Analyzing Patient Selection and the Utility of CNS Prophylaxis for Patients With DLBCL

At the 2023 Great Debates & Updates in Hematologic Malignancies conference in New York, New York, Elizabeth A. Brem, MD, University of California, Irvine, California analyzed patient selection and the role of central nervous system (CNS) prophylaxis for patients with diffuse large B-cell lymphoma (DLBCL). She discussed this topic with Adam J. Olszewski, MD, Brown University, Providence, Rhode Island.

Transcript: 

I'm Liz Brem from the University of California Irvine, and I am here at the Great Debates and Updates in Hematologic Malignancies in New York City.

My job today was to debate whether or not there was a role for CNS prophylaxis for patients with diffuse large B-cell lymphoma. I think at the end of the day, actually, my colleague and I, even though we were arguing different points, actually agree on a lot of things. Obviously all the data is retrospective. What we really need is good prospective data and probably a huge part of what we need are just better biomarkers to select patients.

Certainly in some studies, it seems like the CNS-IPI [International Prognostic Index], which is the best tool we have for now, works fairly well. But in others, it didn't really seem like it was selecting patients the way we'd like it to. And as my colleague pointed out, about 50% of the patients that ultimately relapsed in the CNS did not have a high CNS-IPI.

I went through a lot of the data that's available. In particular, the large retrospective data sets, most of which suggests that whether you do IV high-dose methotrexate or IT prophylaxis, the rates of CNS relapse are about the same. And it may be that for the majority of patients, they don't greatly benefit from any sort of CNS prophylaxis.

I think what we could learn from this is that maybe we need to select patients better. Maybe, at the end of the day, what the problem is, is what we're using as CNS prophylaxis. Maybe IV methotrexate, IT methotrexate isn't the best answer. Whether it's [instead], as my colleague argued, maybe a combination chemotherapy, or some sort of novel agent that crosses the blood-brain barrier.

Source:

Brem, E. Debate - CNS Prophylaxis in Aggressive Lymphoma - Futile. Presented at Great Debates & Updates in Hematologic Malignancies Conference; April 13-15, 2023; New York, NY.