title: Secondary central nervous system relapse in diffuse large B cell lymphoma in a resource limited country: result from the Thailand nationwide multi-institutional registry.
abstract: Secondary central nervous system (CNS) relapse is a serious and fatal complication of diffuse large B cell lymphoma (DLBCL). Data on secondary CNS (SCNS) relapse were mostly obtained from western countries with limited data from developing countries. We analyzed the data of 2034 newly diagnosed DLBCL patients enrolled into the multi-center registry under Thai Lymphoma Study Group from setting. The incidence, September 2006 to December 2013 to represent outcome from a resource limited pattern, management, and outcome of SCNS relapse were described. The 2-year cumulative incidence (CI) of SCNS relapse was 2.7 %. A total of 729, 1024, and 281 patients were classified as low-, intermediate-, and high-risk CNS international prognostic index (CNS-IPI) with corresponding 2-year CI of SCNS relapse of 1.5, 3.1, and 4.6 %, respectively (p < 0.001). Univariate analysis demonstrated advance stage disease, poor performance status, elevated lactate dehydrogenase, presence of B symptoms, more than one extranodal organ involvement, high IPI, and high CNS-IPI group as predictive factors for SCNS relapse. Rituximab exposure and intrathecal chemoprophylaxis offered no protective effect against SCNS relapse. At the time of analysis, six patients were alive. Median OS in SCNS relapsed patients was significantly shorter than relapsed patients without CNS involvement (13.2 vs 22.6 months) (p < 0.001). Primary causes of death were progressive disease (n = 35, 63.6 %) and infection (n = 9, 16.7 %). In conclusion, although the incidence of SCNS relapse in our cohort was low, the prognosis was dismal. Prophylaxis for SCNS involvement was underused even in high-risk patients. Novel approaches for SCNS relapse prophylaxis and managements are warranted.
authors.affiliation: Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV road Pathumwan, Bangkok, Thailand. kwudhikarn@hotmail.com.
authors.forename: Kitsada
authors.identifier: http://orcid.org/0000-0001-9528-8681
authors.initials: K
authors.lastname: Wudhikarn
authors.affiliation: Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV road Pathumwan, Bangkok, Thailand.
authors.forename: Udomsak
authors.initials: U
authors.lastname: Bunworasate
authors.affiliation: Department of Internal Medicine, Prince of Songkla University, Songkhla, Thailand.
authors.forename: Jakrawadee
authors.initials: J
authors.lastname: Julamanee
authors.affiliation: Department of Internal Medicine, Prince of Songkla University, Songkhla, Thailand.
authors.forename: Arnuparp
authors.initials: A
authors.lastname: Lekhakula
authors.affiliation: Department of Internal Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
authors.forename: Suporn
authors.initials: S
authors.lastname: Chuncharunee
authors.affiliation: Department of Internal Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
authors.forename: Pimjai
authors.initials: P
authors.lastname: Niparuck
authors.affiliation: Department of Internal Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
authors.forename: Supachai
authors.initials: S
authors.lastname: Ekwattanakit
authors.affiliation: Department of Internal Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
authors.forename: Archrob
authors.initials: A
authors.lastname: Khuhapinant
authors.affiliation: Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand.
authors.forename: Lalita
authors.initials: L
authors.lastname: Norasetthada
authors.affiliation: Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand.
authors.forename: Weerasak
authors.initials: W
authors.lastname: Nawarawong
authors.affiliation: Department of Internal Medicine, Srinakharinwirot University, Nakhon Nayok, Thailand.
authors.forename: Nisa
authors.initials: N
authors.lastname: Makruasi
authors.affiliation: Department of Internal Medicine, Thammasart University, Bangkok, Thailand.
authors.forename: Nonglak
authors.initials: N
authors.lastname: Kanitsap
authors.affiliation: Department of Internal Medicine, Khon Kaen University, Khon Kaen, Thailand.
authors.forename: Chittima
authors.initials: C
authors.lastname: Sirijerachai
authors.affiliation: Department of Internal Medicine, Khon Kaen University, Khon Kaen, Thailand.
authors.forename: Kanchana
authors.initials: K
authors.lastname: Chansung
authors.affiliation: Department of Internal Medicine, Naresuan University, Phitsanulok, Thailand.
authors.forename: Peerapon
authors.initials: P
authors.lastname: Wong
authors.affiliation: Department of Internal Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand.
authors.forename: Tontanai
authors.initials: T
authors.lastname: Numbenjapon
authors.affiliation: Department of Internal Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand.
authors.forename: Kannadit
authors.initials: K
authors.lastname: Prayongratana
authors.affiliation: Department of Internal Medicine, Rajavithi Hospital, Bangkok, Thailand.
authors.forename: Tawatchai
authors.initials: T
authors.lastname: Suwanban
authors.affiliation: Department of Internal Medicine, Khonkaen Regional Hospital, Khon Kaen, Thailand.
authors.forename: Somchai
authors.initials: S
authors.lastname: Wongkhantee
authors.affiliation: Department of Internal Medicine, Chulabhorn Hospital, Bangkok, Thailand.
authors.forename: Pannee
authors.initials: P
authors.lastname: Praditsuktavorn
authors.affiliation: Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV road Pathumwan, Bangkok, Thailand.
authors.forename: Tanin
authors.initials: T
authors.lastname: Intragumtornchai
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016543:Central Nervous System Neoplasms / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy; D005260:Female; D005500:Follow-Up Studies; D006295:Health Resources / Q000639:trends; D006801:Humans; D016403:Lymphoma, Large B-Cell, Diffuse / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy; D011446:Prospective Studies; D012042:Registries; D013785:Thailand / Q000453:epidemiology; D055815:Young Adult
keywords: CNS prophylaxis; CNS-IPI; Diffuse large B cell lymphoma; Secondary CNS relapse