Primary CNS Lymphoma Treatment – Health Professional Version

Primary central nervous system (CNS) lymphoma is defined as lymphoma limited to the cranial-spinal axis without systemic disease. An increasing incidence of this disease has been seen among patients with AIDS and among other immunocompromised persons. The natural history of this disorder differs between patients with AIDS and those without AIDS. Computed tomographic (CT) scans may show ring enhancement in 50% of AIDS patients while patients without AIDS almost always show only homogeneous enhancement.[1] Both groups do equally poorly without therapy (mean survival, 1–3 months), but the overall survival for treated patients is much better for patients without AIDS (18.9 months) than for those with AIDS (2.6 months).[1,2]

Prognostic Factors

Poor prognostic factors include the following:[3–5]

• Age older than 50 years.[5]
• Performance status (PS) greater than 1 or Karnofsky PS less than 70.[5]
• Elevated serum level of lactate dehydrogenase.
• Elevated cerebrospinal fluid protein concentration.
• Involvement of nonhemispheric areas of the brain (periventricular, basal ganglia, brainstem, and cerebellum).
• Intraocular disease and concomitant brain involvement.[6]

Diagnostics

When tumor progression occurs, it is usually confined to the CNS and/or the eye. Occult systemic disease can be excluded by staging with bone marrow biopsy and CT scans of the chest, abdomen, and pelvis.[7,8]

In one prospective, case series of 282 patients, 17% were found to have meningeal dissemination by cytomorphology, polymerase chain reaction of rearranged, immunoglobulin, heavy-chain genes, or meningeal enhancement on magnetic resonance imaging.[9] The clinical impact of meningeal involvement on prognosis and therapy remains to be evaluated.

Pathogenesis

Although more than 95% of patients with primary CNS lymphoma have lymphoma of B-cell origin, 45 patients with CNS lymphoma of T-cell origin showed no difference in presentation or outcome in a retrospective series with data collected from 12 cancer centers.[10] Almost all primary CNS lymphomas are aggressive neoplasms of the diffuse large B-cell type. In a retrospective case series derived from 18 cancer centers in 5 countries of 40 patients with low-grade primary CNS lymphoma, a better long-term outcome was shown (median survival, 7 years) than is associated with the usual aggressive CNS lymphoma.[11][Level of evidence: 3iiiDiv] Anecdotal cases of primary CNS Hodgkin lymphoma have also been reported.[12]

Related Summaries

Other PDQ summaries containing information related to primary CNS lymphoma include:

• Adult Hodgkin Lymphoma Treatment
• Adult Non-Hodgkin Lymphoma Treatment

References

1. Fine HA, Mayer RJ: Primary central nervous system lymphoma. Ann Intern Med 119 (11): 1093-104, 1993. [PUBMED Abstract]
2. Nasir S, DeAngelis LM: Update on the management of primary CNS lymphoma. Oncology (Huntingt) 14 (2): 228-34; discussion 237-42, 244, 2000. [PUBMED Abstract]
3. Ferreri AJ, Blay JY, Reni M, et al.: Prognostic scoring system for primary CNS lymphomas: the International Extranodal Lymphoma Study Group experience. J Clin Oncol 21 (2): 266-72, 2003. [PUBMED Abstract]
4. Pollack IF, Lunsford LD, Flickinger JC, et al.: Prognostic factors in the diagnosis and treatment of primary central nervous system lymphoma. Cancer 63 (5): 939-47, 1989. [PUBMED Abstract]
5. Abrey LE, Ben-Porat L, Panageas KS, et al.: Primary central nervous system lymphoma: the Memorial Sloan-Kettering Cancer Center prognostic model. J Clin Oncol 24 (36): 5711-5, 2006. [PUBMED Abstract]
6. Kreher S, Strehlow F, Martus P, et al.: Prognostic impact of intraocular involvement in primary CNS lymphoma: experience from the G-PCNSL-SG1 trial. Ann Hematol 94 (3): 409-14, 2015. [PUBMED Abstract]
7. O’Neill BP, Dinapoli RP, Kurtin PJ, et al.: Occult systemic non-Hodgkin’s lymphoma (NHL) in patients initially diagnosed as primary central nervous system lymphoma (PCNSL): how much staging is enough? J Neurooncol 25 (1): 67-71, 1995. [PUBMED Abstract]
8. Abrey LE, Batchelor TT, Ferreri AJ, et al.: Report of an international workshop to standardize baseline evaluation and response criteria for primary CNS lymphoma. J Clin Oncol 23 (22): 5034-43, 2005. [PUBMED Abstract]
9. Fischer L, Martus P, Weller M, et al.: Meningeal dissemination in primary CNS lymphoma: prospective evaluation of 282 patients. Neurology 71 (14): 1102-8, 2008. [PUBMED Abstract]
10. Shenkier TN, Blay JY, O’Neill BP, et al.: Primary CNS lymphoma of T-cell origin: a descriptive analysis from the international primary CNS lymphoma collaborative group. J Clin Oncol 23 (10): 2233-9, 2005. [PUBMED Abstract]
11. Jahnke K, Korfel A, O’Neill BP, et al.: International study on low-grade primary central nervous system lymphoma. Ann Neurol 59 (5): 755-62, 2006. [PUBMED Abstract]
12. Gerstner ER, Abrey LE, Schiff D, et al.: CNS Hodgkin lymphoma. Blood 112 (5): 1658-61, 2008. [PUBMED Abstract]

