Sancho Juan-Manuel, Ribera Josep-Maria
Servicio de Hematología Clínica, Institut Català d'Oncologia-Hospital Germans Trias i Pujol, Institut de Recerca contra la Leucemia Josep Carreras, Universitat Autònoma de Barcelona, Badalona, Barcelona, España.
Servicio de Hematología Clínica, Institut Català d'Oncologia-Hospital Germans Trias i Pujol, Institut de Recerca contra la Leucemia Josep Carreras, Universitat Autònoma de Barcelona, Badalona, Barcelona, España.
Med Clin (Barc). 2016 Jan 15;146(2):74-80. doi: 10.1016/j.medcli.2014.12.025. Epub 2015 Mar 24.
Central nervous system (CNS) involvement by lymphoma is a complication associated, almost invariably, with a poor prognosis. The knowledge of the risk factors for CNS relapse is important to determine which patients could benefit from prophylaxis. Thus, patients with very aggressive lymphomas (such as lymphoblastic lymphoma or Burkitt's lymphoma) must systematically receive CNS prophylaxis due to a high CNS relapse rate (25-30%), while in patients with indolent lymphoma (such as follicular lymphoma or marginal lymphoma) prophylaxis is unnecessary. However, the question about CNS prophylaxis in patients with diffuse large B-cell lymphoma (DLBCL), the most common type of lymphoma, remains controversial. The information available is extensive, mainly based on retrospective and heterogeneous studies. There seems that immunochemotherapy based on rituximab reduces the CNS relapse rate. On the other hand, patients with increased serum lactate dehydrogenase plus more than one extranodal involvement seem to have a higher risk of CNS relapse, but a prophylaxis strategy based only on the presence of these 2 factors does not prevent all CNS relapses. Patients with involvement of testes or breast have high risk of CNS relapse and prophylaxis is mandatory. Finally, CNS prophylaxis could be considered in patients with DLBCL and renal or epidural space involvement, as well as in those cases with MYC rearrangements, although additional studies are necessary.
淋巴瘤累及中枢神经系统（CNS）是一种几乎总是与预后不良相关的并发症。了解CNS复发的危险因素对于确定哪些患者能从预防措施中获益很重要。因此，侵袭性很强的淋巴瘤患者（如淋巴母细胞淋巴瘤或伯基特淋巴瘤）由于CNS复发率很高（25%-30%），必须系统性地接受CNS预防，而惰性淋巴瘤患者（如滤泡性淋巴瘤或边缘区淋巴瘤）则无需预防。然而，对于最常见的淋巴瘤类型——弥漫性大B细胞淋巴瘤（DLBCL）患者是否进行CNS预防，这一问题仍存在争议。现有的信息广泛，主要基于回顾性和异质性研究。基于利妥昔单抗的免疫化疗似乎能降低CNS复发率。另一方面，血清乳酸脱氢酶升高且有不止一处结外受累的患者似乎CNS复发风险更高，但仅基于这两个因素存在的预防策略并不能预防所有的CNS复发。睾丸或乳腺受累的患者CNS复发风险高，必须进行预防。最后，DLBCL合并肾脏或硬膜外腔受累的患者以及存在MYC重排的病例可考虑进行CNS预防，不过还需要更多研究。
