Background and treatment

Question 1

What is the most common histology?

Answer 1

DLBCL 80-85%

Question 2

What are the risk factors?

Answer 2

AIDs with CD4 count <50

Question 3

What elements of the history do you want to evaluate?

Answer 3

Hx: Headache, fatigue, ataxia, focal neurologic deficits, memory loss, changes in speech, mental status change, seizures, changes in vision, floaters, painful red eyes

Question 4

What imaging is needed?

Answer 4

MRI of brain 
CT scan of head
CT scan of chest/abdomen/pelvis 
Testicular US in men 
MRI of spine if symptomatic, or LP is positive

Question 5

What special study is needed at work up?

Answer 5

Slit-lamp exam

Question 6

What labs are needed at work up?

Answer 6

HIV

CBC, BMP

Question 7

What tissue diagnosis is needed at work up?

Answer 7

1. LP and vitreous biopsy (if eye exam is abnormal) if positive, stop
2. Stereotactic brain biopsy

Question 8

What are the MSKCC prognostic model?

Answer 8

Class I: < 50 years old
Class 2: More than 50 and KPS 70 or higher
Class 3: Age 50 ore more and KPS < 70

Question 9

What is the treatment paradigm for patients < 60 years old?

Answer 9

Steroids 4 mg QID
5 biweekly cycles of High dose MTX with rapid infusion: 3 g/m2 over 3 hours combined with Procarbazine, Vincristine

if less than a CR give two more cycles.

Start RT 3-5 weeks after chemo
if CR: whole brain RT to 23.8 Gy at 1.8 Gy/fx
if PR: whole brain RT to 45 Gy at 1.8 Gy/fx

2 cycles of cytarabine 3 gm/m2/day for 2 days. 2nd dose given a month later.

Question 10

What study supports the addition of high dose cytarabine with MTX?

Answer 10

Ferreri et al 2009

MTX
vs.
MTX + Cytarabine

CR rate 18% vs. 46%, p=S
OS also improved with Cytarabine +MTX

Question 11

What is median OS and 5 year OS for patients treated with WBRT alone?

Answer 11

5 year OS: < 5%

Median OS: 10-18 months

Question 12

What are the neurologic consequences of radiation?

Answer 12

1. Memory impairment
2. Attention deficit
3. Treatment related dementia
4. Gait changes
5. Urinary incontinence

Question 13

What imaging changes correlate to the neurologic consequences of RT?

Answer 13

MRI

Confluent diffuse white matter changes and later subcortical atrophy

Question 14

What is the treatment paradigm for patients older 60 years old?

Answer 14

Steroids 4 mg QID
5 biweekly cycles of high dose MTX with rapid infusion: 3 g/m2 over 3 hours. + Vincristine and Procarbazine.
if CR: observe and reserve WBRT until relaspe
if PR: whole brain RT to 45 Gy at 1.8 Gy/fx

Question 15

What is the median OS and 2 year OS for patients managed with WBRT and chemo? For patients who had a CR the chemo?

Answer 15

Median: 40 months
2 years: 67%

if CR to chemo
2 year OS: 89%
2 year PFS: 79%

Question 16

Median age? Range?

Answer 16

60

range: 45 to 70

Question 17

What are the imaging characteristics of CNS lymphoma?

Answer 17

1. T1 enhancement
2. Periventricular involving the deep subcortical structures including the basal ganglia, thalamus, corpus callosum
3. 25% are multifocal

Question 18

What is the virchow-robin space?

Answer 18

Perivascular space, connected to the subarachnoid space, surrounds vessels entering the brain

Question 19

What is the median OS for untreated lesions?

Answer 19

1.5 months

Question 20

What did the MSK study (Gavrilovic et al) show?

Answer 20

Median OS was 51 months with MTX+vincristine and WBRT to 45 Gy overall

OS for patients older than 60 treated with WBRT and Chemo was 0%. 75% experienced neurotoxicity.

Only 12% of patients with chemo only who were older than 60 experienced neurotoxicity.

For patients younger than 60, OS was 68%. Neurotoxicity was 26%.

Question 21

What does the whole brain field include?

Answer 21

Brain and eyes with shielding of the anterior chamber and lens. Shield eyes after 36 Gy.

Question 22

What study promotes the use of reduced dose RT?

Answer 22

Shah et al 2007 MSK

R-MPV x 5 cycles +/- 2 depending on CR status followed by WBRT to 23.8 Gy if CR was achieved.

No neurologic toxicity among patients given 23.4 Gy