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Vidal JE. HIV-Related Cerebral Toxoplasmosis Revisited: Current Concepts and Controversies of an Old Disease. J Int Assoc Provid AIDS Care 2019; 18:2325958219867315. [PMID: 31429353 PMCID: PMC6900575 DOI: 10.1177/2325958219867315] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 06/14/2019] [Accepted: 06/28/2019] [Indexed: 01/06/2023] Open
Abstract
Cerebral toxoplasmosis is the most common cause of expansive brain lesions in people living with HIV/AIDS (PLWHA) and continues to cause high morbidity and mortality. The most frequent characteristics are focal subacute neurological deficits and ring-enhancing brain lesions in the basal ganglia, but the spectrum of clinical and neuroradiological manifestations is broad. Early initiation of antitoxoplasma therapy is an important feature of the diagnostic approach of expansive brain lesions in PLWHA. Pyrimethamine-based regimens and trimethoprim-sulfamethoxazole (TMP-SMX) seem to present similar efficacy, but TMP-SMX shows potential practical advantages. The immune reconstitution inflammatory syndrome is uncommon in cerebral toxoplasmosis, and we now have more effective, safe, and friendly combined antiretroviral therapy (cART) options. As a consequence of these 2 variables, the initiation of cART can be performed within 2 weeks after initiation of antitoxoplasma therapy. Herein, we will review historical and current concepts of epidemiology, diagnosis, and treatment of HIV-related cerebral toxoplasmosis.
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Affiliation(s)
- José Ernesto Vidal
- Departamento de Neurologia, Instituto de Infectologia Emílio Ribas, São
Paulo, Brazil
- Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clínicas
HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Laboratório de Investigação Médica em Protozoologia, Bacteriologia e
Resistência Antimicrobiana (LIM 49), Instituto de Medicina Tropical, Universidade de São
Paulo, São Paulo, Brazil
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Moulignier A, Lamirel C, Picard H, Lebrette MG, Amiel C, Hamidi M, Polivka M, Mikol J, Cochereau I, Pialoux G. Long-term AIDS-related PCNSL outcomes with HD-MTX and combined antiretroviral therapy. Neurology 2017; 89:796-804. [PMID: 28747447 DOI: 10.1212/wnl.0000000000004265] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 05/30/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess the characteristics and outcomes of patients with AIDS-related primary CNS lymphoma (AR-PCNSL) in the combined antiretroviral therapy (cART) era systematically treated with high-dose methotrexate (HD-MTX). METHODS We retrospectively analyzed (intention-to-treat analysis) 51 consecutive patients with AR-PCNSL (median age 39 years) who were diagnosed from 1996 to 2014 and treated with a median of 6 (range 1-15) infusions of HD-MTX (3 g/m2) combined with cART. RESULTS Median all-patients' and survivors' follow-up lasted 23 (range 0-186) and 76 (range 23-186) months, respectively. At PCNSL diagnosis, 83% of the patients were on cART, median plasma HIV load was 175,600 copies/mL, and median CD4+ T-cell count was 24/μL. Median Eastern Cooperative Oncology Group performance status was 2 (range 1-4). Median overall survival (OS) was 5.7 years, with 5- and 10-year rates of 48% and 41%. Median time to progression was not reached (69% at 10 months). PCNSL was the direct cause of 14 deaths, all observed within the 10 months after its diagnosis: 6 patients died before HD-MTX could be administered, 4 had refractory disease, and 4 relapsed. Multivariate analyses retained time interval between AIDS diagnosis and PCNSL diagnosis, age at AR-PCNSL diagnosis, and deep brain structure involvement as independent OS-predictive factors. To restore effective immune function, cART tailored to HIV genotypes was started and combined with HD-MTX; no interactions and no immune reconstitution inflammatory syndrome occurred. No patient died of acute treatment-related toxicity, and 21 of 51 (41%) patients experienced grade 3/4 toxicity. CONCLUSIONS Combined short-term HD-MTX monochemotherapy and optimal cART simply and effectively treat AR-PCNSL, achieving long-term survival with few relapses. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that short-term HD-MTX monochemotherapy improves long-term survival of patients with AIDS with primary CNS lymphoma receiving cARTs.
