CNS+Lymphoma

[5] || Chemotherapy High dose Methotrexate (intrathecal) – Most effective agent [2,12] Whole brain to 40-50 Gy (Include posterior orbits) with/without boost to local primary Boost 20 Gy to local primary to a Total Dose 60-65 Gy Whole eye 30-40 Gy If ocular involvement then shield eyes and continue whole brain total **// Immunosuppressed //** Whole brain to 36-40 Gy [12] **// Elderly patients //** Chemotherapy alone due to risk of neurotoxicity if combined with whole brain irradiation [12] Dose response threshold is between 30 and 50 Gy. [12] Surgery is used as a diagnostic and staging tool. It can also benefit in disease management with splenectomy in patients who exhibit hypersplenism and or resecting involved gastrointestinal tract. [13] Glucorticoids have an anticancer effect on lymphomas. High dose chemotherapy with stem cell infusion. [14] Immunotherapy using [|monoclonal antibodies] target CD-20 including Zevalin, [|Rituxan] and [|Bexxar]. [15] __ Treatment field parameters __
 * Epidemiology: || Primary CNS Lymphoma (PCNSL) appear in 3.1 % of all primary brain tumors. “After a three-fold rise observed two decades ago, the incidence of PCNSL has increased only slightly in the past 10 years in individuals above the age of 60, and now stands at 0.46 per 100,000 patient-years” PCNSL seem to be more male dominate than in women. [1] ||
 * Etiology: || <span style="font-family: 'Times New Roman','serif';">It has been observed that patients with acquired or congenital immunodeficiency have a higher chance of developing Primary CNS lymphoma (PCNSL). Also patients with EpsteinBarr Virus (EBV) have an increase risk of developing PCNSL. “In our experience, a larger than expected number of patients with PCNSL have experienced prior 'autoimmune' disease of systemic or neurologic sites (e.g. conditions resembling chronic inflammatory demyelinating polyneuropathy or multiple sclerosis) or have had therapy with corticosteroids or immunosuppressive agents.” [1] ||
 * Signs & Symptoms: || [[image:CNS_Lymphoma[1].jpg width="560" height="272"]] ||
 * Diagnostic Procedures: || * <span style="color: #cc0000; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Complete History and Work up [2,3]
 * <span style="color: #cc0000; font-family: 'Times New Roman',Times,serif; font-size: 120%;">General Physical exam [2,3]
 * <span style="color: #cc0000; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Complete Blood work (CBC & chemistries)
 * <span style="color: #cc0000; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Immunohistochemical analysis – used to determine B vs T cell type [2]
 * <span style="color: #cc0000; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Complete Neurologic examination- Assess mental status, coordination, reflexes, & motor and cranial nerves [2,3]
 * <span style="color: #cc0000; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Opthalmoscopy – check for papilladema associated with ↑ cranial pressure [2]
 * <span style="color: #cc0000; font-family: 'Times New Roman',Times,serif; font-size: 120%;">CT Scan of brain with/without contrast shows bony extension for disease if present [2,3]
 * <span style="color: #cc0000; font-family: 'Times New Roman',Times,serif; font-size: 120%;">MRI – T1 weighted for anatomy delineation and T2 weighted for edema and tumor localization [2,3]
 * <span style="color: #cc0000; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Biopsy –Stereotactic with needle to confirm tissue diagnosis [2]
 * <span style="color: #cc0000; font-family: 'Times New Roman',Times,serif; font-size: 120%;">CSF Cytolgy is performed [2]
 * <span style="color: #cc0000; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Epstein Barr Virus and HIV serology should be performed [2]
 * <span style="color: #cc0000; font-family: 'Times New Roman',Times,serif; font-size: 120%;">CT chest should be performed if systemic disease is suspected [2]
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">Histology: || <span style="color: #ff0066; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Central nervous system lymphoma is impossible to tell apart hard from non-Hodgkins lymphoma. CNS lymphoma is a labeled as a high grade tumor and the World Health Organization has grouped CNS lymphomas into two categories, large diffuse cells and high-grade Burkitt-like cells. Around 98% of PCNSLs are considered to be CD20+B-cell lymphomas normally diffuse large cell, immuboblastic, or lymphoblastic. [6] ||
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">Lymph Node Drainage: || * <span style="color: #4f6228; font-family: 'Times New Roman',Times,serif; font-size: 120%;">There are no lymphatic channels in the brain and therefore do not metastasize through the lymphatic system [7] ||
