Q: Primary Diffuse Large B-Cell Lymphoma of the Central Nervous System
Part 3: Therapeutic Considerations and Response Assessment
The ASCO Post is pleased to present Hematology Expert Review, an occasional feature that includes a case report detailing a particular hematologic condition followed by questions. Answers to each question appear on page 84 with expert commentary.
In the November 10 issue of The ASCO Post, part 2 of a case report was published and focused on the disease burden and the prognosis of a patient with diffuse large B-cell lymphoma of the central nervous system (CNS). Here is part 3 of this case study, which focuses on therapeutic considerations and response assessment.
Summary of Case Study: A 70-year-old man with an otherwise unremarkable medical history returns for follow-up after having undergone a brain biopsy of a left frontal lesion revealing diffuse large B-cell lymphoma. Magnetic resonance imaging (MRI) had revealed involvement of deeper structures of the brain. Serum studies revealed an elevated LDH at 340 U/L. Staging workup reveals the disease is limited to the CNS (refer to part 1 of this series in the October 25 issue of The ASCO Post).
Based on his age (> 50 years old) and excellent performance status, he would be class II, with a median overall survival of 2.1–3.2 years in the Memorial Sloan Kettering Cancer Center (MSKCC) prognostic model.1 Based on his age
(> 60 years old), involvement of deep brain structures, and elevated serum LDH per the International Extranodal Lymphoma Study Group (IELSG) prognostication system, he would fall into the category with a 2-year overall survival of 48% (± 7%2; refer to part 2 of this series in the November 10 issue of The ASCO Post).
Based on the rationale for the current “standard of care” for primary diffuse large B-cell lymphoma of the CNS, what is the optimal induction therapy?
A. High-dose corticosteroids alone
B. Radiotherapy alone
C. A high-dose methotrexate–based regimen
Continued Case Study: After four cycles of induction therapy, he underwent restaging. On MRI at the site of the prior biopsy, there was a trace amount of enhancement. All of the restricted diffusion on the diffusion-weighted images had resolved. A small area of increased fluid-attenuated inversion recovery abnormality and a trace (~1 mm unidirectional measurement) amount of enhancement remained along the biopsy site. All other restaging studies, including cerebrospinal fluid cytology, ophthalmologic examination, and previously abnormal LDH, were unremarkable. The patient was off all steroids at the time of restaging.
This patient would be classified as having which of the following International Primary Central Nervous System Lymphoma Collaborative Group response criteria?
A. Partial response
B. Unconfirmed complete response
C. Complete response
Continued Case Study: According to the CALGB 50201 (Alliance 50202) protocol, our patient receives another cycle of high-dose methotrexate with temozolomide in preparation for consolidation therapy.
What is the optimal consolidation therapy for this patient?
A. High-dose chemotherapy with autologous hematopoietic rescue
B. Cytarabine followed by reduced-dose whole-brain radiotherapy
C. Evaluation in a National Cancer Institute–sponsored cooperative group phase II trial
Syed A. Abutalib, MD, Assistant Director, Hematology & Bone Marrow Transplantation Service, Cancer Treatment Centers of America, Zion, Illinois
Rimas V. Lukas, MD, Director of Medical Neuro-Oncology, Associate Professor, Department of Neurology, University of Chicago