There remains an open question about whether intermediate risk lymphomas, such as diffuse large cell lymphomas, with poor risk factors (such as extranodal involvement or certain mutatiosn or markers) require prophylaxis against CNS involvement alongside IV chemotherapy, because there is a higher risk of the involvement in these sanctuary sites in these cases. Such prophylaxis can be intrathecal or high dose methotrexate with follinic acid rescue and cytarabine. The consensus is that some, such as testicular lymphoma, should and some should not. ESMO writes: “Patients with high–intermediate- and high-risk IPI, especially those with more than one extranodal site or elevated LDH are at higher risk of CNS relapse. CNS prophylaxis should be recommended in this population but intrathecal injections of methotrexate are probably not an optimal method. Whether some specific involvement sites such as paranasal sinus, upper neck or bone marrow should receive prophylaxis remains to be established. Testicular lymphoma must receive CNS prophylaxis”. The National Comprehensive Cancer Network (www.nccn.org) guidelines for diffuse large B-cell (DLBCL) lymphoma recommend CNS prophylaxis with 4 to 8 doses of intrathecal methotrexate (MTX) and/or cytarabine for patients with aggressive lymphomas who have paranasal sinus, testicular, epidural, bone marrow, 2 extranodal site involvement, or HIV lymphomas. A recent(2012) review of the impact of CNS prophylaxis in DLBCL patients treated with R-CHOP at a tertiary care center over a 7-year period concluded that in the era of R-CHOP there may not be a need for CNS prophylaxis with the exception of testicular lymphoma.
H. Takasaki et al, Intrathecal methotrexate prophylaxis and central nervous system relapse in patients with diffuse large B-cell lymphoma following rituximab plus cyclophosphamide, doxorubicin, vincristine and prednisone Leukemia & Lymphoma Volume 56, 2015 – Issue 3
H. Tilly, M. Dreyling, Diffuse large B-cell non-Hodgkin’s lymphoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up Ann Oncol (2010) 21 (suppl 5): v172-v174.
nccn, NHL, 2018
Hany R et al, Impact of central nervous system (CNS) prophylaxis on the incidence and risk factors for CNS relapse in patients with diffuse large B-cell lymphoma treated in the rituximab era: a single centre experience and review of the literature .British Journal of Haematology Article first published online: 31 JUL 2012 DOI: 10.1111/j.1365-2141.2012.09247.x 2012 Blackwell Publishing Ltd
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