Radiation Therapy

Because of the diffuse nature of central nervous system (CNS) lymphomas, aggressive surgical decompression with partial or gross total removal of the tumor is of no benefit to the patient. Median survival with surgery alone is in the range of only 1 to 5 months. Until the mid-1990s, radiation therapy had been the standard treatment, with doses of up to 45 Gy using standard fractionation. A prospective trial by the Radiation Therapy Oncology Group (RTOG-8315) used 40 Gy whole-brain radiation therapy (WBRT) and a 20 Gy boost to the tumor and found that the results were no better than had been previously reported with a median survival of 1 year and 28% of the patients surviving 2 years.[1,2] Disease recurs in the brain in 92% of patients despite high doses of radiation. The addition of spinal-axis radiation does not affect survival because it does not prevent cerebral relapse.

Combined Chemotherapy and Radiation Therapy

Two multicenter, prospective trials (including RTOG-8806) used preirradiation cyclophosphamide, doxorubicin, vincristine, and dexamethasone followed by WBRT.[3,4] Median survival times were no better than for radiation therapy alone. The failure of these and other combined modality trials [5] has been attributed to poor penetration of standard drugs through the blood-brain barrier and to increased neurologic toxic effects.[3,5–10] A retrospective review of 226 patients suggested improved results with the use of high-dose methotrexate or cytarabine with radiation therapy rather than with other combination regimens.[11]

A multicenter trial (RTOG-9310) of 102 patients used high-dose methotrexate (2.5 g/m2) for five cycles, intravenous vincristine, oral procarbazine, intraventricular methotrexate, and either 45 Gy of WBRT or 36 Gy in a hyperfractionated schedule.[12] Median progression-free survival (PFS) was 24 months, and median overall survival (OS) was 37 months.[13][Level of evidence: 3iiiA] Severe delayed neurologic toxic effects were seen in 15% of patients.

Another multicenter trial (EORTC-20962 [NCT00003061]) was comprised of 52 patients younger than 66 years who used high-dose methotrexate, teniposide, carmustine, methylprednisolone, intrathecal methotrexate, cytarabine, and hydrocortisone followed by 40 Gy of radiation therapy; the median survival was 46 months, but a 10% toxic death rate occurred even in this younger patient population.[14][Level of evidence: 3iiiA] Follow-up was too short (median, 27 months) to fully assess severe delayed neurologic toxic effects.

Chemotherapy Alone

Because of unsatisfactory results of WBRT alone and the neurologic toxic effects of chemotherapy and radiation therapy, a major focus is now on trials with chemotherapy alone.[15] Multiple reports have described systemic chemotherapy, which has been employed alone or with osmotic blood-brain barrier disruption, usually including high-dose methotrexate with frequent hospitalizations.[8,10,16–21]

