Introduction

Most children diagnosed with non-Hodgkin lymphoma (NHL) in high-income countries are expected to achieve long-term survival; however, children in lower income countries are diagnosed with NHL at a disproportionally higher rate and do not experience the same chance for cure. [1-10] This disparity is related to many factors, including late disease detection and challenges in delivering high-intensity treatment, such as methotrexate.[3] High-dose methotrexate (HD-MTX; 1-8 g/m2) is an essential component of pediatric mature B-cell and T-cell NHL treatment.[11] The use of HD-MTX in lower income countries has been challenging due to treatment-related mortality at doses of 1-2 g/m2, yet even higher doses are needed to adequately treat NHL. This discrepancy may reflect differences in healthcare infrastructure and supportive care interventions which permit safe administration of HD-MTX, such as real-time monitoring of methotrexate levels.[3] Some centers have administered HD-MTX in sub-Saharan Africa with aggressive supportive care in the absence of methotrexate monitoring, though with significant treatment-related toxicity and mortality.[1] The purpose of this study was to describe the real-world clinical safety of HD-MTX in patients with NHL where aggressive supportive care was readily available. Our overarching goal is to provide a greater understanding of the safety of HD-MTX in NHL, to inform potential treatment approaches in limited resource settings.