How would you approach therapy for relapsed/refractory mantle cell lymphoma restricted to the CNS?

CNS involvement by mantle cell lymphoma is an uncommon and high-risk scenario. Although it can be seen at diagnosis, it is more common at relapse, particularly CNS-only disease.

Optimal treatment depends on multiple factors, including prior treatment and response, age, performance status, underlying organ function and reserve, and goals of care.

Options include chemotherapy-based approaches incorporating high-dose methotrexate with or without intrathecal methotrexate (depending on whether disease is parenchymal or leptomeningeal); ibrutinib-based treatment (here, higher-dose ibrutinib at 840mg may be considered to increase the CNS penetrant dose); lenalidomide-based treatment; and CAR-T cell therapy. Radiation therapy, although not preferr...