A multicenter trial (NABTT-9607) evaluated high-dose methotrexate alone (8 g/m2) for newly diagnosed patients, with WBRT administered only at disease recurrence. With a median follow-up of 2 years, median PFS was 13 months and median OS had not been reached at 23 plus months.[22][Level of evidence: 3iiiA] Another multicenter trial (EORTC-26952) of 50 patients older than 60 years used high-dose methotrexate (3 g/m2/cycle), lomustine, procarbazine, methylprednisolone, and intrathecal methotrexate and cytarabine. The 1-year PFS was 40%, and the median OS was 14.3 months in this older patient group with a median age of 72 years.[23][Level of evidence: 3iiiA] Another multicenter trial of 65 patients used both high-dose methotrexate and high-dose cytarabine, including ifosfamide, cyclophosphamide, vinca alkaloids, dexamethasone, and intrathecal methotrexate, cytarabine, and prednisolone. The median time-to-treatment failure was 15 months with a median survival of 34 months; 57% of patients age 60 or younger were still alive at a median follow-up of 8 years.[24,25][Level of evidence: 3iiiA] Patients with recurrent or refractory CNS lymphoma after methotrexate-based chemotherapy are candidates for salvage chemotherapy.[26]

Severe delayed neurologic toxic effects were rarely seen in these chemotherapy-only trials (in the absence of subsequent radiation therapy). Reduction of dosage for subsequent radiation to 23.4 Gy has been applied for patients who achieve clinical complete response after induction chemotherapy.[27][Level of evidence: 3iiiDiii]

Many of the aforementioned phase II results have never been tested in a randomized setting because of an insufficient number of patients.

Chemotherapy and Stem Cell Transplant

Intensive chemotherapy with autologous peripheral stem cell transplantation is also under evaluation; neurologic toxic effects were not reported in the absence of radiation therapy.[28–34] A phase II feasibility study used chemotherapy induction with methotrexate, temozolomide, and rituximab (given once every 2 weeks for 10 doses) plus consolidation with etoposide and high-dose cytarabine; with a median follow-up of 4.9 years, this phase II Cancer and Leukemia Group B (CALGB) trial of 44 patients reported a complete radiographic response in 66% of the patients, a 2-year PFS of 57%, and an estimated OS of 65% at 4 years.[35][Level of evidence: 3iiiDiv]

In a phase II study of 32 patients, induction chemotherapy with rituximab plus methotrexate (3.5 g/m2) plus procarbazine plus vincristine was consolidated with high-dose chemotherapy with thiotepa, cyclophosphamide, and busulfan, followed by autologous stem cell transplant (ASCT) and no WBRT. With a median follow-up of 45 months and a median age of 57 years, the 2-year PFS was 79% (95% CI, 58–90) and 2-year OS was 81% (95% CI, 63–91), along with stable neurocognitive function posttransplant.[36][Level of evidence: 3iiiDiv]

Several prospective randomized trials are comparing or have compared the value of WBRT and the value of ASCT as consolidation after high-dose methotrexate induction therapy: International Extranodal Lymphoma Study Group 32 (IELSC32 [NCT01011920]), Pragmatic–Explanatory Continuum Indicator Summary (PRECIS [NCT00863460]), Cancer and Lymphoma Group B/Alliance (CALGB 51101 [NCT01511562]), and International Extranodal Lymphoma Study Group 43 (IELSG43 [NCT02531841]).[34]

Toxicities

Severe cognitive deficits are reported with all intensive therapies due to iatrogenic leukoencephalopathy. Retrospective data suggest a decreased risk of dementia when chemotherapy is employed prior to radiation therapy and even less when radiation therapy is avoided.[11,37,38] The use of systemic chemotherapy alone, with or without osmotic blood-brain barrier disruption, may avoid the cognitive loss observed with radiation therapy.[11,16,17,38] Comparative trials with validated measures of cognitive function will be necessary to determine the value of delaying radiation therapy until relapse after high-dose chemotherapy.[22,38–41] Glucocorticoids can also produce substantial but short-lived remissions. Steroid efficacy may complicate the diagnostic evaluation by obscuring the histologic findings. Other drugs that cross the blood-brain barrier are under clinical evaluation.[42,43]

Randomized Trials

In a prospective, randomized trial of 551 immunocompetent patients with newly diagnosed primary CNS lymphoma, all patients received induction chemotherapy with six cycles of high-dose methotrexate (4 g/m2) with or without ifosfamide.[44] Upon completion of chemotherapy, responders were randomly assigned to WBRT (45 Gy) or to no treatment for complete response patients and cytarabine for partial response patients. There was no statistical difference in median OS with 32.4 months for patients receiving radiation therapy versus 37.1 months for those not receiving radiation (hazard ratio [HR] = 1.06; 95% confidence interval [CI], 0.80–1.40, P = .71).[44][Level of evidence: 1iiA] Treatment-related neurotoxic effects were significantly worse on the radiation therapy arm, and such toxicity must be weighed against the possibility that the survival from chemotherapy alone may be marginally inferior to the survival when radiation is added.

