Current uses of radiation therapy in patients with primary CNS lymphoma

Abstract

High-dose methotrexate (HD-MTX)-based chemotherapy is the current first-line therapy for primary CNS lymphoma. Whole-brain radiotherapy (WBRT) plays an important role in the management of primary CNS lymphoma and is indicated in patients with contraindication to chemotherapy, in patients with unusual histologic subtypes as curative treatment, as complementary therapy for patients failing to achieve complete remission after systemic chemotherapy and as salvage therapy for refractory or relapsing patients when systemic chemotherapy is no longer advisable. The two major pitfalls in WBRT use are transitory efficacy and neurotoxicity with deterioration of quality of life. Accordingly, WBRT administration as consolidation therapy in complete remission patients after first-line chemotherapy is controversial. In the present review, indications of WBRT will be outlined with emphasis on consolidation therapy, treatment-related neurotoxicity and efforts aimed at reducing toxicity.

Keywords::

• extranodal lymphoma
• neurotoxicity
• radiotherapy

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • Whole-brain radiotherapy (WBRT) has high efficacy in the treatment of primary CNS lymphomas.

• • Widely accepted uses are exclusive therapy when chemotherapy is contraindicated, complementary therapy in patients failing to achieve complete remission after high-dose methotrexate-based therapy and salvage therapy in relapsing patients after first- or further-line chemotherapies.

• • Major controversy exists in the setting of consolidation radiotherapy in patients achieving complete remission after primary chemotherapy, where clinical benefit is counterbalanced by neurotoxicity risk.

• • The precise definition of actinic neurotoxicity deserves more basic and translational research as well as specific prospective assessment with psychometric tests in clinical trials.

• • Several methods to reduce or by-pass WBRT-related neurotoxicity are proposed, none of which proved to preserve antitumoral efficacy at present.

• • In the near future, results of well-designed clinical trials addressing the precise role of WBRT in the consolidation setting are expected.