Treatment of elderly patients with primary CNS lymphoma

Abstract

Primary central nervous system lymphoma (PCNSL) has a rising incidence with age and more importantly, the overall increase in life expectancy of the population has resulted in an increasing prevalence of PCNSL. One of the greatest challenges of PCNSL is the care and treatment of older individuals. Choice of optimal treatment and delivery of adequate dose intensity of cytostatic treatment remain two of the main issues when treating elderly patients. Available evidence suggests optimal induction treatment for these patients remains high-dose methotrexate (HD-MTX)-based immuno-chemotherapy, although a poor baseline performance status (PS) and comorbidities make this a challenging prospect. Potential consolidation treatment options include high-dose therapy with stem cell consolidation, non-myeloablative chemotherapy, or whole-brain radiotherapy (WBRT) but the increased risk of delayed neurotoxicity associated with the latter means this is utilized less frequently. The goal of treatment in the elderly remains achieving complete remission (CR) with the aim of improvement in duration of response and quality of life (QoL). A strategy of individualized approaches adapting treatment intensity to age and/or comorbidities for this vulnerable subgroup of patients is desirable, although the lack of specific evidence makes this difficult to define. Assessment of pre-morbid PS and comorbidities are paramount when assessing patients at diagnosis. There is a growing body of evidence that geriatric assessment tools are able to predict outcomes in PCNSL and might be adopted to optimize therapy. Further work in this challenging arena is paramount as improvement in outcome for this patient group is required.