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Affiliation(s)
- Antoine Moulignier
- From the Department of Neurology (A.M.), Department of Ophthalmology (C.L., I.C.), and Clinical Research Unit (H.P.), Fondation Adolphe de Rothschild, Paris; Department of Infectious and Tropical Diseases (A.M., M.-G.L., M.H., G.P.) and Department of Virology (C.A.), Assistance Publique-Hôpitaux de Paris, Hôpital Tenon-Université Paris 6; and Department of Pathology (M.P., J.M.), Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière-Université Paris 7, France.
| | - Cédric Lamirel
- From the Department of Neurology (A.M.), Department of Ophthalmology (C.L., I.C.), and Clinical Research Unit (H.P.), Fondation Adolphe de Rothschild, Paris; Department of Infectious and Tropical Diseases (A.M., M.-G.L., M.H., G.P.) and Department of Virology (C.A.), Assistance Publique-Hôpitaux de Paris, Hôpital Tenon-Université Paris 6; and Department of Pathology (M.P., J.M.), Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière-Université Paris 7, France
| | - Hervé Picard
- From the Department of Neurology (A.M.), Department of Ophthalmology (C.L., I.C.), and Clinical Research Unit (H.P.), Fondation Adolphe de Rothschild, Paris; Department of Infectious and Tropical Diseases (A.M., M.-G.L., M.H., G.P.) and Department of Virology (C.A.), Assistance Publique-Hôpitaux de Paris, Hôpital Tenon-Université Paris 6; and Department of Pathology (M.P., J.M.), Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière-Université Paris 7, France
| | - Marie-Gisèle Lebrette
- From the Department of Neurology (A.M.), Department of Ophthalmology (C.L., I.C.), and Clinical Research Unit (H.P.), Fondation Adolphe de Rothschild, Paris; Department of Infectious and Tropical Diseases (A.M., M.-G.L., M.H., G.P.) and Department of Virology (C.A.), Assistance Publique-Hôpitaux de Paris, Hôpital Tenon-Université Paris 6; and Department of Pathology (M.P., J.M.), Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière-Université Paris 7, France
| | - Corinne Amiel
- From the Department of Neurology (A.M.), Department of Ophthalmology (C.L., I.C.), and Clinical Research Unit (H.P.), Fondation Adolphe de Rothschild, Paris; Department of Infectious and Tropical Diseases (A.M., M.-G.L., M.H., G.P.) and Department of Virology (C.A.), Assistance Publique-Hôpitaux de Paris, Hôpital Tenon-Université Paris 6; and Department of Pathology (M.P., J.M.), Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière-Université Paris 7, France
| | - Mohammed Hamidi
- From the Department of Neurology (A.M.), Department of Ophthalmology (C.L., I.C.), and Clinical Research Unit (H.P.), Fondation Adolphe de Rothschild, Paris; Department of Infectious and Tropical Diseases (A.M., M.-G.L., M.H., G.P.) and Department of Virology (C.A.), Assistance Publique-Hôpitaux de Paris, Hôpital Tenon-Université Paris 6; and Department of Pathology (M.P., J.M.), Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière-Université Paris 7, France
| | - Marc Polivka
- From the Department of Neurology (A.M.), Department of Ophthalmology (C.L., I.C.), and Clinical Research Unit (H.P.), Fondation Adolphe de Rothschild, Paris; Department of Infectious and Tropical Diseases (A.M., M.-G.L., M.H., G.P.) and Department of Virology (C.A.), Assistance Publique-Hôpitaux de Paris, Hôpital Tenon-Université Paris 6; and Department of Pathology (M.P., J.M.), Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière-Université Paris 7, France
| | - Jacqueline Mikol
