Central Nervous System Relapse of Aggressive B-cell Lymphoma: Insights Into Current Treatment Approaches

Authors

  • Chathuri Abeyakoon, MBBS Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario
  • Anca Prica, MD, MSc Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario

DOI:

https://doi.org/10.58931/cht.2025.4164

Abstract

Central nervous system (CNS) relapse of lymphoma, also known as relapse with secondary CNS lymphoma (SCNSL), is a rare but devastating complication that confers poor survival outcomes and treatment decision challenges. Diffuse large B-cell lymphoma (DLBCL) accounts for most cases with an incidence of 4-6% and commonly occurs within 1 year of diagnosis (median of 5 months). However, CNS relapse is also seen in the context of other aggressive B-cell lymphoma histological subtypes, such as Burkitt lymphoma and mantle cell lymphoma, with an incidence of 20% and 4%, respectively. Identifying patients at risk of CNS relapse has been limited by the low sensitivity of diagnostic variables and scores. More recently, the use of CNS prophylaxis with high-dose methotrexate (HD-MTX) in DLBCL has also been challenged. CNS involvement can be parenchymal (40-50%), leptomeningeal (30-40%), or both (10-15%). Clinical presentation can occur with a range of neurological symptoms depending on the location of CNS involvement (e.g. motor deficits, symptoms related to increased intracranial pressure, cognitive/personality changes, visual disturbance) together with possible systemic symptoms in the presence of concurrent systemic disease involvement. For ease of making treatment decisions and understanding various approaches to management, SCNSL can be divided into 3 distinct clinical scenarios: 1) treatment-naïve-SCNSL, in which CNS involvement of lymphoma occurs concurrently with systemic disease at diagnosis; 2) relapsed isolated-SCNSL, in which relapse of previously treated systemic disease occurs isolated to the CNS; and 3) relapsed concurrent-SCNSL, in which relapse of previously treated systemic disease occurs both within the CNS and systemically.

This review will focus on treatment approaches for SCNSL in the relapsed setting, both relapsed isolated-SCNSL and relapsed concurrent-SCNSL, confined to DLBCL.

Author Biographies

Chathuri Abeyakoon, MBBS, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario

Dr Chathuri Abeyakoon has recently completed a clinical research fellowship in Lymphoma, Myeloma and Autologous Stem Cell Transplantation at the Princess Margaret Cancer Centre. Prior to her Fellowship in Canada, she completed Hematology training in Australia and is a Fellow of both the Royal Australasian College of Physicians and Royal College of Pathologists Australasia. She has now returned to Melbourne, Australia to continue her career as a Clinician Investigator. Her interest lies in optimizing treatment outcomes with novel and targeted agents in aggressive lymphomas.

Anca Prica, MD, MSc, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario

Dr. Anca Prica is a staff hematologist at Princess Margaret Cancer Centre, and associate professor in the division of hematology at University of Toronto, appointed in 2014. She completed her initial medical training in Toronto, and her clinical training in Internal Medicine and Hematology in the University of Toronto Program. She then completed a 2-year fellowship in Malignant Hematology and a Masters in Health Research Methodology at McMaster University, with research interests in quality of life and economic evaluations. Her clinical work focuses in both lymphoproliferative and plasma cell disorders, as well as autologous stem cell transplantation and CAR-T therapy. Her research interests focus on health services research, particularly economic evaluations and decision analyses for oncologic questions, examining resource use and cost of care, as well as toxicity of chemotherapies, and their effects on quality of life and caregiver burden.

References

Alderuccio JP, Nayak L, Cwynarski K. How I treat secondary CNS involvement by aggressive lymphomas. Blood. 2023;142(21):1771-83. DOI: https://doi.org/10.1182/blood.2023020168

Lewis KL, Jakobsen LH, Villa D, Smedby KE, Savage KJ, Eyre TA, et al. High-Dose Methotrexate as CNS Prophylaxis in High-Risk Aggressive B-Cell Lymphoma. J Clin Oncol. 2023;41(35):5376-87. DOI: https://doi.org/10.1200/JCO.23.00365

