I do not usually offer HD IV methotrexate for DHL without documented CNS disease. Instead, I use 4 cycles of IT methotrexate in addition to DA R-EPOCH (Blood 2017). For patients with documented CNS involvement, you can place an Ommaya reservoir for an intensive intrathecal therapy and I recommend us...

This is a great question. DHL have high risk of CNS involvement and primary prophylaxis is very important. Most of the lymphoma experts would prefer R-DA-EPOCH approach if the patient can tolerate an aggressive approach. In my practice, I prefer high dose methotraxate over intrathecal chemotherapy (...