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Lisa M. DeAngelis, Whither whole brain radiotherapy for primary CNS lymphoma?, Neuro-Oncology, Volume 16, Issue 8, August 2014, Pages 1032–1034, https://doi.org/10.1093/neuonc/nou122
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Whole brain radiotherapy (WBRT) is usually avoided in the initial treatment of patients with primary central nervous system lymphoma (PCNSL). Although efficacious, combined modality therapy has been abandoned by most physicians due to reports of neurotoxicity in patients who received it. WBRT has been so vilified that many physicians will not even consider it when a patient has primary chemorefractory disease. It is time to review this approach and clarify the potential role of WBRT in patients with PCNSL.
Historically, WBRT was the sole treatment for the disease we now recognize as PCNSL. Previously called microglioma or reticulum cell sarcoma, it was only in the 1970's that the lymphoid origin of PCNSL was recognized. WBRT was, at the time, the standard treatment for all primary CNS neoplasms, including malignant glioma; it was often combined with a boost to areas of bulky disease. Eventually, several trials showed that limited field radiation was as effective and less toxic for malignant gliomas, and WBRT was abandoned. WBRT continued to be used in the treatment of PCNSL largely because insufficient patient numbers obviated a comprehensive study. However, the first trial completed by the Radiation Therapy Oncology Group (RTOG) proved that WBRT plus a focal boost as sole therapy effectively caused tumor regression and prolonged survival but only achieved a median survival of about 1 year, largely because of tumor regrowth.1 Most importantly, they and others identified that tumor recurred as frequently within as outside the boosted field, supporting the need for whole brain but eliminating the need for a boost to areas of bulky disease.1,2 Subsequent studies in Japan demonstrated that focal RT resulted in increased relapse in regions of the brain excluded from the RT port, confirming the need for WBRT in PCNSL when RT is used.3
