Patients over 60 years with primary central nervous system lymphoma represent a distinct clinical population requiring a tailored treatment approach. Advancing age introduces specific risks that directly shape which therapies are appropriate and which must be avoided.
In patients over 60 years, the risk of delayed neurotoxicity following whole-brain radiotherapy (WBRT) — particularly when preceded by high-dose methotrexate — is unacceptably high. For this reason, WBRT is avoided in this age group.
The treatment is centred on HD-MTX-based chemotherapy, incorporating agents capable of crossing the blood-brain barrier — including an oral alkylating agent. The specific combination and sequencing of these agents, as well as eligibility criteria based on performance status and renal function, are detailed in the full structured regimen.
In patients >60 years, the risk of delayed neurotoxicity, after WBRT especially if following HDMTX, is unacceptably high and WBRT should be avoided in these elderly patients (Level B).
HD-MTX-based chemotherapy is feasible in elderly patients with adequate performance status and renal function (Level B).
Overall, if elderly patients are considered eligible, they should receive HD-MTX-based chemotherapy including drugs that cross the BBB such as an oral alkylating agent.
However, formal comparisons of different HD-MTX-based regimens have not been published except in a randomized phase II study, where toxicity was similar and CR rate was 53% with MPV-A (MTX, procarbazine, vincristine, and cytarabine) vs 38% for MTX and temozolomide, although the difference was not statistically significant (Class IIa).
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