Bobillo S, Khwaja J, Ferreri AJM, Cwynarski K. Prevention and management of secondary central nervous system lymphoma. Haematologica. 2023;108(3):673-89. DOI: https://doi.org/10.3324/haematol.2022.281457

El-Galaly TC, Cheah CY, Bendtsen MD, Nowakowski GS, Kansara R, Savage KJ, et al. Treatment strategies, outcomes and prognostic factors in 291 patients with secondary CNS involvement by diffuse large B-cell lymphoma. Eur J Cancer. 2018;93:57-68. DOI: https://doi.org/10.1016/j.ejca.2018.01.073

Korfel A, Elter T, Thiel E, Hanel M, Mohle R, Schroers R, et al. Phase II study of central nervous system (CNS)-directed chemotherapy

including highdose chemotherapy with autologous stem cell transplantation for CNS relapse of aggressive lymphomas. Haematologica. 2013;98(3):364-70. DOI: https://doi.org/10.3324/haematol.2012.077917

Ferreri AJ, Donadoni G, Cabras MG, Patti C, Mian M, Zambello R, et al. High Doses of Antimetabolites Followed by High-Dose Sequential Chemoimmunotherapy and Autologous Stem-Cell Transplantation in Patients With Systemic B-Cell Lymphoma and Secondary CNS Involvement: Final Results of a Multicenter Phase II Trial. J Clin Oncol.2015;33(33):3903-10. DOI: https://doi.org/10.1200/JCO.2015.61.1236

Doorduijn JK, van Imhoff GW, van der Holt B, Schouten HC, Schaafsma MR, MacKenzie MA, et al. Treatment of secondary central nervous system lymphoma with intrathecal rituximab, high-dose methotrexate, and R-DHAP followed by autologous stem cell transplantation: results of the HOVON 80 phase 2 study. Hematol Oncol. 2017;35(4):497-503. DOI: https://doi.org/10.1002/hon.2342

Ferreri AJM, Doorduijn JK, Re A, Cabras MG, Smith J, Ilariucci F, et al. MATRix-RICE therapy and autologous haematopoietic stem-cell transplantation in diffuse large B-cell lymphoma with secondary CNS involvement (MARIETTA): an international, single-arm, phase 2 trial. Lancet Haematol. 2021;8(2):e110-e21. DOI: https://doi.org/10.1016/S2352-3026(20)30366-5

Damaj G, Ivanoff S, Coso D, Ysaebert L, Choquet S, Houillier C, et al. Concomitant systemic and central nervous system non-Hodgkin lymphoma: the role of consolidation in terms of high dose therapy and autologous stem cell transplantation. A 60-case

retrospective study from LYSA and the LOC network. Haematologica. 2015;100(9):1199-206. DOI: https://doi.org/10.3324/haematol.2015.126110

Nijland M, Jansen A, Doorduijn JK, Enting RH, Bromberg JEC, Kluin-Nelemans HC. Treatment of initial parenchymal central nervous system involvement in systemic aggressive B-cell lymphoma. Leuk Lymphoma. 2017;58(9):1-6. DOI: https://doi.org/10.1080/10428194.2017.1285026

Fleming M, Huang Y, Dotson E, Bond DA, Reneau J, Epperla N, et al. Feasibility of high-dose methotrexate administered on day 1 of (R)CHOP in aggressive non-Hodgkin lymphomas. Blood Advances. 2022;6(2):460-72. DOI: https://doi.org/10.1182/bloodadvances.2021005999

Wight JC, Yue M, Keane C, Johnston A, Linton K, Chin C, et al. Outcomes of synchronous systemic and central nervous system (CNS) involvement of diffuse large B-cell lymphoma are dictated by the CNS disease: a collaborative study of the Australasian Lymphoma Alliance. Br J Haematol. 2019;187(2):174-84. DOI: https://doi.org/10.1111/bjh.16064

Ferreri AJM, Cwynarski K, Pulczynski E, Fox CP, Schorb E, Celico C, et al. Long-term efficacy, safety and neurotolerability of MATRix regimen followed by autologous transplant in primary CNS lymphoma: 7-year results of the IELSG32 randomized trial.

Leukemia. 2022;36(7):1870-8.