- From the Department of Neurology (A.M.), Department of Ophthalmology (C.L., I.C.), and Clinical Research Unit (H.P.), Fondation Adolphe de Rothschild, Paris; Department of Infectious and Tropical Diseases (A.M., M.-G.L., M.H., G.P.) and Department of Virology (C.A.), Assistance Publique-Hôpitaux de Paris, Hôpital Tenon-Université Paris 6; and Department of Pathology (M.P., J.M.), Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière-Université Paris 7, France
| | - Isabelle Cochereau
- From the Department of Neurology (A.M.), Department of Ophthalmology (C.L., I.C.), and Clinical Research Unit (H.P.), Fondation Adolphe de Rothschild, Paris; Department of Infectious and Tropical Diseases (A.M., M.-G.L., M.H., G.P.) and Department of Virology (C.A.), Assistance Publique-Hôpitaux de Paris, Hôpital Tenon-Université Paris 6; and Department of Pathology (M.P., J.M.), Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière-Université Paris 7, France
| | - Gilles Pialoux
- From the Department of Neurology (A.M.), Department of Ophthalmology (C.L., I.C.), and Clinical Research Unit (H.P.), Fondation Adolphe de Rothschild, Paris; Department of Infectious and Tropical Diseases (A.M., M.-G.L., M.H., G.P.) and Department of Virology (C.A.), Assistance Publique-Hôpitaux de Paris, Hôpital Tenon-Université Paris 6; and Department of Pathology (M.P., J.M.), Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière-Université Paris 7, France
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Outcomes for HIV-positive patients with primary central nervous system lymphoma after high-dose chemotherapy and auto-SCT. Bone Marrow Transplant 2015; 50:999-1000. [DOI: 10.1038/bmt.2015.18] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Westwood TD, Hogan C, Julyan PJ, Coutts G, Bonington S, Carrington B, Taylor B, Khoo S, Bonington A. Utility of FDG-PETCT and magnetic resonance spectroscopy in differentiating between cerebral lymphoma and non-malignant CNS lesions in HIV-infected patients. Eur J Radiol 2013; 82:e374-9. [PMID: 23578921 DOI: 10.1016/j.ejrad.2013.03.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 03/12/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE In HIV infected patients, MRI cannot reliably differentiate between central nervous system (CNS) lymphoma and non-malignant CNS lesions, particularly cerebral toxoplasmosis (CTOX). This study prospectively investigates the utility of FDG PET-CT and magnetic resonance spectroscopy (MRS) in discriminating CNS lymphoma from non-malignant CNS lesions in HIV infected patients, and assesses the ability of FDG PET-CT to guide the use of early brain biopsy. METHODS 10 HIV patients with neurological symptoms and contrast enhancing lesions on MRI were commenced on anti-toxoplasmosis therapy before undergoing FDG PET-CT and MRS. Brain biopsies were sought in those with FDG PET-CT suggestive of CNS lymphoma, and in those with a negative FDG PET-CT scan who failed to respond to therapy. Final diagnosis was based on histology or treatment response. RESULTS Two patients were confirmed to have CNS lymphoma and FDG PET-CT was consistent with this diagnosis in both. Six patients had cerebral toxoplasmosis in all of whom FDG PET-CT was consistent with non-malignant disease. One patient had progressive multifocal leukoencephalopathy (PML), FDG PET-CT was equivocal. One patient had a haemorrhagic brain metastasis and FDG PET-CT wrongly suggested non-malignant disease. MRS was performed successfully in eight subjects: three results were suggestive of CNS lymphoma (one true positive, two false positive), four suggested CTOX (two false negative, two true negative), one scan was equivocal. CONCLUSION FDG PET-CT correctly identified all cases of CNS lymphoma and CTOX, supporting its use in this situation. MRS was unhelpful in our cohort.