In a randomized, nonblinded, multicenter trial, 79 patients were randomly assigned to high-dose methotrexate versus high-dose methotrexate plus cytarabine.[45] While 3-year PFS was better for the 2-drug regimen (HR, 0.54; 95% CI, 0.31–0.92; P = .01), there was no difference in 3-year OS (46% for the 2-drug regimen vs. 32% for the 1-drug regimen, HR, 0.65; 95% CI, 0.38–1.13; P = .07).[45][Level of evidence: 1iiDiii]

In a prospective randomized trial of 410 immunocompetent patients with newly diagnosed primary CNS lymphoma, all patients were scheduled to receive high-dose methotrexate and randomly assigned to receive WBRT or no radiation. In the intent-to-treat population, WBRT was associated with a prolongation of PFS at 15.4 months versus 9.9 months (HR, 0.79; 95% CI, 0.64–0.98; P = .034), but no difference in OS at 32.4 months versus 36.1 months (HR, 0.98; 95% CI, 0.79–1.26; P = .98). However, the study lacked the power to exclude a benefit or harm from the WBRT.[46][Level of evidence: 1iiDiii] In this study, 19 patients were diagnosed with intraocular involvement at diagnosis; intraocular lymphoma was an independent negative prognostic indicator.[47]

HIV-Associated Primary CNS Lymphoma

Patients with HIV-associated primary CNS lymphoma usually have very advanced infections with CD4 counts less than 50 cells/mm3.[48] Consequently, most patients die of opportunistic infections regardless of therapy for the lymphoma. Groups that benefit most from radiation therapy, with or without antecedent chemotherapy, include those HIV-seropositive patients with no previous opportunistic infections or tumors for whom the CNS lymphoma is the AIDS-defining illness, and those patients with a good performance status, high CD4 lymphocyte count (>100mm3), and symptoms referable only to the CNS lymphoma.[37,49] Treatment of these patients requires special consideration. (Refer to the PDQ summary on AIDS-Related Lymphoma Treatment for more information.)

Intraocular Lymphoma

An international consortium performed a retrospective review of 83 HIV-negative patients with primary intraocular lymphoma.[50] In selected patients with no evidence of disseminated CNS disease, localized therapy with intraocular methotrexate or ocular radiation therapy is associated with equivalent outcomes seen with systemic chemotherapy and/or WBRT. Localized therapy with intraocular methotrexate or ocular radiation therapy did not affect relapse rate, median PFS, or median OS compared with systemic chemotherapy and WBRT.[50][Level of evidence: 3iiiDiv] Patients with intraocular disease and concomitant brain involvement had a worse prognosis than those with brain involvement alone (19 patients with both, 391 patients with brain involvement only).[46]

Current Clinical Trials

Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.