Kasenda B, Schorb E, Fritsch K, Finke J, Illerhaus G. 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. 2012;23(10):2670-5. DOI: https://doi.org/10.1093/annonc/mds059

Scordo M, Wang TP, Ahn KW, Chen Y, Ahmed S, Awan FT, et al. Outcomes Associated With Thiotepa-Based Conditioning in Patients With Primary Central Nervous System Lymphoma After Autologous Hematopoietic Cell Transplant. JAMA Oncol. 2021;7(7):993-1003. DOI: https://doi.org/10.1001/jamaoncol.2021.1074

Akin S, Hosing C, Khouri I, Ahmed S, Alousi A, Fowler N, et al. Autologous stem cell transplantation for large B-cell lymphoma with secondary central nervous system involvement. Blood Adv. 2022;6(7):2267-74. DOI: https://doi.org/10.1182/bloodadvances.2021005602

Maziarz RT, Wang Z, Zhang MJ, Bolwell BJ, Chen AI, Fenske TS, et al. Autologous haematopoietic cell transplantation for non Hodgkin lymphoma with secondary CNS involvement. Br J Haematol. 2013;162(5):648-56. DOI: https://doi.org/10.1111/bjh.12451

Khwaja J, Kirkwood AA, Isbell LK, Steffanoni S, Goradia H, Pospiech L, et al. International multicenter retrospective analysis of thiotepa-based autologous stem cell transplantation for secondary central nervous system lymphoma. Haematologica. 2023;108(3):882-8. DOI: https://doi.org/10.3324/haematol.2022.281640

Bromberg JE, Doorduijn JK, Illerhaus G, Jahnke K, Korfel A, Fischer L, et al. Central nervous system recurrence of systemic lymphoma in the era of stem cell transplantation--an International Primary Central Nervous System Lymphoma Study Group project. Haematologica. 2013;98(5):808-13. DOI: https://doi.org/10.3324/haematol.2012.070839

Alderuccio JP, Khwaja J, Han S, Ghione P, Nizamuddin IA, Saha A, et al. Prognostication and Treatment- Related Outcomes in Secondary Central Nervous System Involvement of Large B-Cell Lymphoma (SCNSL): Evidence from a Large International Cohort. Blood. 2024;144(Supplement 1):571-. DOI: https://doi.org/10.1182/blood-2024-199781

Locke FL, Miklos DB, Jacobson CA, Perales MA, Kersten MJ, Oluwole OO, et al. Axicabtagene Ciloleucel as Second-Line Therapy for Large B-Cell Lymphoma. N Engl J Med. 2022;386(7):640-54. DOI: https://doi.org/10.1056/NEJMoa2116133

Abramson JS, Solomon SR, Arnason J, Johnston PB, Glass B, Bachanova V, et al. Lisocabtagene maraleucel as second-line therapy for large B-cell lymphoma: primary analysis of the phase 3 TRANSFORM study. Blood. 2023;141(14):1675-84. DOI: https://doi.org/10.1182/blood.2022018730

Crump M, Neelapu SS, Farooq U, Van Den Neste E, Kuruvilla J, Westin J, et al. Outcomes in refractory diffuse large B-cell lymphoma: results from the international SCHOLAR-1 study. Blood. 2017;130(16):1800-8. DOI: https://doi.org/10.1182/blood-2017-03-769620

Neelapu SS, Jacobson CA, Ghobadi A, Miklos DB, Lekakis LJ, Oluwole OO, et al. Five-year followup of ZUMA-1 supports the curative potential of axicabtagene ciloleucel in refractory large B-cell lymphoma. Blood. 2023;141(19):2307-15.

