Primary CNS Lymphoma: Consolidation After Induction Chemotherapy in Fit Patients with Adequate Renal and Cardiac Function

Clinical Scenario

This protocol addresses fit patients with primary CNS lymphoma who have adequate renal function (creatinine clearance >50 ml/min), adequate hepatic function, and adequate cardiac function (left ventricular ejection fraction >45%), and who are able to tolerate intensified treatments and are suitable candidates for autologous stem cell transplantation.

Following Induction Chemotherapy

This is the consolidation step for patients who have received induction chemotherapy including high-dose methotrexate-based regimens. The induction phase aimed to achieve complete remission or partial response on gadolinium-enhanced brain MRI, assessed every two courses. Once induction response is established, this consolidation protocol applies to eligible fit patients.

Consolidation Approach — Partial Overview

For fit patients who meet the organ-function thresholds above, consolidation centres on high-dose chemotherapy combined with autologous stem cell transplantation using a thiotepa-based conditioning approach. An alternative consolidation strategy exists for fit patients who are not suitable ASCT candidates — the full protocol details the complete decision pathway.

Treatment Goal

The target is complete remission on gadolinium-enhanced brain MRI, assessed 2 months after consolidation.

Instant Access to Structured Evidence-Based Regimens

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.

HDC–ASCT is recommended as consolidation in fit patients with responsive or stable disease after suitable induction ChT.

Thiotepa-based ASCT conditioning regimens should be used. The dose of thiotepa combined with either busulfan or carmustine should be based on established protocols and informed by patient fitness and comorbidities.

Consolidation WBRT at a dose of 36–40 Gy/20 fractions is recommended in young patients who are not suitable candidates for ASCT.

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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