Recent updates on central nervous system prophylaxis in patients with high-risk diffuse large B-cell lymphoma

• Published in: Experimental hematology & oncology Vol. 13; no. 1; p. 1
• Main Authors: Chua, Bernard Ji Guang, Low, Chen Ee, Yau, Chun En, Tan, Ya Hwee, Chiang, Jianbang, Chang, Esther Wei Yin, Chan, Jason Yongsheng, Poon, Eileen Yi Ling, Somasundaram, Nagavalli, Rashid, Mohamed Farid Bin Harunal, Tao, Miriam, Lim, Soon Thye, Yang, Valerie Shiwen
• Format: Journal Article
• Language: English
• Published: England BioMed Central Ltd 03.01.2024; BioMed Central; BMC
• Subjects: Adrenal glands; Central Nervous System; Chemotherapy; CNS Prophylaxis; Diffuse Large B-Cell Lymphoma; Disease prevention; Kidneys; Lymphoma; Lymphomas; Medical prognosis; Methotrexate; Nervous system; Non-Hodgkin’s Lymphoma; Practice guidelines (Medicine); Review; Vincristine; Central Nervous System; Diffuse Large B-Cell Lymphoma; Methotrexate; Non-Hodgkin’s Lymphoma; CNS Prophylaxis
• ISSN: 2162-3619; 2162-3619
• DOI: 10.1186/s40164-023-00467-2

The use of central nervous system (CNS) prophylaxis for patients with diffuse large B-cell lymphoma (DLBCL) remains controversial. Although uncommon, CNS relapses are invariably fatal in this otherwise curable disease. Accurate identification of patients at risk and the optimal approach to CNS prophylaxis therefore remains an area of unmet need. The existing literature, largely retrospective in nature, provides mixed conclusions regarding the efficacy of CNS prophylaxis. The utility of CNS prophylaxis has itself been challenged. In this review, we dissect the issues which render the value of CNS prophylaxis uncertain. We first compare international clinical guidelines for CNS prophylaxis. We then interrogate the factors that should be used to identify high-risk patients accurately. We also explore how clinical patterns of CNS relapse have changed in the pre-rituximab and rituximab era. We then discuss the efficacy of CNS-directed approaches, intensification of systemic treatment and other novel approaches in CNS prophylaxis. Improved diagnostics for early detection of CNS relapses and newer therapeutics for CNS prophylaxis are areas of active investigation. In an area where prospective, randomized studies are impracticable and lacking, guidance for the use of CNS prophylaxis will depend on rigorous statistical review of retrospective data.