Schuster SJ, Bishop MR, Tam CS, Waller EK, Borchmann P, McGuirk JP, et al. Tisagenlecleucel in Adult Relapsed or Refractory Diffuse Large B-Cell Lymphoma. N Engl J Med. 2019;380(1):45-56. DOI: https://doi.org/10.1056/NEJMoa1804980

Abramson JS, Palomba ML, Gordon LI, Lunning M, Wang M, Arnason J, et al. Two-year follow-up of lisocabtagene maraleucel in relapsed or refractory large B-cell lymphoma in TRANSCEND NHL 001. Blood. 2024;143(5):404-16. DOI: https://doi.org/10.1182/blood.2023020854

Bishop MR, Dickinson M, Purtill D, Barba P, Santoro A, Hamad N, et al. Second-Line Tisagenlecleucel or Standard Care in Aggressive B-Cell Lymphoma. N Engl J Med. 2022;386(7):629-39. DOI: https://doi.org/10.1056/NEJMoa2116596

Alsouqi A, Ahmed G, Wang J, Cassanello G, Szabo A, Rojek AE, et al. Chimeric antigen receptor T-cell therapy in secondary central nervous system lymphoma: A multicenter analysis. Am J Hematol. 2024;99(8):1624-7. DOI: https://doi.org/10.1002/ajh.27354

Epperla N, Feng L, Shah NN, Fitzgerald L, Shah H, Stephens DM, et al. Outcomes of patients with secondary central nervous system lymphoma following CAR T-cell therapy: a multicenter cohort study. J Hematol Oncol. 2023;16(1):111. DOI: https://doi.org/10.1186/s13045-023-01508-3

Ahmed S, Kallam A, Frigault M, Hunter BD, Patel SS, Bernasconi D, et al. Real-World (RW) Outcomes of Lisocabtagene Maraleucel (liso-cel) in Patients (pts) with Relapsed or Refractory (R/R) Large B-Cell Lymphoma (LBCL) and Secondary Central Nervous

System (sCNS) Involvement from the Center for International Blood and Marrow Transplant Research (CIBMTR) Registry. Blood. 2024;144(Supplement 1):472-. DOI: https://doi.org/10.1182/blood-2024-199702

Hashmi H, Epperla N, Ahn K, Allbee-Johnson M, Mercadal S, Lee CJ, et al. Outcomes of Large B-Cell Lymphoma (LBCL) Patients with Secondary Central Nervous System Involvement Following Chimeric Antigen Receptor T-Cell Therapy: A CIBMTR Analysis. Transplantation and Cellular Therapy, Official Publication of the American Society for Transplantation and Cellular Therapy. 2024;30(2):S42. DOI: https://doi.org/10.1016/j.jtct.2023.12.073

Luttwak E, Cassanello G, Brown S, Devlin SM, Imber BS, Ip A, et al. CAR T-Cell Therapy for DLBCL with CNS

Involvement: Overall Safe and Effective with Limited Efficacy in Patients with Leptomeningeal Disease. Blood. 2024;144(Supplement 1):4509-. DOI: https://doi.org/10.1182/blood-2024-212274

Ossami Saidy A, Fuhrmann S, Peczynski C, Boumendil A, Michel E, Galimard J-E, et al. Efficacy of CD19-Directed CAR T Cell Therapy in Patients with Primary or Secondary CNS Lymphoma - an Analysis of the EBMT Lymphoma WP and the Gocart Coalition. Blood. 2023;142(Supplement 1):1031-. DOI: https://doi.org/10.1182/blood-2023-174883

Ahmed G, Alsouqi A, Szabo A, Rojek AE, Riedell PA, Awan FT, et al. Chimeric Antigen Receptor T-Cell (CAR-T) Therapy in Secondary Central Nervous System Large B-Cell Lymphoma (SCNSL): A Multicenter Retrospective Analysis. Blood. 2023;142(Supplement 1):3088-. DOI: https://doi.org/10.1182/blood-2023-184345

Cederquist GY, Schefflein J, Devlin SM, Shah GL, Shouval R, Hubbeling H, et al. CNS bridging radiotherapy achieves rapid cytoreduction before CAR T-cell therapy for aggressive B-cell lymphomas. Blood Advances. 2024;8(19):5192-9. DOI: https://doi.org/10.1182/bloodadvances.2024013393

Published

2025-05-05

How to Cite

1.
Abeyakoon C, Prica A. Central Nervous System Relapse of Aggressive B-cell Lymphoma: Insights Into Current Treatment Approaches. Can Hematol Today [Internet]. 2025 May 5 [cited 2025 Jun. 1];4(1):16–26. Available from: https://canadianhematologytoday.com/article/view/4-1-Abeyakoon_et_al

Issue

Section

Articles

Most read articles by the same author(s)