OS of 28% and 15% at 2 and 5 years, respectively [2]. With the introduction of high-dose (HD) methotrexate (
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