References

1. Pollack IF, Lunsford LD, Flickinger JC, et al.: Prognostic factors in the diagnosis and treatment of primary central nervous system lymphoma. Cancer 63 (5): 939-47, 1989. [PUBMED Abstract]
2. Nelson DF, Martz KL, Bonner H, et al.: Non-Hodgkin’s lymphoma of the brain: can high dose, large volume radiation therapy improve survival? Report on a prospective trial by the Radiation Therapy Oncology Group (RTOG): RTOG 8315. Int J Radiat Oncol Biol Phys 23 (1): 9-17, 1992. [PUBMED Abstract]
3. O’Neill BP, O’Fallon JR, Earle JD, et al.: Primary central nervous system non-Hodgkin’s lymphoma: survival advantages with combined initial therapy? Int J Radiat Oncol Biol Phys 33 (3): 663-73, 1995. [PUBMED Abstract]
4. Schultz C, Scott C, Sherman W, et al.: Preirradiation chemotherapy with cyclophosphamide, doxorubicin, vincristine, and dexamethasone for primary CNS lymphomas: initial report of radiation therapy oncology group protocol 88-06. J Clin Oncol 14 (2): 556-64, 1996. [PUBMED Abstract]
5. Bessell EM, Graus F, López-Guillermo A, et al.: CHOD/BVAM regimen plus radiotherapy in patients with primary CNS non-Hodgkin’s lymphoma. Int J Radiat Oncol Biol Phys 50 (2): 457-64, 2001 Jun 1. [PUBMED Abstract]
6. Chamberlain MC, Levin VA: Primary central nervous system lymphoma: a role for adjuvant chemotherapy. J Neurooncol 14 (3): 271-5, 1992. [PUBMED Abstract]
7. Fine HA: Treatment of primary central nervous system lymphoma: still more questions than answers. Blood 86 (8): 2873-5, 1995. [PUBMED Abstract]
8. Blay JY, Bouhour D, Carrie C, et al.: The C5R protocol: a regimen of high-dose chemotherapy and radiotherapy in primary cerebral non-Hodgkin’s lymphoma of patients with no known cause of immunosuppression. Blood 86 (8): 2922-9, 1995. [PUBMED Abstract]
9. O’Brien P, Roos D, Pratt G, et al.: Phase II multicenter study of brief single-agent methotrexate followed by irradiation in primary CNS lymphoma. J Clin Oncol 18 (3): 519-26, 2000. [PUBMED Abstract]
10. Gavrilovic IT, Hormigo A, Yahalom J, et al.: Long-term follow-up of high-dose methotrexate-based therapy with and without whole brain irradiation for newly diagnosed primary CNS lymphoma. J Clin Oncol 24 (28): 4570-4, 2006. [PUBMED Abstract]
11. Blay JY, Conroy T, Chevreau C, et al.: High-dose methotrexate for the treatment of primary cerebral lymphomas: analysis of survival and late neurologic toxicity in a retrospective series. J Clin Oncol 16 (3): 864-71, 1998. [PUBMED Abstract]
12. Fisher B, Seiferheld W, Schultz C, et al.: Secondary analysis of Radiation Therapy Oncology Group study (RTOG) 9310: an intergroup phase II combined modality treatment of primary central nervous system lymphoma. J Neurooncol 74 (2): 201-5, 2005. [PUBMED Abstract]
13. DeAngelis LM, Seiferheld W, Schold SC, et al.: Combination chemotherapy and radiotherapy for primary central nervous system lymphoma: Radiation Therapy Oncology Group Study 93-10. J Clin Oncol 20 (24): 4643-8, 2002. [PUBMED Abstract]
14. Poortmans PM, Kluin-Nelemans HC, Haaxma-Reiche H, et al.: High-dose methotrexate-based chemotherapy followed by consolidating radiotherapy in non-AIDS-related primary central nervous system lymphoma: European Organization for Research and Treatment of Cancer Lymphoma Group Phase II Trial 20962. J Clin Oncol 21 (24): 4483-8, 2003. [PUBMED Abstract]
15. Ekenel M, Iwamoto FM, Ben-Porat LS, et al.: Primary central nervous system lymphoma: the role of consolidation treatment after a complete response to high-dose methotrexate-based chemotherapy. Cancer 113 (5): 1025-31, 2008. [PUBMED Abstract]
16. Dahlborg SA, Henner WD, Crossen JR, et al.: Non-AIDS Primary CNS Lymphoma: First Example of a Durable Response in a Primary Brain Tumor using Enhanced Chemotherapy Delivery without Cognitive Loss and without Radiotherapy Cancer J Sci Am 2 (3): 166-74, 1996. [PUBMED Abstract]
