Lymphoma relapse in CNS

[Gfunk6]

For primary CNS lymphoma, I know that the standard of care is MTX-chemotherapy +/- WBRT. However, what would you do in a situation where a patient had Stage III/IV extracranial DLBCL with an isolated intracranial relapse?

Man in late 60s
Stage IV DLBC (extracranial only) with cCR s/p x6c R-CHOP.
~ 1 year later presented with HAs + double vision.
MRI Brain showed ~ 2 cm pineal mass. Extracranial imaging = NED.
LP x2 was negative for disease. Pt started empirically on dexamethasone with 50% shrinkage in mass on f/u MRI. Symptoms resolved, but return quickly when steroid is tapered off.

Empirically it would seem to be an isolated DLBCL relapse in CNS, but pineal gland is an odd place for this. Trying to push for stereotactic biopsy. If biopsy = DLBCL or if biopsy not possible would anyone treat with SRS? I realize chance of elsewhere CNS failure is high but could always salvage with WBRT.

Thoughts appreciated.

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[medgator]

Maybe WBRT with SIB (simultaneous integrated boost) to the pineal gland utilizing IMRT. I'd feel weird focally treating a lymphoma like DLBCL with SRS, while ignoring rest of a sanctuary site like the CNS, personally.

With DLBCL, you shouldn't need conventional SRS dosing anyways to control disease (should be able to keep max Rx to 45-50 Gy with good control I would think). Maybe something like 30 Gy/15 Fx to the negative CNS parenchyma, and 37.5 Gy-45 Gy/15 Fx to the involved pineal gland

 

[Palex80]

What else could it be than DLBCL, if it responded to steroids that well?
No other tumor would respond with shrinkage to steroids. Thus, if it's cancer, it's lymphoma.
So you should only rule out any potential inflammatory CNS-disease, that may look like it.
A good neuroradiologist may however be able to rule that out and LP is helpful too.

I wouldn't do SRS. No data on that for CNS-lymphoma.

Since he's in his late 60s I presume high-dose chemo is not an option, right?

Thus you may try a combined modality treatment with chemo + WBRT, followed by a focal boost.
Rituximab is also an option additionally to RT if the patient is too ill for chemo.


There are some data advocating hyperfractionated treatment for CNS-lymphoma.
I've done it once (36/1.0 bid, followed by boost) and the patient is still quite fit.

 

[Gfunk6]

Thanks for the input guys. It sounds like a relatively modest dose of WBRT (24-30 Gy) + sequential/concomitant boost would work well.

 

[Cancerdancer]

It sounds like you're thinking RT alone? I've treated two patients like this, and both times treated per the recent PCNSL protocol with R-MPV followed by 23.4 Gy. With a CNS relapse and a CNS that hasn't yet seen MTX I think chemo needs to be the backbone, +/- RT, no?

 

[Gfunk6]

It sounds like you're thinking RT alone? I've treated two patients like this, and both times treated per the recent PCNSL protocol with R-MPV followed by 23.4 Gy. With a CNS relapse and a CNS that hasn't yet seen MTX I think chemo needs to be the backbone, +/- RT, no?

Possibly. We are discussing his case in Tumor Board this week. Will see how the Med Onc feels about more chemo.