Would you ever consider SRS as a salvage option as an alternative to whole brain radiation for secondary CNS lymphoma?

The optimal management of secondary CNS lymphoma is not clear. Clinical considerations include the age and performance status of the patient, distribution of disease (CNS only versus systemic and CNS), prior treatment, etc. In most cases, high-dose methotrexate (HD MTX) based regimens are pursued. If a patient responds favorably to salvage chemotherapy, then high-dose chemotherapy and autologous stem cell rescue are often recommended for those with good performance status.

Similar to primary CNS lymphoma, the role of RT in this setting remains unclear. I would consider low-dose WBRT (23.4 Gy) in patients who achieve a complete response to HD-MTX based regimens who do not proceed to autologous SCT. Patients, especially those > age 60, need t...

This is a great question, as the dominant paradigm for radiation treatment for CNS lymphoma has historically been WBRT, often with expanded fields (inclusion of posterior globe, etc) compared to WBRT for brain metastases or other consolidation regimens.

Most of the data is confined to retrospective series which demonstrate excellent local control of treated lesions. The series published show 1 year LC for lesions refractory to prior chemo/WBRT in the 75-90% range. Obviously, out-of-field control rate is worse in this setting, but the in-field control is excellent.

There is one prospective, observational cohort study of patients receiving upfront Gamma Knife followed by chemotherapy who demonstrated no local recurrences in median f/u period an...