Background: Diffuse large B-cell lymphoma (DLBCL) patients (pts) with risk factors based on the R-IPI (Sehn et al. 2007 http://ow.ly/k4Xu308hsBM) and CNS IPI (Schmitz et al. 2016http://ow.ly/dZIb301YyQ4) may relapse in the central nervous system (CNS). NCCN Guidelines (v2.2016) rec lumbar puncture (LP) if 4-6 risk factors present or HIV, testicular, breast, or double expresser and notes optimal management is uncertain. We wished to evaluate the use of CNS px in a large community health system. Methods: The Aurora Health Care cancer registry was searched for DLBCL from 1/1/16 to 12/31/16. Pts with CNS px were selected for more detailed analysis for stage, Myc, R-IPI, CNS IPI and cost of px. CNS px was categorized as: 1) intravenous (IV) high dose methotrexate (HD MTX), 2) IT chemo via Ommaya, or 3) IT via LP. Outcomes were CNS px utilization, survival, and costs. Results: 146 DLBCL pts were treated (5 R-CHOP, 2 DA-R-EPOCH). CNS px was given in 7/146 (4.8%). Pts were 5 males, 2 females. Median age was 58, (range: 38-76). Median R-IPI was 2.4 (range: 0-5). Median CNS IPI was 2.7 (range: 0-5). HD MTX was used in 3 pts. IT was used in 4 pts, with 0 by Ommaya and 4 by LP. Except for one death, there was no CNS or other recurrences yet. Costs per cycle were (drug + administration): 1) HD MTX: $587+ 3166 (hospitalization and leucovorin) = $3753, 2) IT Ommaya: $20 + 921 = $941 (not including Ommaya surgery), 3) IT LP: $20 + 2460 (includes interventional radiology) = $2480. Conclusions: CNS px rate was low across a range of stages and risk scores, which potentially reflects lack of recognition of risk as well as uncertainly about the value including utility (risk reduction) vs cost ($ and pt toxicity). Evaluating for improved utility is necessary, such as lenalidomide (a small molecule with CNS penetration) in R2CHOP (Ayed et al. 2016 http://ow.ly/6s5d308G4I4). If that 6 fold risk reduction holds, the value may be high for lenalidomide added to high risk CNS IPI DLBCL pts therapy.

NA= not applicable