Central nervous system relapse in patients with diffuse large B-cell lymphoma: analysis of incidence and prognostic factors

Improved method to stratify lymphoma patients with risk of secondary central nervous system involvement: A multicenter retrospective analysis

Secondary central nervous system (SCNS) involvement is an infrequent but universally fatal event in diffused large B-cell lymphoma. The occurrence rate of SCNS involvement is approximately 5% but comes with a poor prognosis ever after. However, existing risk models to predict the incidence and prognosis of these patients with SCNS involvement lack both efficiency and accuracy. Controversy has also been reported regarding which risk factor may best identify the population with a high CNS relapse rate. In this study, we retrospectively analyzed 831 patients with diffused large B-cell lymphoma, diagnosed between March 2008 and June 2018 in Tianjin Medical University Cancer Institute and Hospital, Beijing Cancer Hospital, and Cancer Hospital of The University of Chinese Academy of Science. Risk factors and nomogram were identified and established based on Fine and Gray's competing risk analysis. Among these patients, 55 (6.6%) of them eventually developed SCNS involvement. The 1- and 2-year incidence for SCNS involvement were 3.9% and 4.7%, respectively. The median time from de novo diagnosis to CNS relapse was 8 months, and the median overall survival of these patients was 28 months. Considering the competing mortality before SCNS involvement, Fine and Gray's competing risk model was performed to analyze the characteristics related to SCNS involvement, and identified risk factors as the multiple extranodal involvements, elevated LDH and AMC level, and the involvement of breast, adrenal gland/kidney, pulmonary and bone. Corresponding factors were integrated into the competing nomogram for SCNS involvement (c-index = 0.778). In conclusion, we present the first predictive nomogram to evaluate the risk to develop SCNS involvement in de novo DLBCL patients, which may help in both prognostic evaluation and clinical decision for this subgroup.

Advances in risk assessment and prophylaxis for central nervous system relapse in diffuse large B-cell lymphoma

Central nervous sytem recurrence of diffuse large B-cell lymphoma is an uncommon but devastating event, making identification of patients at high risk for relapse within the central nervous system essential for clinicians. Modern risk stratification includes both clinical and biological features. A validated clinical risk model employing the five traditional International Prognostic Index risk factors plus renal or adrenal involvement can identify a high-risk patient population with a central nervous system recurrence risk of greater than 10%. Lymphoma involvement of certain discrete extranodal sites such as the testis also confers increased risk, even in stage I disease. Adverse biological risk factors for central nervous system relapse include presence of translocations of MYC, BCL2 and/or BCL6, in so-called double- or triple-hit lymphoma. Immunohistochemically detectable co-expression of MYC and BCL2 in the absence of translocations also portends an increased risk of relapse within the central nervous system, particularly in the setting of the activated B-cell-like subtype of diffuse large B-cell lymphoma. The role, method, and timing of prophylactic therapy remain controversial based on the available data. We review both intrathecal and systemic strategies for prophylaxis in high-risk patients. Our preference is for systemic methotrexate in concert with standard chemoimmunotherapy in the majority of cases. Several novel agents have also demonstrated clinical activity in primary and secondary central nervous system lymphoma and warrant future investigation in the prophylactic setting.

Diffuse large B-cell lymphoma with pulmonary and cerebral involvement: A case report

Primary diffuse large B-cell lymphoma (DLBCL) is the most common type of non-Hodgkin lymphoma; however, the involvement of the lung and central nervous system (CNS) in patients with DLBCL is rare. Furthermore, patients with DLBCL rarely exhibit specific clinical symptoms, which may delay definitive diagnosis. The present study reports the case of a 42-year-old man suffering from primary DLBCL with concurrent pulmonary and cerebral involvement. The patient suffered from human immunodeficiency virus infection and presented with symptoms including dry cough, thoracalgia, intermittent mild fever and mild headache. Thoracic computed tomography scans revealed multiple pulmonary masses, and brain magnetic resonance imaging scans revealed nodules in the left frontal cortex and bilateral basal ganglia. A percutaneous lung needle biopsy test confirmed the diagnosis of DLBCL. In addition, positron emission tomography revealed the involvement of other parts of the body in DLBCL. The aim of the present study was to present the clinical, radiological and histological characteristics of the patient, which may aid physicians in diagnosing pulmonary and CNS involvement in DLBCL.