title: Primary CNS lymphoma in patients younger than 60: can whole-brain radiotherapy be deferred?
abstract: Whole brain radiotherapy (WBRT) has been increasingly omitted as the first treatment of primary central nervous system lymphoma (PCNSL) because of neurotoxicity risks. However, neurotoxicity risks are lower in young (<60 years) patients; deferring WBRT may not be necessary and may compromise disease control. To investigate this question, we report a consecutive series of young (<60 years) PCNSL patients uniformly treated with a response-adjusted approach, with WBRT omitted in patients with chemosensitive disease. Treatment started with induction chemotherapy consisting of methotrexate (3 g/m(2)), CCNU, procarbazine, methylprednisolone and intrathecal methotrexate, cytarabine, and methylprednisolone. Patients achieving complete response (CR) received five additional chemotherapy cycles and no further treatment. Patients with less than CR were treated on an individual basis, typically with WBRT or high-dose chemotherapy (HDC) with stem cell rescue. Sixty-four patients were included (median age: 47; median KPS: 70). Median progression-free survival (PFS) was 12 months; median overall survival (OS) was 63 months (median follow-up: 108 months). Objective response after induction was 87% (CR: 54%; PR: 33%). To date, salvage WBRT has been given to a total of 27 patients and HDC to 29. Neurotoxicity developed in five patients (none in patients treated with chemotherapy only). Deferring WBRT in chemosensitive patients seems to compromise PFS but not OS. Neurotoxicity was reduced but not eliminated, as salvage WBRT was frequently required. HDC and WBRT were effective salvage treatments. As the objective of treatment in this population is a cure, withholding WBRT may not be the best strategy and deserves further investigation. Ongoing studies are investigating whether upfront treatment with HDC can replace WBRT in this setting.
authors.affiliation: AP-HP, Groupe Hospitalier Pitie-Salpetriere, Service de Neurologie Mazarin, et Universite Pierre & Marie Curie Paris VI, Paris, France. omuroa@mskcc.org
authors.forename: Antonio
authors.initials: A
authors.lastname: Omuro
authors.forename: Luc
authors.initials: L
authors.lastname: Taillandier
authors.forename: Olivier
authors.initials: O
authors.lastname: Chinot
authors.forename: Monica
authors.initials: M
authors.lastname: Sierra Del Rio
authors.forename: Charlotte
authors.initials: C
authors.lastname: Carnin
authors.forename: Marylin
authors.initials: M
authors.lastname: Barrie
authors.forename: Carole
authors.initials: C
authors.lastname: Soussain
authors.forename: Marie-Laure
authors.initials: ML
authors.lastname: Tanguy
authors.forename: Sylvain
authors.initials: S
authors.lastname: Choquet
authors.forename: Veronique
authors.initials: V
authors.lastname: Leblond
authors.forename: Khe
authors.initials: K
authors.lastname: Hoang-Xuan
mesh_terms: D000328:Adult; D001921:Brain / Q000187:drug effects*; D016543:Central Nervous System Neoplasms / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D016001:Confidence Intervals; D018572:Disease-Free Survival; D004358:Drug Therapy / Q000379:methods; D005260:Female; D006801:Humans; D008223:Lymphoma / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011878:Radiotherapy / Q000379:methods*; D055815:Young Adult