Treatment of Primary CNS Lymphoma with Adequate Renal Function and Left Ventricular Ejection Fraction >45%
This first-line protocol addresses primary central nervous system lymphoma in patients who have adequate renal, hepatic, and cardiac organ function and are eligible for intensified chemotherapy and autologous stem cell transplantation.
Patient Eligibility
- Adequate renal function — creatinine clearance >50 ml/min
- Adequate hepatic function
- Adequate cardiac function — left ventricular ejection fraction >45%
- Able to tolerate intensified treatment regimens
- Suitable candidate for autologous stem cell transplantation
Eligibility is informed by performance status, organ function, comorbidities, and frailty — not age alone.
Treatment Approach
Treatment is built around induction chemotherapy anchored by high-dose methotrexate combined with additional cytotoxic agents capable of crossing the blood–brain barrier.
Treatment Goal
The aim is to achieve complete remission or partial response, assessed by gadolinium-enhanced brain MRI every two courses during induction.
References
DOI: 10.1016/j.annonc.2023.11.010
- Moreover, the use of high-dose (HD) methotrexate (MTX), the most important component of chemotherapy (ChT) regimens used as first-line treatment, requires suitable renal (creatinine clearance >50 ml/min), hepatic and cardiac (left ventricular ejection fraction >45%) functions.
- Accordingly, stratification between ‘young’ and ‘elderly’ patients should not be made considering exclusively the patient’s age but also the ability to tolerate intensified treatments, informed by performance status (PS), organ function, comorbidities and frailty.
- When a prospective trial is not available, induction ChT including HD-MTX is recommended at a minimum dose of 3 g/m² delivered in a 3-h infusion.
- Combinations of HD-MTX with other cytotoxic agents that cross the blood–brain barrier and have been tested in prospective (preferably randomised) trials are recommended.
- Response to treatment should follow IPCG criteria: gadolinium-enhanced MRI of the brain should be carried out every two courses during induction ChT and 2 months after consolidation, and compared with baseline MRI, with the addition of ocular and CSF exams if involved at baseline.
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