CNS Lymphoma

Question 1

RT vs. ASCT

Answer 1

IESLG-32: WBRT and ACST are both effective. PFS and toxicity outcomes seem to favor WBRT.

Newly-diagnosed, HIV negative PCNSL
“MC vs. R-MC vs. R-MTC →
36 Gy WBRT (+9 Gy for PR)
vs. carmustine thiopeta ASCT”

“Results for WBRT vs. ASCT:
2-yr PFS 80% vs. 69% (p=0.17)
With ASCT, more heme toxicity and 2 infectious deaths”

Question 2

Omission of RT?

Answer 2

G-PCNSL-SG-1: Omission of RT was not noninferior to WBRT. Per protocol PFS outcomes seemed to favor WBRT. OS was similar.

Newly-diagnosed, immunocompetent PCNSL

"MTX+ifosphamide →
→WBRT 45 Gy 
vs. 
→no RT 
(Cytarabine given for PR with no RT)"

"WBRT vs. no RT
Results not noninferior
Per protocol PFS from last MTX 25.5 vs. 12 mos (SS)
Per protocol PFS 18.2 vs. 11.9 mos (NS)
ITT PFS from last MTX 19.9 vs. 11.9 mos
ITT PFS 15.4 vs. 9.9 mos
Per protocol median OS ~ 36 mos (NS)"

Question 3

ChemoRT

Answer 3

RTOG 9310: Chemo with WBRT has favorable outcomes but risk of severe neurotoxicity.

Phase II: MPV (MTX, procarbazine, vincristine, IT MTX) x5 → WBRT 45 Gy → Ara-C

CR 58%, median PFS 24 mos, median OS 37 mos. Severe delayed neurotoxicity in 15%. Increased risk in age >60

Question 4

Decreased RT, TMZ?

Answer 4

NRG RTOG 0227: This regimen has improved outcomes compared to RTOG 9310.

Phase I and II. Phase II portion: R/ MTX/ LV/ TMZ → WBRT 36 Gy/1.2 Gy BID → TMZ x36 wks

“2-yr OS 80.8% and 2-yr PFS 63.6%
ORR 85.7%”