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Affiliation(s)
- Thomas D Westwood
- Department of Radiology, The Christie NHS Foundation Trust, Wilmslow Road, Manchester, United Kingdom.
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Nagai H, Odawara T, Ajisawa A, Hagiwara S, Watanabe T, Uehira T, Uchiumi H, Yotsumoto M, Miyakawa T, Watanabe A, Kambe T, Konishi M, Saito S, Takahama S, Tateyama M, Okada S. Whole brain radiation alone produces favourable outcomes for AIDS-related primary central nervous system lymphoma in the HAART era. Eur J Haematol 2010; 84:499-505. [DOI: 10.1111/j.1600-0609.2010.01424.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kreisl TN, Panageas KS, Elkin EB, Deangelis LM, Abrey LE. Treatment patterns and prognosis in patients with human immunodeficiency virus and primary central system lymphoma. Leuk Lymphoma 2008; 49:1710-6. [PMID: 18661394 DOI: 10.1080/10428190802238560] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The incidence of human immunodeficiency virus (HIV)-associated primary central nervous system lymphoma (PCNSL) has decreased in the era of highly active anti-retroviral therapy, but PCNSL continues to be a prominent AIDS-defining illness. Using surveillance epidemiology and end results, cancer registry data linked with Medicare, we identified PCNSL cases diagnosed from 1994 to 2002. The effects of comorbidity, year of diagnosis, and sociodemographic characteristics on the odds of receiving treatment were assessed. One hundred and eighty-four patients with both HIV and PCNSL were identified. Forty-six per cent were treated with radiation therapy (RT) alone, 10% received RT and chemotherapy, 4% received chemotherapy alone, and 40% received no treatment. No time trends in treatment patterns were observed, and no sociodemographic factors were associated with receipt of treatment. Median survival was 2 months. Age did not impact survival. Survival was improved for patients diagnosed with PCNSL after 1996 (p = 0.028). Despite improved treatment for both diseases over the past decade, survival remains dismal in this cohort of Medicare/Medicaid beneficiaries with HIV-related PCNSL. These results may not apply to the general HIV population.
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Affiliation(s)
- Teri N Kreisl
- Neuro-Oncology Branch, National Cancer Institute, Bethesda, MD 20892, USA.
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Primary central nervous system lymphoma. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/s0072-9752(07)85015-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Bower M, Powles T, Nelson M, Mandalia S, Gazzard B, Stebbing J. Highly Active Antiretroviral Therapy and Human Immunodeficiency Virus–Associated Primary Cerebral Lymphoma. ACTA ACUST UNITED AC 2006; 98:1088-91. [PMID: 16882946 DOI: 10.1093/jnci/djj302] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
From a cohort of 9621 human immunodeficiency virus type 1-infected individuals, we identified 61 patients with primary central nervous system lymphoma (PCL) who had a median survival of 1.3 months. We compared clinicopathologic variables of patients who were treated in the pre-highly active antiretroviral therapy (HAART) and HAART eras and investigated whether exposure to antiretroviral agents with differing cerebrospinal fluid penetrations was associated with risk for PCL. All statistical tests were two-sided. Incidence of PCL was lower in the HAART era (1.2 cases per 1000 patient-years, 95% confidence interval [CI] = 0.8 to 1.9) than in the pre-HAART era (three cases per 1000 years, 95% CI = 2.1 to 4.0; P<.001), and overall survival was longer (median survival = 32 days, range = 5-315 days, versus 48 days, range = 15-1136 days; log rank P = .03). In the HAART era, fewer patients had prior acquired immunodeficiency syndrome-defining illnesses than in the pre-HAART era (64% versus 90%; P = .013), and patients were more likely to have the diagnosis of PCL confirmed histologically or by polymerase chain reaction (77% versus 26%; P<.001). Exposure to specific antiretroviral agents was not associated with risk for PCL.