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">Metastatic Spread: || <span style="background-color: transparent; color: #ff0066; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: 115%; text-decoration: none; vertical-align: auto;">Typically, CNS lymphoma does not metastasize from the central nervous sytem or the eye. [8] ||
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">Grading: || <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;"> Primary Central Nervous System Lymphoma (PCNSL) is now known to be a form of extranodal, high-grade non-Hodgkin B-cell neoplasm, usually large cell or immunoblastic type. [9] ||
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">Staging: || <span style="color: #7030a0; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: 150%;">It originates in the brain, leptomeninges, spinal cord, or eyes; typically remains confined to the CNS; and rarely spreads outside the nervous system. Therefore, it can be classified as stage 2 disease. [9] ||
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">Radiation Side Effects: || * <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Alopecia
 * <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Headaches
 * <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Cataracts
 * <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Seizures
 * <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Memory deficiency
 * <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Thinking and speech problems
 * <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Difficulty with learning, reading and writing[10]
 * <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Loss of balance and/or trouble walking
 * <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Otitis externa
 * <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Serous otitis media
 * <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Dermatitis
 * <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Hormone dysfunction
 * <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">High tone hearing loss
 * <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Vestibular damage
 * <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Nausea and vomiting
 * <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Fatigue
 * <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Secondary tumor
 * <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Leukoencephalopathy
 * <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Opportunistic infections
 * <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Death[10,11] ||
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">Prognosis: || ** <span style="color: #4f6228; font-family: 'Times New Roman',Times,serif; font-size: 120%;">The three most important prognostic factors are age, performance status, and tumor type. Tumor grade is a stronger factor than size. The median survival with radiation therapy alone is 18 months. [6] ||
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">Treatments: || <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">**// Non-immunosuppressed //**

<span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Whole brain || <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">**Shun** Epidemiology and Etiology <span style="color: #cc0000; font-family: 'Times New Roman',Times,serif; font-size: 120%;">**Eric** Signs and Symptoms, Diagnostic procedures <span style="color: #ff0066; font-family: 'Times New Roman',Times,serif; font-size: 120%;">**Lisa** Histology and Metastatic spread <span style="color: #4f6228; font-family: 'Times New Roman',Times,serif; font-size: 120%;">**Curtis** Lymph node drainage, Prognosis and TD 5/5 <span style="color: #7030a0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">**Kim** Grading and Staging <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 120%;">**LaDonna** Side effects and Treatment <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">**__References__** <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">[1] Primary CNS Lymphoma: Epidemiology and risk factors. Web site. Available at: []. Accessed May 30th 2011. <span style="background-color: transparent; color: #cc0000; font-family: 'Times New Roman',Times,serif; font-size: 120%; text-decoration: none; vertical-align: auto;">[2] Chao C, Perez C, Brandy L. Radiation Oncology Management Decisions. 2nd ed. Lippincott Williams & Wilkins, Philadelphia, PA. 2002 <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;"> [3] National Cancer Institute at the National Institutes of health. Available at: [] Accessed June 1, 2011 <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;"> [4] <span style="background-color: transparent; color: #cc0000; line-height: 115%; text-decoration: none; vertical-align: auto;">[4] American Cancer Society. Brain and spinal cord tumors in adults. <span style="background-color: transparent; color: #cc0000; line-height: 115%; text-decoration: none; vertical-align: auto;">Available atNational Cancer Institute at the National Institutes of health. Available at: [] accessed 6/1/11 <span style="color: #cc0000; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: normal; margin-bottom: 0pt; text-indent: -0.25in;">[5] [5]Nucleus catalog. Available at: [] Accessed June 1, 2011 <span style="color: #ff0066; font-family: 'Times New Roman',Times,serif; font-size: 120%;">[6] Nakamura, M, Shimada E, Isiada, Konishi N. Histopathology, pathogenesis and molecular genetics in primary central nervous system lymphomas. Histology and Histopathology. 