ICML 2025 | Guidelines and recommendations for managing patients with CNS lymphoma

I think this is a great question because it is a host of diseases. So first we have primary CNS lymphoma, so disease really in the central nervous system and confined to the central nervous system. And then we’re having, in our world as radiation oncologists, we’re seeing this more and more, especially on call, secondary CNS lymphomas. So extracranial lymphomas that then spread to the central nervous system. And I should say even beyond lymphomas, I mean, we think about this in leukemia, we think about this in myeloma, and we’re seeing the CNS as a sanctuary site for these diseases to spread as all our novel therapies continue to improve and patients live longer. We’re seeing this disease spread to the brain and the spinal canal. So I would say that secondary CNS lymphoma is something I’m also very interested in. Again, we’re seeing it more in the urgent and emergent setting. And so I was speaking with my good friend, Susie Hiniker at Stanford and Dana Casey at University of North Carolina were saying, we’re seeing more and more of these patients. What are you guys doing over there? What are you guys doing? And so we put our heads together and we got a group of experts. So from Stanford, UNC, Sloan Kettering at UCSD, and we put together guidelines. So I’d like everyone to be aware of the guidelines that we wrote for urgent and emergent use of radiation for secondary CNS hematologic malignancies. It was published in Frontiers in Oncology earlier this year. And what we do is we go through histology-specific and disease compartment-specific, meaning is it in the brain parenchyma, the vitreous, is it in the spinal fluid, do they have gross radiographic leptomeningeal disease. So we go through these different clinical scenarios and we provide dosing guidelines as well as treatment volume guidelines in terms of are we treating focally just to the site of disease or do we need to treat the whole brain or craniospinal axis? So we come through and provide a table to basically guide you through answering some of those questions. I think the most important thing that I want everyone to take home from that paper is that radiation is an effective and very fast-acting tool for hematologic malignancies. And while systemic therapy can also be very fast-acting and very effective, for some of these patients we’re seeing on call, some of them, vision changes. I just had someone last week, acute visual changes, neurologic deficits, paralysis. When patients are coming in with these new-onset, urgent and emergent symptoms that are neurologic, often early radiation can resolve some of these symptoms. So I really encourage my colleagues out in the community to really consider radiation early on for these patients to help improve and prevent further worsening of neurologic compromise. Even if your systemic therapy colleagues, your medical oncology colleagues really want to start with systemic therapy, which I don’t necessarily think is the wrong thing to do. We talk about it in the guidelines, even simulating your patient early on to get a scan and get a plan ready to go just in case the systemic therapy doesn’t work as quickly as you want it to. So you have it as a backup. So I recommend looking into those Frontiers in Oncology guidelines. Fantastic.

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