Central Nervous System Lymphoma in HIV Treatment & Management
- Author: Florian P Thomas, MD, PhD, Drmed, MA, MS; Chief Editor: Niranjan N Singh, MD, DM more...
No consensus exists on treatment. Few studies have addressed the management of HIV-associated CNS lymphoma, and most algorithms were formulated on the basis of protocols in immunocompetent individuals.
Patients with HIV-associated lymphoma who receive radiation therapy alone have an average survival of less than 6 months. In a recent Japanese study, however, patients receiving a curative intent radiation dose (30 Gy or higher) of whole-brain radiation therapy achieved prolonged survival while maintaining a good quality of life. Performance status was a significant prognostic indicator: the estimated 3-year overall survival rates of patients with a good and poor performance status were 100% and 38%, respectively.
Survival can be prolonged greatly if a combination of radiation therapy and chemotherapy is used. However, few data exist to support the use of steroids.
Based on the consistent association of HIV-associated CNS lymphoma with Epstein-Barr virus (EBV), antiviral and immunomodulatory treatments are being tried. Treatment with ganciclovir has been associated with increased survival and undetectable CSF EBV DNA load. In a prospective study using high-dose ganciclovir and interleukin-2 (IL-2), 3 patients died but 1 had complete remission. There are anecdotal reports of responses to systemic and intrathecal methotrexate (3 g/m2 q14d with leucovorin rescue), thiotepa, and procarbazine.
The CNS is a sanctuary site for lymphoma and can be a barrier to cure. CNS prophylaxis is recommended for all patients with HIV-associated lymphoma, even those without current clinical CNS involvement.
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