Diagnosis
The diagnosis of CNS lymphoma usually includes a brain biopsy or surgery, performed by a neurosurgeon, and the tumor material will then be examined by a neuropathologist. Diagnostic work-up will include an extent of disease evaluation to determine if there is involvement outside of the central nervous system. This could include an MRI of the brain and spinal cord, examination of the eyes, evaluation of the cerebrospinal fluid, and PET/CT scan of the body.
Systemic Therapy
The treatment of CNS lymphoma has evolved over the past several decades, resulting in a reduction in the rate of disease recurrence. Treatment for CNS lymphoma includes chemotherapy including high-dose methotrexate, an anti-cancer drug given systemically (intravenously). High-dose methotrexate is an inpatient chemotherapy treatment; our experienced medical oncology nurses administer the drug and carefully monitor patients throughout their treatment. Some patients may be considered for autologous stem cell transplant or low-dose radiation.
- Clinicians at our Center for Neuro-Oncology have pioneered the treatment of CNS lymphoma through a number of clinical trials:
- Combinations of high-dose methotrexate-based chemotherapy, and autologous stem cell transplant or non-myeloablative chemotherapy are promising therapy options now being tested through clinical trials.
- We are currently conducting a clinical trial that compares myeloablative therapy versus non-myeloablative therapy.
- We have a clinical trial combating the recurrence of primary CNS lymphoma and CNS relapse of primary testicular lymphoma (secondary CNS lymphoma) using an immunotherapy approach with an anti-PD1 antibody, nivolumab.
- We have clinical trials to evaluate tumor tissue to determine mechanism of response and resistance to targeted and immunotherapeutic agents.
- We are developing novel clinical trials that use a combination of chemotherapy, targeted therapy, and immunotherapy to further advance the treatment of CNS lymphoma.
Surgery
When surgery is indicated (when a large mass is causing acute symptoms), our cancer neurosurgeons use the most advanced technologies available to remove as much of the tumor as possible, while preserving the surrounding brain tissue. Pre-surgical and surgical techniques include:
- Functional MRI (fMRI) prior to surgery: Helps to identify where important functions live in the brain; maps areas of the brain responsible for critical functions, such as movement and speech; also measures blood flow and activity throughout the brain.
- Intra-operative MRI in our advanced multimodality image-guided (AMIGO) operating suite: A revolutionary, open-style MRI scanner that lets our neurosurgeons see MRI images in real time during surgery. The intra-operative MRI helps the neurosurgeon to remove the tumor more precisely, reducing the risk of damage to other parts of the brain.
- 3-D navigation system (NeuroNavigation), a GPS-like system for the brain: Allows our neurosurgeons to precisely locate deep-seated or small brain tumors. This allows us to make surgery safer and more effective by minimizing the amount of brain exposure and manipulation needed to find and remove the tumor.
- Intraoperative monitoring: The activity and integrity of important areas of the brain, for example those controlling movement and speech, can be monitored in real time during surgery by measuring their electrical activity. This helps the surgeon when deciding which parts of the brain are safe to operate on, and which parts should not be touched. The final result is a major increase in surgical safety and positive outcomes.
- "Awake surgery": Occasionally, when tumors are very close to essential brain areas, the best way to prevent brain damage is to perform the surgery with the patient awake, so that our cancer neurosurgeons can have a continuous assessment of the brain function and maximize tumor resection, while keeping the risk of brain injury to a minimum.
Radiation Therapy
Radiation therapy is a cancer treatment that uses high-energy X-rays or other types of radiation to eradicate cancer cells or keep them from growing. The method of radiation therapy depends on the type of tumor and its location in the brain or spinal cord. Our radiation oncologists are experts in radiation techniques; if radiation therapy is indicated for your specific brain tumor, they will discuss the neuro-cognitive effects of radiation therapy with you and your family.
Our radiation and neuro-oncologists work together to approach radiation therapy as a treatment option. We are committed to providing the safest approaches to radiation and are careful in adopting new treatment technologies. At our Center, radiation therapy is moving away from whole-brain radiation as a standard, and whenever possible, toward techniques that target specific areas of concern in the brain without harming the surrounding healthy tissue.
We often use the following radiation therapy approaches, which cause less damage to the healthy tissue surrounding the tumor:
- 3-dimensional conformal radiation therapy: A procedure that uses a computer to create a three-dimensional (3-D) picture of the brain or spinal cord tumor. This allows doctors to give the highest possible dose of radiation to the tumor, with the least possible damage to normal tissue. This type of radiation therapy is also called three-dimensional radiation therapy, or 3D-CRT.
- Intensity-modulated radiation therapy (IMRT): A type of 3-D radiation therapy that uses a computer to make pictures of the size and shape of the brain or spinal cord tumor. Thin beams of radiation of different intensities are aimed at the tumor from many angles. This type of radiation therapy causes less damage to healthy tissue near the tumor.
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Stereotactic radiosurgery (SRS): A procedure that uses radiation and computer targeting to direct focused radiation to specific targets in the brain that may be difficult to reach through conventional neurosurgery. This minimizes injury to surrounding structures that are not affected by the tumor. The procedure is performed under local sedation, with patients fitted with a face mask to guide targeting; neither a head frame nor a surgical incision is needed.
At Dana-Farber Brigham Cancer Center, we are moving towards the implementation of a smaller, more comfortable face mask for patients and reducing the time it takes to complete the treatment. Patients who receive SRS usually return home the same day.
- Stereotactic radiotherapy: A radiation treatment that is used in some instances for larger brain tumors and is divided, or fractionated, over several days.
Clinical Trials
Clinical trials are research studies that evaluate the safety and effectiveness of new treatments, such as new systemic therapies, surgical techniques, or radiation treatments.
Dana-Farber Brigham Cancer Center offers an extensive number of clinical trials for patients with CNS lymphoma, including those appropriate for recurrent disease, or even as a first treatment.
Dana-Farber Brigham Cancer Center researchers are nationally and internationally recognized for their leadership and expertise in designing and implementing innovative clinical trials for CNS lymphoma.
You can meet with a neuro-oncologist who specializes in CNS lymphoma to discuss clinical trial options. We offer clinical trials for patients with upfront and relapsed CNS lymphoma, as well as studies of neuro-cognition as patients undergo treatment as our team works to develop less neurotoxic treatments.