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Affiliation(s)
- Mark Bower
- Department of Oncology and HIV Medicine, The Chelsea and Westminster Hospital, 369 Fulham Rd., London SW10 9NH, United Kingdom
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Bower M, Palmieri C, Dhillon T. AIDS-related malignancies: changing epidemiology and the impact of highly active antiretroviral therapy. Curr Opin Infect Dis 2006; 19:14-9. [PMID: 16374212 DOI: 10.1097/01.qco.0000200295.30285.13] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Three cancers in people with HIV denote an AIDS diagnosis: Kaposi's sarcoma, high-grade B-cell non-Hodgkin's lymphoma and invasive cervical cancer. In addition a number of other cancers occur at increased frequency in this population group but are not AIDS-defining illnesses. This review discusses the impact of highly active antiretroviral therapy on the epidemiology and outcome of AIDS-defining cancers. RECENT FINDINGS The incidence of both Kaposi's sarcoma and non-Hodgkin's lymphoma has declined in the era of highly active antiretroviral therapy and the outcome of both tumours has improved. Moreover, highly active antiretroviral therapy alone produces a response in a majority of antiretroviral-naïve patients with Kaposi's sarcoma. In contrast, highly active antiretroviral therapy has had little impact on the incidence of human papilloma virus-associated tumours (cervical and anal cancer) in people with HIV, although it may improve survival by reducing opportunistic infection deaths. As people with HIV live longer with highly active antiretroviral therapy, an increased incidence of other non AIDS-defining cancers that have no known association with oncogenic infections is becoming apparent. SUMMARY For those with access to highly active antiretroviral therapy, the good news from the AIDS-defining cancers - particularly Kaposi's sarcoma and non-Hodgkin's lymphoma - may be balanced by the increasing numbers of non AIDS-defining cancers.
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Affiliation(s)
- Mark Bower
- Department of Oncology, Chelsea and Westminster Hospital, London, UK.
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Bower M, Stebbing J. AIDS-associated malignancies. CANCER CHEMOTHERAPY AND BIOLOGICAL RESPONSE MODIFIERS 2005; 22:687-706. [PMID: 16110634 DOI: 10.1016/s0921-4410(04)22030-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Mark Bower
- Department of Oncology, Chelsea & Westminster Hospital, London, UK.
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Stebbing J, Gazzard B, Mandalia S, Teague A, Waterston A, Marvin V, Nelson M, Bower M. Antiretroviral Treatment Regimens and Immune Parameters in the Prevention of Systemic AIDS-Related Non-Hodgkin's Lymphoma. J Clin Oncol 2004; 22:2177-83. [PMID: 15169806 DOI: 10.1200/jco.2004.11.097] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Immunosuppression induced by HIV-1 increases the risk of developing non-Hodgkin's lymphoma (NHL). We measured the influence of immunologic factors and highly active antiretroviral therapy (HAART) on this risk. As there are no data demonstrating that specific antiretroviral regimens are effective at protecting from NHL, we compared different HAART regimens. Patients and Methods The protective effect of HAART regimens, containing protease inhibitors (PI) and/or non-nucleoside reverse transcriptase inhibitors (NNRTIs) on the development of NHL was examined in a prospectively recorded cohort of 9,621 HIV-infected individuals. Lymphocyte and natural killer subset data were also entered in univariate and multivariate analyses to establish and stratify the risk of NHL. Results From this cohort of 9,621 patients, 102 have been diagnosed with systemic AIDS-related NHL since 1996, when HAART became freely available here. By univariate analysis, increased age, higher nadir CD4 and CD8 T-cell counts, CD19 B-cell count, CD16/56 natural killer count and exposure to NNRTI or PI containing HAART conferred significant protection against NHL (P < .05). In a multivariate analysis, age, nadir CD4 and CD8 T-cell counts, and exposure to HAART were independent predictors of risk of NHL (P < .02). NNRTI-based HAART (adjusted rate ratio, 0.4; 95% CI, 0.3 to 0.5) was as protective as PI-based HAART, and these were significantly more protective than nucleoside analogues alone (rate ratio, 0.5; 95% CI, 0.4 to 0.7) or no antiretrovirals (P < .001). Conclusion Effective HAART-induced maintenance of CD4 and CD8 counts protects from systemic AIDS-related NHL.
