What is your approach to a patient with an advanced stage diffuse large B-cell lymphoma treated with chemotherapy alone (with a PET CR) who then develops an isolated CNS relapse?

If the patient cannot tolerate methotrexate or further chemotherapy, how effective is radiation therapy (e.g. WBRT) in rendering the patient disease-free? If they only have a single brain lesion, would you consider local RT over WBRT?

1 Answer

Mednet Member

Radiation Oncology · Washington University School of Medicine

Answered on

This is a challenging albeit relatively rare situation. First, I would make sure to complete systemic workup, including MRI of brain/spine, CSF cytology, and PET/CT. I would not consider radiosurgery even for a single brain lesion, as this is ultimately a more diffuse disease process. If patient has systemic disease and is not a candidate for curative systemic therapy, then palliative RT (ie WBRT for symptomatic brain mets) may be considered. If truly isolated CNS relapse, high dose methotrexate would be the first consideration. If not eligible or progressed on Methotrexate, then one may consider craniospinal irradiation (CSI). There is a retrospective study from MDACC by Sanders et al (Cancer 2004; 100(10):2176-80) that retreated 16 leukemia patients with CNS relapse, with 13/16 had no CSF disease at death or last follow-up. As similar data does not exist in DLBCL (to my knowledge), this would be considered extrapolation of data, and DLBCL likely has worse prognosis. However, given the lack of other alternatives, I have tried this on rare occasions.