To protect and defend: central nervous system prophylaxis in patients with non-Hodgkin's lymphoma

Despite remarkable advances in the treatment of non-Hodgkin's lymphoma of all histologic subtypes, nervous system involvement remains a dire complication associated with a rapid decline in quality of life, few good treatment options, and a short overall survival. In fact, these advances in treatment may be fueling an increase in the frequency of nervous system relapse. A better understanding of the epidemiology, diagnostic techniques, and options for prophylaxis of the central nervous system may be one of the best strategies for improving the outcome in patients with non-Hodgkin's lymphoma.

Central nervous system relapse in patients with non-Hodgkin's lymphoma is, typically, an early event, occurs in the setting of well described histologic, demographic, and clinical risk factors, and is characterized primarily by the involvement of the cerebrospinal fluid. Cerebrospinal fluid prophylaxis in high-risk patients appears to be effective in reducing the frequency of this complication.

More aggressive attention to diagnosis, focused on cytologic and flow cytometric evaluation of the cerebrospinal fluid in high-risk patients, will identify more patients with early and potentially more treatable central nervous system lymphoma. Cerebrospinal fluid prophylaxis appears to reduce the frequency of this complication in high-risk populations, but controversy remains regarding the most important high-risk characteristics and the optimum prophylactic interventions.