Chemotherapy as first treatment for primary malignant non-Hodgkin's lymphoma of the central nervous system preliminary data

Management of primary central nervous system lymphoma

A rare tumor, primary central nervous system lymphoma can affect immunocompetent and immunocompromised patients. While sensitive to radiotherapy or chemotherapy crossing the blood-brain barrier, it often recurs. Modern treatment consists of high-dose methotrexate-based induction chemotherapy, often followed by consolidation with either radiotherapy or further chemotherapy. Neurotoxicity is however a concern with radiotherapy, especially for patients older than 60 years. The benefit of the addition of rituximab to chemotherapy is unclear. Targeted therapies and immunotherapy have been effective in some patients and are tested on a larger scale. Survival has improved in the last decade, but remains poor in older patients.

Non-Hodgkin lymphoma: the clinician's perspective--a view from the receiving end

Optimal treatment of non-Hodgkin lymphoma depends on establishing an accurate diagnosis and determining the stage or anatomic extent of the lymphoma. With this information, the treating clinician can assign the lymphoma to a subgroup characterized by expected natural history: indolent, aggressive, acute leukemia-like or viral, which generally reflects the typical behavior of the disease unmodified by treatment and indicates the urgency with which intervention must be offered. Finally, a number of special circumstances and problems posed by specific lymphomas must be anticipated and the therapeutic plan altered to accommodate them. After primary treatment, special secondary events such as transformation to more aggressive histologic types must be recognized and the treatment plan must be altered to address these events. This article reviews standard diagnostic grouping of lymphomas, special problems encountered during primary diagnosis and subsequent clinical evolution and emphasizes the cooperative interaction between the hematopathologist and the treating clinician that underlies optimal management.

Preliminary individual adjuvant chemotherapy for primary central nervous system lymphomas based on the expression of drug-resistance genes

Individual adjuvant chemotherapy based on the expression of drug-resistance genes by reverse transcription-polymerase chain reaction (RT-PCR) was applied for the treatment of patients with primary central nervous system lymphoma (PCNSL). Three patients were included in this study. The drug-resistance genes were investigated in tumor tissues by RT-PCR with the specific primers for MDR-1, MRP-1, MRP-2, MXR-1, MGMT, GST-pei, and topoisomerase II alpha. We selected proper anticancer agents based on mRNA expression of these drug-resistance genes. In case 1, RT-PCR showed overexpression of MDR-1, MRP-1, MGMT, and topoisomerase II alpha mRNA, whereas neither MRP-2, MXR-1, nor GST-pei was expressed. The patient was given high-dose methotrexate (HD-MTX) for the first cycle of treatment; however, the reduced tumor showed regrowth before the second cycle of treatment, and therefore the patient was given carboplatin, mitoxantrone, and HD-MTX in the second and third cycles. Finally, magnetic resonance (MR) images showed a complete response. The other two cases showed similar patterns of drug-resistance gene expression, such that mRNAs of MRP-2, MXR-1, MGMT, GST-pei, and topoisomerase II alpha were overexpressed, whereas neither MDR-1 nor MRP-1 was expressed. They were successfully treated with combined HD-MTX and CHOP (cyclophosphamide, doxorubicin, vincristine, and predonsone). Our preliminary trial of individual adjuvant chemotherapy based on RT-PCR suggested that it was an effective and beneficial therapy for PCNSL. Although HD-MTX therapy is supposed to be effective for patients with MDR-1-negative PCNSL, MTX alone should be avoided in the choice of the anticancer drug for the treatment of MDR-1-positive PCNSL.

Treatment of primary CNS lymphoma with methotrexate and deferred radiotherapy: a report of NABTT 96-07

PURPOSE

A multicenter, phase II study of single-agent, intravenous methotrexate in newly diagnosed non-AIDS-related primary CNS lymphoma was conducted in the New Approaches to Brain Tumor Therapy (NABTT) CNS Consortium.

METHODS

Methotrexate (8 g/m(2)) was initially administered every 2 weeks. The primary end point was radiographic CR or PR, as defined by standard radiographic criteria, and secondary end points were survival and drug-related toxicity.

