MRI performed at the tertiary centre showed no evidence of a cerebral lesion. You therefore plan with the neurosurgical team to stop the steroids and repeat the MRI after a short interval (2-4 weeks) whilst monitoring the patient closely.
Alongside this plan you have requested the following investigations
- FBC, – within normal parameters
- U&ES, – no abnormality
- LFTS, – no abnormality
- blood film – morphologically normal
- LDH, – elevated
- testicular ultrasound – no evidence of testicular lesion
- CSF examination – flow cytometry or PCR for IGHV gene rearrangements – no clonal B cell population identified
- PET-CT – no evidence of systemic involvement
- HIV/hepatitis screen – negative
- Paraprotein – no evidence of a paraprotein
- opthalomology review – slit lamp exam – no abnormality
Repeat MRI exam at 2 weeks shows evidence of a cerebral lesion. A biopsy is carried out which confirms DLBCL. Steroids are recommenced. The MRI and histology findings are discussed at MDT.
How would you manage this patient? How do you decide upon treatment plan?
What type of regime would you use?
How would you assess response to treatment?
What are the risks to the patient? how would these be managed?
Would you offer any other treatment alongside intensive chemotherapy?