In their thorough review of mantle cell lymphoma (MCL), Ghielmini and Zucca describe that central nervous system (CNS) disease involvement, albeit rare at presentation, has an incidence of 4% to 22% in relapsed patients. Nevertheless, they do not state their recommendations regarding prophylaxis to MCL patients. The National Comprehensive Cancer Network guidelines for diffuse large B-cell (DLBCL) lymphoma recommend CNS prophylaxis with 4 to 8 doses of intrathecal methotrexate (MTX) and/or cytarabine for patients with aggressive lymphomas who have paranasal sinus, testicular, epidural, bone marrow, 2 extranodal site involvement, or HIV lymphomas. The guidelines for MCL patients further suggest lumbar puncture at diagnosis for patients with blastic variants or with neurologic symptoms, but do not state any recommendations for prophylactic treatment at either diagnosis or relapse. Because there are no definite guidelines, and most patients are not treated with CNS-penetrating agents such as high dose MTX/cytarabine regimens, it is left to the physician's discretion whether to administer CNS prophylaxis or not. For instance, in the United Kingdom, one-third of hematologists administer prophylaxis to MCL patients and only in specific circumstances. Among the many reports of MCL in the literature, 4 concentrated their efforts on direct assessment of CNS involvement in MCL, and all are retrospective ; therefore, the true incidence is unknown.
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