RESULTS

Twenty-five patients were enrolled with a mean age of 60 years and median Karnofsky Performance Score of 80. Three of 14 patients who underwent lumbar puncture had malignant cells on CSF cytopathology, and five of 25 patients had ocular involvement. Two patients could not be evaluated for the primary end point because of the absence of measurable disease in one and death before radiologic imaging in another. All patients have completed the treatment program or progressed. Among 23 patients, there were 12 CR (52%), five PR (22%), one (4%) with stable disease, and five progressions (22%) while on therapy. Seven patients died of tumor progression, and two died of other causes. Median progression-free survival was 12.8 months. Median overall survival for the entire group had not been reached at 22.8+ months. The toxicity of this regimen was modest, with no grade 3 or 4 toxicity in 13 of 25 patients, grade 3 toxicity in eight of 25 patients, and grade 4 toxicity in four of 25 patients after 287 cycles of chemotherapy.

CONCLUSION

These results indicate that high-dose methotrexate is associated with modest toxicity and a radiographic response proportion (74%) comparable to more toxic regimens.

Importance of radiotherapy in the outcome of patients with primary CNS lymphoma: an analysis of the CHOD/BVAM regimen followed by two different radiotherapy treatments

PURPOSE

To assess the effect of a reduced dose of radiotherapy (RT) in patients with primary CNS lymphoma (PCNSL) responding to the cyclophosphamide, doxorubicin, vincristine, and dexamethasone (CHOD)/carmustine, vincristine, methotrexate, and cytarabine (BVAM) regimen.

PATIENTS AND METHODS

Patients received one cycle of CHOD and two of BVAM. In the first trial, all 31 patients received 45-Gy whole-brain RT (CHOD/BVAM I). In the second, with 26 patients, RT dose was reduced to 30.6 Gy if there was a complete response (CR) after chemotherapy (CHOD/BVAM II).

RESULTS

Age, performance status, and chemotherapy received were similar in both protocols. CR rate at the end of all treatment was 68% for CHOD/BVAM I and 77% and for CHOD/BVAM II. Treatment modality was the only predictor of relapse, with 3-year relapse risks of 29% and 70% for CHOD/BVAM I and II, respectively. This was specifically important in the 25 patients less than 60 years old (3-year relapse risk, 25% v 83%; P =.01). The 5-year overall survival (OS) was 36%. Age (< 60 v > or = 60 years) was the only predictor for OS in the multivariate analysis (relative risk, 2.1; 95% confidence interval, 1.4 to 2.8). RT dose was the only predictor of OS in patients younger than 60 years old who achieved CR at the end of all treatment (3-year OS, 92% v 60% for patients receiving 45 or 30.6 Gy, respectively; P =.04).

CONCLUSION

Reduction of the RT dose from 45 Gy to 30.6 Gy in patients younger than 60 years old with PCNSL who achieved CR resulted in an increased risk of relapse and lower OS.

Therapeutic management of primary CNS lymphoma in immunocompetent patients

The best therapeutic management in primary CNS lymphomas remains to be defined because of the small size and short follow-up of retrospective series, the methodological pitfalls and limited number of prospective studies, and the paucity of randomized trials. The purpose of this article is to analyze, discuss and summarize the current therapeutic approaches, namely chemotherapy or radiotherapy as exclusive treatment, combined treatment, most commonly used drugs, intrathecal chemotherapy and consolidation radiotherapy and to provide recommendations for ordinary clinical practice. Some important therapeutic issues such as the management of intraocular lymphomas, elderly patients and patients without histological diagnosis, as well as the relevance of salvage therapy as a playground for the evaluation of new drugs are also analyzed. Finally, the main open questions as well as current and expected investigation trends are discussed.

Clinical relevance of consolidation radiotherapy and other main therapeutic issues in primary central nervous system lymphomas treated with upfront high-dose methotrexate

PURPOSE

To evaluate the optimal dose of methotrexate (MTX) and the efficacy of other drugs, intrathecal chemotherapy (CHT), and radiotherapy (RT) in primary brain lymphomas.

METHODS AND MATERIALS

Two hundred eighty-eight immunocompetent patients with histologically documented, previously untreated primary brain lymphomas, receiving CHT containing high-dose MTX (> or =1 g/m(2)) with or without RT were selected from 19 prospective series. The impact on survival of the MTX dose (<3 g/m(2) vs.> or =3 g/m(2)), the main drugs, intrathecal CHT, and combination CHT (mono-CHT vs. poly-CHT) was assessed, according to the intention-to-treat principle. The role of post-CHT irradiation (immediate vs. delayed RT) was evaluated in 119 patients with a complete response to CHT. The whole brain and tumor bed dose (<40 Gy vs. > or =40 Gy) was assessed in 70 irradiated complete responders.