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Affiliation(s)
- Justin Stebbing
- Department of Oncology, The Chelsea and Westminster Hospital, 369 Fulham Rd, London SW10 9NH, United Kingdom
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Stebbing J, Marvin V, Bower M. The evidence-based treatment of AIDS-related non-Hodgkin’s lymphoma. Cancer Treat Rev 2004; 30:249-53. [PMID: 15059648 DOI: 10.1016/j.ctrv.2003.12.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
As we enter the third decade of the AIDS epidemic, it is apparent that a large number of cancers are more common in people with the human immunodeficiency virus type 1 (HIV). Non-Hodgkin's lymphoma (NHL) remains the second most common tumour in such patients. At the onset of the epidemic, dose-intense combination regimens were used but these were quickly abandoned in favour of dose-modified strategies because of difficulties in tolerating aggressive chemotherapy in the presence of underlying immunosuppression. With the improvements in supportive care including more effective anti-retroviral therapies, colony-stimulating factors and prophylaxis against opportunistic infections, we are returning to the traditional chemotherapeutic approaches similar to those utilised in the non-HIV infected individual including infusional regimens. In this review, we discuss the evidence for choosing particular therapies in patients with AIDS-related NHL.
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MESH Headings
- Administration, Oral
- Adult
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antiretroviral Therapy, Highly Active/methods
- Drug Therapy, Combination
- Evidence-Based Medicine
- Female
- Humans
- Infusions, Intravenous
- Lymphoma, AIDS-Related/diagnosis
- Lymphoma, AIDS-Related/drug therapy
- Lymphoma, AIDS-Related/epidemiology
- Lymphoma, Non-Hodgkin/diagnosis
- Lymphoma, Non-Hodgkin/drug therapy
- Lymphoma, Non-Hodgkin/epidemiology
- Male
- Middle Aged
- Prognosis
- Randomized Controlled Trials as Topic
- Recurrence
- Risk Assessment
- Severity of Illness Index
- Survival Analysis
- Treatment Outcome
- United Kingdom/epidemiology
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Affiliation(s)
- Justin Stebbing
- Medical Day Unit, Department of Oncology, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK
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Newell ME, Hoy JF, Cooper SG, DeGraaff B, Grulich AE, Bryant M, Millar JL, Brew BJ, Quinn DI. Human immunodeficiency virus-related primary central nervous system lymphoma. Cancer 2004; 100:2627-36. [PMID: 15197806 DOI: 10.1002/cncr.20300] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The current study evaluated factors influencing survival in patients diagnosed with human immunodeficiency virus (HIV)-related primary central nervous system lymphoma (PCNSL), with a focus on the effects of therapeutic radiotherapy (RT) and highly active antiretroviral therapy (HAART). METHODS A retrospective chart review of patients with a diagnosis of HIV-related PCNSL at one of five university hospitals between 1987 and 1998 was performed. Clinical details including antiretroviral agent use, brain imaging scan results, RT use, and survival outcomes were recorded. RESULTS One hundred eleven patients with HIV-related PCNSL were identified. The annual incidence decreased significantly between 1992 and 1995 and between 1996 and 1998 (P = 0.04). The median survival period was 50 days (mean, 109 days; range, 4-991 days), with improved survival for patients diagnosed after 1993. Patients treated with two or more antiretroviral agents had improved survival (P = 0.01), as did patients who received RT (P < 0.0001). For patients who received RT, completion of the prescribed course and treatment to > or = 30 Gray (Gy) independently predicted a more favorable outcome. RT used in conjunction with antiretroviral therapy involving two or more agents had an additive positive effect on survival. For patients who did not receive RT, poor performance status and encephalopathy predicted a shorter survival duration. CONCLUSIONS The results of the current study suggest that HAART and treatment with RT to > or = 30 Gy improve survival for patients with HIV-related PCNSL. This combination of therapies may provide a standard of care as the basis for further trials of chemotherapy, novel adjunctive treatment, and quality of life assessment.
