Survival and failure outcomes in PCNSL with WBRT followed by CHOP Chemotherapy: An alternative treatment approach in community settings in low resource countries

Introduction: Primary central nervous system lymphoma (PCNSL) is relatively uncommon malignancy with potentially aggressive behavior. The standard management of PCNSL is high-dose methotrexate (HD-MTX) based chemotherapy and whole brain radiotherapy (WBRT). This treatment is associated with toxicity and requires in-patient admission with intensive monitoring. An alternative approach with WBRT followed by systemic chemotherapy with standard cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) regimen can be used in community settings in a cohort of patients who cannot receive the standard treatment due to logistic reasons. Materials and Methods: We retrospectively reviewed the patients of PCNSL treated in our institute from January 2004 to May 2010. A total of 39 patients of PCNSL were treated. All patients received WBRT followed by systemic chemotherapy with standard CHOP regimen. Survival analysis was done with Kaplan-Meier method using Statistical Package for Statistical Analysis (SPSS version 15). Prognostic factor influencing survival was evaluated using Cox regression analysis. Toxicity and overall treatment compliance analysis was also evaluated. Results: Overall compliance to RT and chemotherapy was excellent, 37 (94.9%) patients completed planned treatment within the stipulated time period. Grades II-III skin toxicity was seen in three patients and Grade II hematological toxicity was seen in two patients. At 1 month after completion of planned treatment, 15 patients had no symptoms and 20 patients had significant improvement while four patients deteriorated clinically while radiological imaging showed complete response, partial response, progression of disease in 22, 12 and 5 patients respectively. Mean overall survival (OS) was 36.34 months and median OS was 20.0 months with 3-year actuarial OS of 38%. Age of 50-year was a significant (P < 0.05) prognostic factor for survival. Conclusions: The standard of care in management of PCNSL is HD-MTX based chemotherapy. However, considering poor compliance and tolerability to treatment in low resource countries in routine clinical setting, WBRT followed by systemic chemotherapy with standard CHOP regimen for treatment of PCNSL demonstrate reasonably good outcome. This regimen is quite economic as well as simple to implement.