2004; 19:211-219 <span style="background-color: transparent; color: #76923c; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: 115%; text-decoration: none; vertical-align: auto;">[7]Washington, Charles, and Dennis Leaver. Principles and Practices of Radiation Therapy. St. Louis, Missouri: Mosby Elsevier, 2010. Print <span style="background-color: transparent; color: #ff0066; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: 115%; text-decoration: none; vertical-align: auto;">[8] Cancer.gov. Staging Primary CNS Lymphoma. Available at: [] <span style="background-color: transparent; color: #ff0066; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: 115%; text-decoration: none; vertical-align: auto;">Accessed June 3, 2011. <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: 150%; margin: 0in 0in 0pt;"> [9]Tarakad S Ramachandran, MBBS, FRCP(C), FACP; Chief Editor: Stephen A Berman, MD, PhD, MBA//.// // Primary CNS Lymphoma //. Available at [|http://emedicine.medscape.com]. Accessed 6/2/2011. <span style="background-color: transparent; color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: 115%; text-decoration: none; vertical-align: auto;">[10] National Cancer Institute at the National Institutes of health. //Primary CNS lymphoma treatment//. Available at: [Accessed on May 29, 2011|http://www.cancer.gov/cancertopics/pdq/treatment/primary-CNS-lymphoma/Patient/page5] <span style="background-color: transparent; color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: 115%; text-decoration: none; vertical-align: auto;">[Accessed on May 29, 2011|Accessed] on May 29, 2011 <span style="background-color: transparent; color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: 115%; text-decoration: none; vertical-align: auto;">[11] WebMD. Cancer Health Center //Primary CNS lymphoma treatment-treatment option overview//. Available at: [] Accessed on May 29, 2011 <span style="background-color: transparent; color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: 115%; text-decoration: none; vertical-align: auto;">[12]Halperin E, Perez CA, Brady LW. //Perez and Brady's Principles and Practice of Radiation Oncology//. 5th edition. Philadelphia: Lippincott, Williams & Wilkins. 2008 <span style="background-color: transparent; color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: 115%; text-decoration: none; vertical-align: auto;">[13]Holleb, AI, Fink, DJ and Murphy, GP. American cancer society textbook of clinical oncology. New York: Genell Subak-Sharpe. 1999 <span style="background-color: transparent; color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%; text-decoration: none; vertical-align: auto;">[14]National Cancer Institute at the National Institutes of health. Available at: [Accessed on May 29, 2011|http://www.cancer.gov/cancertopics/pdq/treatment/primary-CNS-lymphoma/Patient/page4]<span style="background-color: transparent; color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%; text-decoration: none; vertical-align: auto;">[Accessed on May 29, 2011|Accessed] on May 29, 2011 <span style="background-color: transparent; color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%; text-decoration: none; vertical-align: auto;">[15] Lymphomainfo.net. Primary central nervous system CNS lymphoma. Available at: [Accessed on May 29, 2011|http://www.lymphomainfo.net/nhl/types/cns.html]<span style="background-color: transparent; color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%; text-decoration: none; vertical-align: auto;">[Accessed on May 29, 2011| Accessed] on May 29, 2011 <span style="background-color: transparent; color: #76923c; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%; text-decoration: none; vertical-align: auto;">[16]Khan FM. Treatment Planning in Radiation Oncology. 2nd ed. Philadelphia, PA; Lippincott Williams & Wilkins; 2007.
 * <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Superior 1-2 cm flash off cranium
 * <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Inferior C2-C3 interface
 * <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Posterior 1-2 cm flash off cranium
 * <span style="color: #0070c0; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Anterior 1-2 cm flash off cranium
 * TD5/5: || [[image:5_table[1]_(2).jpg width="480" height="225"]] [16] ||