Treatment Of Hivassociated Primary Cerebral Lymphoma

The standard treatment modality is whole brain irradiation, but the median survival time is just 2.5 months or less. Although patients who were treated with radiotherapy or chemotherapy lived longer than those who received best supportive care only, no randomized studies have been conducted and it remains uncertain whether therapy improves survival.92 There is an increasing enthusiasm for the treatment of PCL in immunocompetent patients with both radiotherapy and chemotherapy, and recent results have been encouraging. The use of chemotherapy for PCL is limited by the poor penetration of cytotoxics into brain parenchyma due to the blood-brain barrier and the toxicity, especially myelosuppression, of these agents in patients with advanced immunosuppression and poor performance status. Combination chemotherapy prolongs survival in immunocompetent patients with PCL but at the cost of severe myelotoxicity. Singleagent chemotherapy with intravenous high-dose methotrexate and folinic acid rescue was studied in AIDS patients with PCL in the context of a prospective uncontrolled study that included 15 patients. The results showed a complete response in 47% of patients, a median survival of 19 months, a low relapse rate of approximately 14%, and no evidence of neurologic impairment nor treatment-limiting myelotoxicity.93 A controlled trial of intravenous methotrexate versus whole brain irradiation is needed to confirm these encouraging results. Now that antiretroviral therapies are improving survival, it may be necessary to reassess currently available diagnostic and treatment modalities aiming to cure HIV-associated PCL.

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