RESULTS

No difference in overall survival (OS) was detected between mono-CHT and combination CHT (p = 0.38). MTX > or =3 g/m(2) (p = 0.04), thiotepa (p = 0.03), and intrathecal CHT (p = 0.03) improved the OS, and nitrosoureas (p = 0.01) correlated with a worse survival. In multivariate analysis, limited to patients receiving MTX > or =3 g/m(2), only the addition of cytarabine improved the OS; nitrosoureas reduced MTX efficacy. Of the 119 complete responders, 70 received immediate RT. A RT dose of > or =40 Gy to the whole brain or tumor bed did not improve OS. The 3-year OS was similar between the immediate and delayed RT groups. In multivariate analysis, RT delay had no negative impact on survival.

CONCLUSIONS

MTX > or =3 g/m(2) seems to improve survival in primary brain lymphoma patients. The efficacy of additional drugs, except for cytarabine, remains unproved. Randomized trials are needed to confirm that RT withdrawal yields no detrimental effect in complete responders.

Primary nervous-system lymphoma

Primary nervous-system lymphoma is a rare type of non-Hodgkin lymphoma, which is confined to the nervous system. This disease is managed quite differently from the usual treatment of either primary brain tumours or systemic non-Hodgkin lymphoma. Although whole-brain radiotherapy results in responses in more than 90% of cases, this treatment is associated with high relapse rates and with delayed neurotoxicity in elderly patients. First-generation chemotherapy regimens used successfully in systemic non-Hodgkin lymphoma (eg cyclo-phosphamide, adriamycin, vincristine, and prednisone) are ineffective in primary nervous-system lymphoma, partly because of the blood-brain barrier. Median survival of patients treated with radiotherapy alone or chemotherapy plus radiotherapy is similar, and ranges from 10 to 16 months. The addition of methotrexate-based chemotherapy has improved survival for these patients, extending median survival to more than 30 months. When used alone, methotrexate-based chemotherapy is associated with significantly fewer treatment-associated toxic effects. Leptomeningeal lymphoma and intraocular lymphoma are topics of particular relevance in primary nervous-system lymphoma and are addressed in this review.

CHOD/BVAM regimen plus radiotherapy in patients with primary CNS non-Hodgkin's lymphoma

PURPOSE

To assess the efficacy and toxicity, including long-term neurotoxicity, of combined therapy with the CHOD/BVAM regimen given before cranial radiotherapy in the treatment of primary CNS lymphoma (PCNSL).

METHODS AND MATERIALS

Thirty-one consecutive patients with PCNSL were treated with one cycle of cyclophosphamide, doxorubicin, vincristine, and dexamethasone (CHOD) and two of carmustine (BCNU), vincristine, cytosine arabinoside, and methotrexate (BVAM), followed by cranial radiotherapy (45 Gy whole brain plus a 10-Gy boost for single lesions). The median age was 59 years (range 21-70) and 39% had poor performance status. The median follow-up of patients was 4.1 years (range 2.7-9.0).

RESULTS

Twenty-one patients had no PCNSL at the end of treatment. The 5-year actuarial probability of survival was 31% (95% confidence interval [CI]: 11%-57%), with a median survival of 38 months. Patients < 60 years had a survival significantly longer than those > or = 60 years (4-year survival: 58% (95% CI: 34-82%) vs. 29% (95% CI: 5-53%), respectively; p = 0.04). Two patients died during chemotherapy from pulmonary embolism and bronchopneumonia, respectively, with no evidence of PCNSL at the autopsy. Dementia probably related to treatment occurred in 5 (62%) of the 8 patients 60 years and older, and 4 of them died without evidence of relapse of PCNSL. Dementia correlated with developing brain atrophy and leuco-encephalopathy on serial CT or MR scans.

CONCLUSION

This regimen can be given with the planned dose intensity to patients aged less than 70 years, and produces better survival than that reported with radiotherapy alone; however, dementia occurs in the majority of patients aged 60 years of age or more.

Advances in the therapy of primary central nervous system lymphoma

Primary central nervous system lymphoma (PCNSL) is a rare type of non-Hodgkin's lymphoma (NHL) confined to the nervous system. The management of PCNSL is quite different from the usual treatment of either primary brain tumors or systemic NHL. First-generation chemotherapy regimens used successfully in systemic NHL are ineffective in PCNSL, in large part due to the existence of the blood-brain barrier. Whole-brain radiation therapy (WBRT) results in high response rates but rapid relapse, and this treatment is associated with delayed neurotoxicity in patients with PCNSL. The addition of methotrexate-based chemotherapy has improved survival and lessened toxicity for this patient population. Fundamental issues that remain unresolved in PCNSL include identification of the optimal chemotherapy regimen for newly diagnosed and relapsed PCNSL, the role of WBRT and intrathecal chemotherapy in the treatment of PCNSL, and the optimal management of intraocular lymphoma. Finally, the optimal clinical study design for this rare disease has yet to be defined and implemented.

