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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...
 
Updated: Dec 28, 2015
 

Approach Considerations

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.[12] 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.[13] In a prospective study using high-dose ganciclovir and interleukin-2 (IL-2), 3 patients died but 1 had complete remission.[14] 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.

 
 
Contributor Information and Disclosures
Author

Florian P Thomas, MD, PhD, Drmed, MA, MS Director, National MS Society Multiple Sclerosis Center; Professor and Director, Clinical Research Unit, Department of Neurology, Adjunct Professor of Physical Therapy, Associate Professor, Institute for Molecular Virology, St Louis University School of Medicine; Editor-in-Chief, Journal of Spinal Cord Medicine

Florian P Thomas, MD, PhD, Drmed, MA, MS is a member of the following medical societies: Academy of Spinal Cord Injury Professionals, American Academy of Neurology, American Neurological Association, Consortium of Multiple Sclerosis Centers, National Multiple Sclerosis Society, Sigma Xi

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Glenn Lopate, MD Associate Professor, Department of Neurology, Division of Neuromuscular Diseases, Washington University School of Medicine; Consulting Staff, Department of Neurology, Barnes-Jewish Hospital

Glenn Lopate, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

Niranjan N Singh, MD, DM Associate Professor of Neurology, University of Missouri-Columbia School of Medicine

Niranjan N Singh, MD, DM is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Headache Society

Disclosure: Nothing to disclose.

References
  1. Maher EA, Fine HA. Primary CNS lymphoma. Semin Oncol. 1999 Jun. 26(3):346-56. [Medline].

  2. Gasser O, Bihl FK, Wolbers M, et al. HIV patients developing primary CNS lymphoma lack EBV-specific CD4+ T cell function irrespective of absolute CD4+ T cell counts. PLoS Med. 2007 Mar 27. 4(3):e96. [Medline]. [Full Text].

  3. Wolf T, Brodt HR, Fichtlscherer S. Changing incidence and prognostic factors of survival in AIDS-related non-Hodgkin's lymphoma in the era of highly active antiretroviral therapy (HAART). Leuk Lymphoma. 2005 Feb. 46(2):207-15. [Medline].

  4. Haldorsen IS, Krakenes J, Goplen AK, Dunlop O, Mella O, Espeland A. AIDS-related primary central nervous system lymphoma: a Norwegian national survey 1989-2003. BMC Cancer. 2008 Aug 6. 8:225. [Medline]. [Full Text].

  5. Bayraktar S, Bayraktar UD, Ramos JC, Stefanovic A, Lossos IS. Primary CNS lymphoma in HIV positive and negative patients: comparison of clinical characteristics, outcome and prognostic factors. J Neurooncol. 2011 Jan. 101 (2):257-65. [Medline].

  6. Matinella A, Lanzafame M, Bonometti MA, Gajofatto A, Concia E, Vento S, et al. Neurological complications of HIV infection in pre-HAART and HAART era: a retrospective study. J Neurol. 2015 May. 262 (5):1317-27. [Medline].

  7. Bossolasco S, Falk KI, Ponzoni M, et al. Ganciclovir is associated with low or undetectable Epstein-Barr virus DNA load in cerebrospinal fluid of patients with HIV-related primary central nervous system lymphoma. Clin Infect Dis. 2006 Feb 15. 42(4):e21-5. [Medline].

  8. Biggar RJ, Engels EA, Ly S. Survival after cancer diagnosis in persons with AIDS. J Acquir Immune Defic Syndr. 2005 Jul 1. 39(3):293-9. [Medline].

  9. Skiest DJ, Crosby C. Survival is prolonged by highly active antiretroviral therapy in AIDS patients with primary central nervous system lymphoma. AIDS. 2003 Aug 15. 17(12):1787-93. [Medline].

  10. Ambinder RF, Bhatia K, Martinez-Maza O, Mitsuyasu R. Cancer biomarkers in HIV patients. Curr Opin HIV AIDS. 2010 Nov. 5(6):531-7. [Medline]. [Full Text].

  11. Corcoran C, Rebe K, van der Plas H, Myer L, Hardie DR. The predictive value of cerebrospinal fluid Epstein-Barr viral load as a marker of primary central nervous system lymphoma in HIV-infected persons. J Clin Virol. 2008 Aug. 42(4):433-6. [Medline].

  12. Nagai H, Odawara T, Ajisawa A, Tanuma J, Hagiwara S, Watanabe T, et al. Whole brain radiation alone produces favourable outcomes for AIDS-related primary central nervous system lymphoma in the HAART era. Eur J Haematol. 2010 Jun. 84(6):499-505. [Medline].

  13. Bossolasco S, Falk KI, Ponzoni M. Ganciclovir is associated with low or undetectable Epstein-Barr virus DNA load in cerebrospinal fluid of patients with HIV-related primary central nervous system lymphoma. Clin Infect Dis. 2006 Feb 15. 42(4):e21-5. [Medline].

  14. Aboulafia DM, Ratner L, Miles SA. Antiviral and immunomodulatory treatment for AIDS-related primary central nervous system lymphoma: AIDS Malignancies Consortium pilot study 019. Clin Lymphoma Myeloma. 2006 Mar. 6(5):399-402. [Medline].

 
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On CT scan, cerebral lymphoma appears as focal lesions with nodular ring enhancement, mass effect, and surrounding edema. Common sites include the periventricular white and gray matter and cerebellum.
Light microscopic examination of primary CNS lymphoma is characterized by dense infiltrates of large lymphocytes with irregular nuclei. The tumor cells can display a prominent vasocentric pattern and infiltrate blood vessel walls. Areas of necrosis may be present. Contributed by Dr Beth Levy, Saint Louis University School of Medicine, St Louis, Missouri.
 
 
 
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