78-year-old male diagnosed with EBV positive advanced diffuse large B-cell lymphoma is now s/p 6 Pola CHP with complete response. His CNS IPI -2 (intermediate risk for age, and, stage) - c myc, bcl 2 and 6 and IRF could not be performed on the specimen given at the inadequate specimen. I did not do Baseline MRI or LP before starting Pola C HP. He does not have any other high risk features that predispose him to CNS disease, no testicular involvement no primary cutaneous diffuse large B cell, no kidney or adrenal involvement. However, given I do not know whether he had the MYC Bcl-2 BCL6 rearrangements, and no baseline MRI and LP, would you give CNS intrathecal prophylaxis, or skip it. In these patients do you recommend getting baseline MRI brain or LP to get a more confident answer?
Based on recent multicenter studies showing less benefit for cns prophylaxis in general, I do not routinely add any more given low benefit. I do often get an MRI +/- Lp at baseline to r/o cns involvement in high risk patients which helps me feel more comfortable in eliminating prophylaxis. In general if I give it I give 2 cycles of HD MTX, but this is actually not approved after pola-r-chp. I’m not sure about IT prophylaxis.