Therapeutic management of primary central nervous system lymphoma: lessons from prospective trials

Primary central nervous system lymphomas (PCNSL) are aggressive malignancies, exhibiting one of the worst prognoses among lymphomas. The best treatment modality for PCNSL has not yet been identified. Several therapeutic questions still remain unanswered, and some methodological pitfalls in clinical trials prevent definitive conclusions from being drawn. In this review, certain aspects of trial design as well as emerging therapeutic guidelines are analyzed, and future perspectives are discussed. In the vast majority of prospective trials, general criteria for treatment of aggressive lymphomas were adopted, choosing primary chemotherapy (CHT) followed by radiotherapy (RT) as therapeutic modality. This strategy produced a five-year survival of 22%- 40% in comparison to the 3%-26% reported with RT alone. Systemic high-dose methotrexate (HD-MTX) seems to be the most effective drug, producing a response rate of 80%-90% and a two-year survival of 60%-65%. To date, the addition of other drugs at conventional doses have not consistently improved outcome. With a few exceptions, any regimen without HD-MTX comprehensively performed no better than RT alone. In combined treatment. RT doses should be decided on the bases of response to primary CHT and the number of lesions, and, until definitive conclusions from well-designed trials are available, RT parameters should follow the widely accepted principles used for other aggressive lymphomas. CHT as exclusive treatment, keeping RT for relapses or persistent disease, appears to be an attractive strategy. However, the worldwide experience with this modality is still limited, and corroborating data are needed. Intrathecal CHT still has not found a defined role in PCNSL management. Preliminary data seem to indicate that adequate meningeal treatment with HD-MTX, but without intrathecal CHT, could also be suitable in positive-cerebrospinal fluid patients. Future efforts should be addressed to identify new active drugs and more efficient CHT combinations, to evaluate the efficacy of high-dose CHT supported by autologous peripheral blood stem cells transplantation, and to clarify the impact of RT delay in complete responders, the usefulness of intrathecal CHT, and the best management for elderly patients. The assessment of impact of treatment on neuropsychological functions and quality of life is a mandatory endpoint in clinical trials.

Phase II multicenter study of brief single-agent methotrexate followed by irradiation in primary CNS lymphoma

PURPOSE

To assess, in a multi-institutional setting, the impact on relapse, survival, and toxicity of adding two cycles of intravenous methotrexate to cranial irradiation for immunocompetent patients with primary CNS lymphoma.

PATIENTS AND METHODS

Forty-six patients with a median age of 58 years and Eastern Cooperative Oncology Group performance status 0 to 3 were entered onto this phase II study. The protocol consisted of methotrexate 1 g/m(2) on days 1 and 8 followed by cranial irradiation on day 15. A whole-brain dose of 45 Gy was followed by a boost of 5.4 Gy. Intrathecal chemotherapy and spinal irradiation were given only to patients for whom cytologic examination of CSF was positive for CNS lymphoma. The median follow-up time was 36 months, with a minimum potential follow-up of 12 months.

RESULTS

Median survival was 33 months, with 2-year probability of survival 62% +/- 15% (95% confidence interval). Twenty patients have relapsed. The predominant site of relapse was the brain. Neither performance status nor age was found to influence survival. Six patients developed a dementing illness at a median of 16 months after treatment, and three of these died as a consequence.

CONCLUSION

A brief course of intravenous methotrexate before cranial irradiation is associated with 2-year and median survival rates superior to those reported for radiotherapy alone and similar to more intensive combined-modality regimens. Neurotoxicity remains an important competing risk for these patients.

Rapid infusion of high-dose methotrexate resulting in enhanced penetration into cerebrospinal fluid and intensified tumor response in primary central nervous system lymphomas

OBJECT

Twenty-nine nonimmunocompromised patients with primary central nervous system (CNS) lymphoma were treated with high-dose methotrexate (MTX) therapy followed by irradiation. The authors investigated the correlation of infusion schedules with MTX penetration into cerebrospinal fluid (CSF), tumor response, and survival to develop a regimen that would lead to better clinical results.