17. Gabbai AA, Hochberg FH, Linggood RM, et al.: High-dose methotrexate for non-AIDS primary central nervous system lymphoma. Report of 13 cases. J Neurosurg 70 (2): 190-4, 1989. [PUBMED Abstract]
18. Sandor V, Stark-Vancs V, Pearson D, et al.: Phase II trial of chemotherapy alone for primary CNS and intraocular lymphoma. J Clin Oncol 16 (9): 3000-6, 1998. [PUBMED Abstract]
19. DeAngelis LM: Primary central nervous system lymphomas. Curr Treat Options Oncol 2 (4): 309-18, 2001. [PUBMED Abstract]
20. Kiewe P, Fischer L, Martus P, et al.: Primary central nervous system lymphoma: monocenter, long-term, intent-to-treat analysis. Cancer 112 (8): 1812-20, 2008. [PUBMED Abstract]
21. Angelov L, Doolittle ND, Kraemer DF, et al.: Blood-brain barrier disruption and intra-arterial methotrexate-based therapy for newly diagnosed primary CNS lymphoma: a multi-institutional experience. J Clin Oncol 27 (21): 3503-9, 2009. [PUBMED Abstract]
22. Batchelor T, Carson K, O’Neill A, et al.: Treatment of primary CNS lymphoma with methotrexate and deferred radiotherapy: a report of NABTT 96-07. J Clin Oncol 21 (6): 1044-9, 2003. [PUBMED Abstract]
23. Hoang-Xuan K, Taillandier L, Chinot O, et al.: Chemotherapy alone as initial treatment for primary CNS lymphoma in patients older than 60 years: a multicenter phase II study (26952) of the European Organization for Research and Treatment of Cancer Brain Tumor Group. J Clin Oncol 21 (14): 2726-31, 2003. [PUBMED Abstract]
24. Pels H, Schmidt-Wolf IG, Glasmacher A, et al.: Primary central nervous system lymphoma: results of a pilot and phase II study of systemic and intraventricular chemotherapy with deferred radiotherapy. J Clin Oncol 21 (24): 4489-95, 2003. [PUBMED Abstract]
25. Juergens A, Pels H, Rogowski S, et al.: Long-term survival with favorable cognitive outcome after chemotherapy in primary central nervous system lymphoma. Ann Neurol 67 (2): 182-9, 2010. [PUBMED Abstract]
26. Khimani NB, Ng AK, Chen YH, et al.: Salvage radiotherapy in patients with recurrent or refractory primary or secondary central nervous system lymphoma after methotrexate-based chemotherapy. Ann Oncol 22 (4): 979-84, 2011. [PUBMED Abstract]
27. Shah GD, Yahalom J, Correa DD, et al.: Combined immunochemotherapy with reduced whole-brain radiotherapy for newly diagnosed primary CNS lymphoma. J Clin Oncol 25 (30): 4730-5, 2007. [PUBMED Abstract]
28. Soussain C, Suzan F, Hoang-Xuan K, et al.: Results of intensive chemotherapy followed by hematopoietic stem-cell rescue in 22 patients with refractory or recurrent primary CNS lymphoma or intraocular lymphoma. J Clin Oncol 19 (3): 742-9, 2001. [PUBMED Abstract]
29. Abrey LE, Moskowitz CH, Mason WP, et al.: Intensive methotrexate and cytarabine followed by high-dose chemotherapy with autologous stem-cell rescue in patients with newly diagnosed primary CNS lymphoma: an intent-to-treat analysis. J Clin Oncol 21 (22): 4151-6, 2003. [PUBMED Abstract]
30. Illerhaus G, Marks R, Ihorst G, et al.: High-dose chemotherapy with autologous stem-cell transplantation and hyperfractionated radiotherapy as first-line treatment of primary CNS lymphoma. J Clin Oncol 24 (24): 3865-70, 2006. [PUBMED Abstract]
31. Colombat P, Lemevel A, Bertrand P, et al.: High-dose chemotherapy with autologous stem cell transplantation as first-line therapy for primary CNS lymphoma in patients younger than 60 years: a multicenter phase II study of the GOELAMS group. Bone Marrow Transplant 38 (6): 417-20, 2006. [PUBMED Abstract]
32. Soussain C, Hoang-Xuan K, Taillandier L, et al.: Intensive chemotherapy followed by hematopoietic stem-cell rescue for refractory and recurrent primary CNS and intraocular lymphoma: Société Française de Greffe de Moëlle Osseuse-Thérapie Cellulaire. J Clin Oncol 26 (15): 2512-8, 2008. [PUBMED Abstract]
