How should you treat a patient with lymphoma who developed “chemo brain” after R-CHOP therapy?

Here’s how readers responded to a You Make the Call question about neurologic toxicity following R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone).

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Would rule out rituximab leukoencephalopathy and continue treatment with the same schedule.

Sebastián Isnardi, MD
Buenos Aires, Argentina

She has meningeal lymphoma with or without brain involvement.

Evan D. Slater, MD
Ventura, CA

It is too early to call it chemo brain. I wonder why a spinal tap and MRI was done before the start of treatment. Either there is a preexisting condition or a flare up or a viral infection.

Nalini Janakiraman, MD
Henry Ford Hospital
Detroit, MI

Would repeat MRI brain looking for evidence of posterior reversible encephalopathy syndrome. Would also repeat LP and evaluate for viral and lymphoma etiology. Would defer further treatment until neurologic recovery.

Juan M. Alcantar, MD
UCLA Health

Los Angeles, CA

A serious brain injury can take six to 12 months to heal.

Unless you have accurate neuropsychological testing before treatment, then you probably just have to wait. If she recovers, then she has chemo brain, if not then she probably has permanent brain damage.

In the meantime, I would have her see a neurologist, review her medications, and obtain a CT of the brain and some thyroid function tests, and look for any reversible cause of her altered mental state.

Steven Sandler, MD
Skokie, IL

Progressive multifocal leukoencephalopathy.

Kanjaksha Ghosh, MD
Gujrat, India

I would order brain angiography MRI and investigate her cerebrospinal fluid for lymphoma infiltration, giving chemotherapy IT prophylactically.

Chrystalla Prokopiou, MD
Limassol General Hospital

Nicosia, Cyprus

She needs a follow-up brain MRI and LP for viral serology including JC virus, plus toxo-crypto, cytology, and immunophenotyping. Withhold further treatment until cause is established.

Michael Pidcock, MBBS
Canberra, Australia

I would consider central nervous system localization of lymphoma or encephalitis due to JC virus and would do a brain MRI and lumbar puncture.

Achiel Van Hoof, MD
Bruges, Belgium