METHODS

In this study, 100 mg/kg MTX was administered on either a rapid (3-hour) or regular (6-hour) infusion schedule for two or three cycles. Of 28 assessable patients, a complete or partial response was achieved in 15 (93.8%) of 16 who received rapid and in seven (58.3%) of 12 who received regular infusion therapy (p = 0.034). Rapid infusion significantly increased levels of MTX in the CSF (p < 0.001) and resulted in significant tumor volume reduction (p < 0.001). The mean tumor volume after the first, second, and third cycle of rapid infusion therapy was reduced to 34%, 14%, and 9%, respectively, of the initial volume, whereas the corresponding values were 54%, 42%, and 37% for regular infusion. The reduction between the second and third cycle was small and not significant for either schedule. Despite the longer median survival time in patients who underwent rapid MTX infusion and irradiation (> 60 compared with 20 months), the difference in survival was not significant (p = 0.147) because of the small number of patients enrolled. The median survival time was 39.3 months for all assessable patients who received high-dose MTX and radiation therapy, and the median relapse-free survival time was 35.2 months.

CONCLUSIONS

Rapid infusion enhanced both MTX penetration into the CSF and tumor response and may improve patient survival. Administration of three or more cycles of therapy should be carefully weighed in terms of cytoreductive benefits.

Intravitreal chemotherapy for the treatment of recurrent intraocular lymphoma

AIM

To develop and assess a protocol for the treatment of intraocular lymphoma by intravitreal injection of methotrexate and thiotepa.

METHODS

A patient with intraocular non-Hodgkin's lymphoma which recurred after radiotherapy and repeated systemic chemotherapeutic regimens underwent repeated intravitreal injections of methotrexate and thiotepa. The patient was closely monitored by cytology, anterior chamber flare measurements, IL-10 and IL-6 levels. Methotrexate drug clearance studies were performed on vitreous samples taken before each injection.

RESULTS

Complete tumour clearance was achieved by the third week of therapy. IL-10 and IL-6 levels quickly dropped to barely detectable levels as the tumour was cleared from the eye. Flare measurements decreased from 500 to 15 photons/s over the same time. A plot of the methotrexate levels over time revealed a first order kinetic rate of elimination with an effective tumoricidal intravitreal dose persisting for 5 days after injection.

CONCLUSION

Intravitreal chemotherapy for the treatment of recurrent intraocular lymphoma appears effective in prolonging local remission of ocular disease even in the presence of an aggressively growing tumour. A single intravitreal injection of methotrexate can lead to a prolonged tumoricidal concentration lasting for a longer period than that achieved by systemic administration.

Second-line treatment for primary central nervous system lymphoma

Failure after first-line treatment was reported in 35-60% of immunocompetent patients with primary central nervous system lymphoma (PCNSL). There are currently no reports focusing on salvage therapy. This review analyses prognostic factors and the efficacy of salvage therapy by focusing on data from papers reporting results of first-line treatment in 355 cases. The study group consisted of 173 patients presenting treatment failure. The interval between failure and death (TTD) was compared for age at relapse (< or =60 vs. >60 years), type of failure (relapse vs. progression), time to relapse (< or =12 vs. >12 months) and salvage treatment (yes vs no). Median TTD was similar in younger and older patients (P = 0.09). Relapsed patients had a longer TTD than patients with progressive disease (P = 0.002). Early relapse led to a shorter TTD than late relapse (P = 0.005). Median TTD was 14 months for patients who underwent salvage therapy and 2 months for untreated cases (P<0.00001). A multivariate analysis showed an independent prognostic role for salvage therapy and time to relapse. Age and type of failure had no predictive value. Salvage therapy significantly improves outcome and, possibly, quality of life. As many different treatments were used conclusions cannot be made regarding an optimal treatment schedule.

Therapeutic management of primary central nervous system lymphoma in immunocompetent patients: results of a critical review of the literature

BACKGROUND

The optimal treatment for primary central nervous system lymphomas (PCNSL) has not been defined.

PATIENTS AND METHODS

Therapeutic results of 1180 immunocompetent patients (pts) with PCNSL reported in 50 series published in English between 1980 and 1995 were analysed. The impact on survival of age, treatment strategy, radiation field and doses, systemic and intrathecal chemotherapy (CHT) and treatment sequence was evaluated.

