RATIONALE: Drugs used in chemotherapy, such as methotrexate, cyclophosphamide, etoposide
phosphate, dexamethasone, and cytarabine, work in different ways to stop cancer cells from
dividing so they stop growing or die. Osmotic blood-brain barrier disruption uses certain
drugs to open the blood vessels around the brain and allow anticancer substances to be
delivered directly to the brain. Giving methotrexate, cyclophosphamide, and etoposide
phosphate with osmotic blood-brain barrier disruption plus dexamethasone and cytarabine may
kill more cancer cells.
PURPOSE: Phase II trial to study the effectiveness of giving methotrexate, cyclophosphamide,
and etoposide phosphate with osmotic blood-brain barrier disruption plus dexamethasone and
cytarabine in treating patients who have primary CNS lymphoma.
- Determine the toxicity and efficacy of methotrexate, cyclophosphamide, and etoposide
phosphate administered in conjunction with osmotic blood-brain barrier disruption and
dexamethasone and cytarabine in patients with primary CNS lymphoma.
- Determine the ability to recruit an adequate number of patients for this study.
- Compare progression-free and dementia-free survival with standard measures of overall
survival, progression-free survival, disease-free survival, complete response rate,
cognitive function, and quality of life of patients treated with this regimen.
- Determine the feasibility of conducting a future phase III study of this treatment
regimen in this patient population.
- Correlate neuropsychological outcomes with neuroimaging (MRI) outcomes in patients
treated with this regimen.
OUTLINE: This is a multicenter study.
Patients receive methotrexate (MTX) intra-arterially over 10 minutes, cyclophosphamide IV
over 10 minutes, and etoposide phosphate IV over 10 minutes on days 1 and 2 in conjunction
with osmotic blood-brain barrier disruption. Patients also receive oral dexamethasone every
6 hours on days 2-15 (followed by a taper) and intraventricular or intrathecal cytarabine on
day 14. Beginning 48 hours after the last dose of MTX, patients receive filgrastim (G-CSF)*
subcutaneously once daily for 7-10 days or until blood counts recover. Treatment repeats
every 4 weeks for 12 courses in the absence of disease progression or unacceptable toxicity.
NOTE: *Alternatively, patients may receive a single dose of pegfilgrastim, administered 24
hours after the completion of chemotherapy
Patients with intraocular lymphoma also receive MTX intravitreally twice weekly until the
vitreous is clear of cells by slit lamp exam and then weekly for 1 month and monthly for 1
Quality of life is assessed at baseline, at 6 months, at the completion of treatment, and
then every 6 months for 2 years and annually thereafter.
Patients are followed every 3 months for 1 year, every 6 months for 2 years, and then
PROJECTED ACCRUAL: A total of 90 patients will be accrued for this study within 3 years.
- Histologically or cytologically confirmed intermediate- or high-grade primary CNS
lymphoma by brain biopsy or cerebrospinal fluid or vitrectomy analysis
- No more than 90 days since diagnosis
- No systemic lymphoma NOTE: A new classification scheme for adult non-Hodgkin's
lymphoma has been adopted by PDQ. The terminology of "indolent" or "aggressive"
lymphoma will replace the former terminology of "low", "intermediate", or "high"
grade lymphoma. However, this protocol uses the former terminology.
- 16 to 75
- ECOG 0-3 OR
- Karnofsky 40-100%
- Not specified
- Hematocrit at least 25% (transfusion allowed)
- WBC at least 2,500/mm^3
- Absolute granulocyte count at least 1,200/mm^3
- Platelet count at least 100,000/mm^3 OR at least lower limit of normal (transfusion
- Bilirubin no greater than 2.0 times upper limit of normal
- Creatinine clearance at least 30 mL/min
- Adequate cardiac function to tolerate general anesthesia
- Adequate pulmonary function to tolerate general anesthesia
- Not pregnant or nursing
- Negative pregnancy test
- Fertile patients must use effective contraception for 2 months before and during
- No other uncontrolled clinically significant confounding medical condition within the
past 30 days
- No known allergy to study agents
- HIV negative
PRIOR CONCURRENT THERAPY:
- Not specified
- More than 4 weeks since prior chemotherapy (6 weeks for nitrosoureas)
- Single-agent methotrexate administered within the past 14 days allowed
- Not specified
- No prior cranial or spinal radiotherapy
- Prior surgery or biopsy allowed