33. Kasenda B, Schorb E, Fritsch K, et al.: Prognosis after high-dose chemotherapy followed by autologous stem-cell transplantation as first-line treatment in primary CNS lymphoma–a long-term follow-up study. Ann Oncol 23 (10): 2670-5, 2012. [PUBMED Abstract]
34. Ferreri AJ, Illerhaus G: The role of autologous stem cell transplantation in primary central nervous system lymphoma. Blood 127 (13): 1642-9, 2016. [PUBMED Abstract]
35. Rubenstein JL, Hsi ED, Johnson JL, et al.: Intensive chemotherapy and immunotherapy in patients with newly diagnosed primary CNS lymphoma: CALGB 50202 (Alliance 50202). J Clin Oncol 31 (25): 3061-8, 2013. [PUBMED Abstract]
36. Omuro A, Correa DD, DeAngelis LM, et al.: R-MPV followed by high-dose chemotherapy with TBC and autologous stem-cell transplant for newly diagnosed primary CNS lymphoma. Blood 125 (9): 1403-10, 2015. [PUBMED Abstract]
37. Fine HA, Mayer RJ: Primary central nervous system lymphoma. Ann Intern Med 119 (11): 1093-104, 1993. [PUBMED Abstract]
38. Nasir S, DeAngelis LM: Update on the management of primary CNS lymphoma. Oncology (Huntingt) 14 (2): 228-34; discussion 237-42, 244, 2000. [PUBMED Abstract]
39. DeAngelis LM: Primary Central Nervous System Lymphoma: Curable Without Toxicity? Cancer J Sci Am 2 (3): 137-9, 1996. [PUBMED Abstract]
40. Bessell EM, López-Guillermo A, Villá S, et al.: 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. J Clin Oncol 20 (1): 231-6, 2002. [PUBMED Abstract]
41. Abrey LE, Batchelor TT, Ferreri AJ, et al.: Report of an international workshop to standardize baseline evaluation and response criteria for primary CNS lymphoma. J Clin Oncol 23 (22): 5034-43, 2005. [PUBMED Abstract]
42. Reni M, Ferreri AJ, Landoni C, et al.: Salvage therapy with temozolomide in an immunocompetent patient with primary brain lymphoma. J Natl Cancer Inst 92 (7): 575-6, 2000. [PUBMED Abstract]
43. Wong ET, Tishler R, Barron L, et al.: Immunochemotherapy with rituximab and temozolomide for central nervous system lymphomas. Cancer 101 (1): 139-45, 2004. [PUBMED Abstract]
44. Thiel E, Korfel A, Martus P, et al.: High-dose methotrexate with or without whole brain radiotherapy for primary CNS lymphoma (G-PCNSL-SG-1): a phase 3, randomised, non-inferiority trial. Lancet Oncol 11 (11): 1036-47, 2010. [PUBMED Abstract]
45. Ferreri AJ, Reni M, Foppoli M, et al.: High-dose cytarabine plus high-dose methotrexate versus high-dose methotrexate alone in patients with primary CNS lymphoma: a randomised phase 2 trial. Lancet 374 (9700): 1512-20, 2009. [PUBMED Abstract]
46. Korfel A, Thiel E, Martus P, et al.: Randomized phase III study of whole-brain radiotherapy for primary CNS lymphoma. Neurology 84 (12): 1242-8, 2015. [PUBMED Abstract]
47. Kreher S, Strehlow F, Martus P, et al.: Prognostic impact of intraocular involvement in primary CNS lymphoma: experience from the G-PCNSL-SG1 trial. Ann Hematol 94 (3): 409-14, 2015. [PUBMED Abstract]
48. Levine AM: Acquired immunodeficiency syndrome-related lymphoma. Blood 80 (1): 8-20, 1992. [PUBMED Abstract]
49. Corn BW, Donahue BR, Rosenstock JG, et al.: Performance status and age as independent predictors of survival among AIDS patients with primary CNS lymphoma: a multivariate analysis of a multi-institutional experience. Cancer J Sci Am 3 (1): 52-6, 1997 Jan-Feb. [PUBMED Abstract]
50. Grimm SA, Pulido JS, Jahnke K, et al.: Primary intraocular lymphoma: an International Primary Central Nervous System Lymphoma Collaborative Group Report. Ann Oncol 18 (11): 1851-5, 2007. [PUBMED Abstract]

These references have been identified by members of the PDQ Adult Treatment Editorial Board as significant in the field of primary CNS lymphoma treatment. This list is provided to inform users of important studies that have helped shape the current understanding of and treatment options for primary CNS lymphoma. Listed after each reference are the sections within this summary where the reference is cited.