RESULTS

Univariate analyses showed a longer survival in pts of < or = 60 years (P < 0.00001): pts treated with > 40 Gy to whole brain (WB) (P = 0.02): pts receiving > 50 Gy to the tumor bed after a WB dose > 40 Gy (P = 0.02): pts submitted to a combined treatment as opposed to CHT alone (P = 0.007) or radiotherapy alone (P < 0.00001): pts receiving CHT followed by radiotherapy rather than in the reverse sequence (P = 0.05); pts treated with high-dose methotrexate (HDMTX) (P = 0.04) and pts receiving intrathecal CHT (P = 0.03). Multivariate analysis confirmed the independent prognostic value of age, WB dose, HD-MTX and intrathecal CHT.

CONCLUSIONS

Current data confirm the prognostic value of age and appear to support the use of systemic CHT consisting of HD-MTX and intrathecal drug administration followed by 41-50 Gy to WB and > 50 Gy to the tumor bed in the treatment of PCNSL in immunocompetent pts.

Glucocorticoid-induced long-term remission in primary cerebral lymphoma: case report and review of the literature

We report a 25-year old immunocompetent woman with a high grade primary non-Hodgkin's lymphoma of the central nervous system (PNHL-CNS) in whom the administration of dexamethasone alone during three months produced a complete clinical and radiological response lasting over four years. If complete remission of PNHL-CNS induced by glucocorticoids are well known, the opportunity to observe glucocorticoid-induced remission for a long period of time without radio- and chemotherapy is rare. Only nine other cases of PNHL-CNS with complete remission induced by glucocorticoids lasting from 6 to 60 months, were found in the literature and are summarized here. Duration of glucocorticoids therapeutic effect in PNHL-CNS is probably underestimated. Glucocorticoids cannot be recommended as sole initial treatment for PNHL-CNS. However, we suggest standard therapies to be delayed in those patients responding completely to glucocorticoids where radio- and chemotherapy should be contraindicated (kidney, liver, bone marrow failure, pregnancy).

Primary cerebral non-Hodgkin's lymphoma (PCNSL): a review of new trends in management

Primary central nervous system lymphoma (PCNSL) is a rare tumor but it is rising in incidence in both AIDS and non AIDS populations. It is a non-Hodgkin's lymphoma that usually presents itself as a brain tumor, but leptomeninges, eyes and also spinal cord are frequently affected. The management of PCNSL patients has evolved in the last years. The role of surgery has been restricted for diagnosis only because the exeresis of the tumor is ineffective owing to its multifocal and infiltrative nature. Therefore, stereotactic biopsy is the way of choice for documenting the diagnosis. The standard treatment was radiotherapy started after diagnosis and followed by chemotherapy at recurrence. PCNSL is radiosensitive and chemosensitive: about 70% of patients respond to one or other of these treatment modalities but usually PCNSL recurs locally after radiotherapy. More recently the inclusion of high doses ARA-C and Methotrexate delivered prior radiotherapy have shown significant high responses and prolonged survivals.

Importance of complete staging in non-Hodgkin's lymphoma presenting as a cerebral mass lesion

BACKGROUND

The high incidence of local failure and the lack of evidence of systemic dissemination of primary central nervous system lymphoma (PCNSL) has led some authors to conclude that complete staging with extensive tests is not necessary in patients with a lymphomatous cerebral mass who present with a focal neural syndrome. Moreover, De Angelis emphasizes that there is no report in the literature of systemic lymphoma presenting as a cerebral mass lesion, whereas others conclude that an extensive systemic evaluation is unnecessary or that the staging should be limited to physical examination, routine blood studies, and a chest radiography.

METHODS

In 16 PCNSL patients observed between 1982 and 1992, we found two patients showing systemic involvement of lymphoma after staging workup with chest X-ray, total body computerized tomographic (CT) scan, cerebrospinal fluid cytology examination, and bone marrow biopsy. In one patient, a CT abdominal scan showed retroperitoneal and pelvic lymphonodal involvement, whereas in the second patient, bone marrow biopsy was positive. These systemic onsets were found no later than 2 months after the diagnosis of central nervous system involvement, which is sufficient time to conclude that these locations were present at the diagnosis of the cerebral mass.

RESULTS

In the present study, complete staging demonstrated widespread dissemination (lymph nodes or bone marrow) in two patients with initial neurologic symptoms and a cerebral mass lesion.

CONCLUSIONS

In our experience, complete staging allowed detection of systemic lymphoma in two patients initially considered to have PCNSL.