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Affiliation(s)
- Mark E Newell
- National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, Australia
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Skiest DJ, Crosby C. Survival is prolonged by highly active antiretroviral therapy in AIDS patients with primary central nervous system lymphoma. AIDS 2003; 17:1787-93. [PMID: 12891064 DOI: 10.1097/00002030-200308150-00007] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the effects of highly active antiretroviral therapy (HAART) on survival in AIDS-related primary central nervous system lymphoma (PCNSL). METHODS Survival in consecutive patients with PCNSL at a large county teaching hospital from 1995 to 2001 were analyzed by the log rank test and Cox proportional hazards ratios (HR) were calculated for factors potentially affecting survival. RESULTS During the study period, 25 patients were diagnosed with PCNSL: 19 definite and 6 probable. At diagnosis, median CD4 cell count was 12 x 10(6) cells/l (range 1-151) and median HIV viral load was 5.3 log(10) copies/ml (range 3.9-5.9). Sixteen patients died (median survival 87 days; range, 0 to > 2112). Longer survival was noted for patients who received HAART after diagnosis [HR for death, 0.06; 95% confidence interval (CI), 0.01-0.48]. Six of seven HAART-treated patients were alive versus 0/18 untreated patients at a median follow-up time of 667 days (P = 0.0007 by log rank test). A survival benefit was seen for patients who had >/= 0.5 log(10) copies/ml decrease in HIV viral load after diagnosis (n = 6; HR, 0.07; 95% CI, 0.01-0.55) and for patients with a significant CD4 cell rebound (increase >/= 50 x 106 cells/l) in response to HAART (n = 6): all survived versus 0/19 survived (P = 0.0003). Cranial radiation therapy (n = 13) prolonged survival (HR, 0.20; 95% CI, 0.07-0.58). Median survival was only 29 days for 11 patients who received neither radiation nor HAART. CONCLUSIONS Receipt of HAART after diagnosis is associated with a significantly longer survival in patients with AIDS-related CNS lymphoma.
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Affiliation(s)
- Daniel J Skiest
- The University of Texas Southwestern Medical Center, Division of Infectious Diseases, 5323 Harry Hines Blvd, Dallas, TX 75390-9113, USA
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Aboulafia DM. Interleukin-2, ganciclovir, and high-dose zidovudine for the treatment of AIDS-associated primary central nervous system lymphoma. Clin Infect Dis 2002; 34:1660-2. [PMID: 12032910 DOI: 10.1086/340724] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Skiest DJ. Focal neurological disease in patients with acquired immunodeficiency syndrome. Clin Infect Dis 2002; 34:103-15. [PMID: 11731953 DOI: 10.1086/324350] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Focal neurological disease in patients with acquired immunodeficiency syndrome may be caused by various opportunistic pathogens and malignancies, including Toxoplasma gondii, progressive multifocal leukoencephalopathy (PML), cytomegalovirus (CMV), and Epstein-Barr virus-related primary central nervous system (CNS) lymphoma. Diagnosis may be difficult, because the findings of lumbar puncture, computed tomography (CT), and magnetic resonance imaging are relatively nonspecific. Newer techniques have led to improved diagnostic accuracy of these conditions. Polymerase chain reaction (PCR) of cerebrospinal fluid specimens is useful for diagnosis of PML, CNS lymphoma, and CMV encephalitis. Recent studies have indicated the diagnostic utility of new neuroimaging techniques, such as single-photon emission CT and positron emission tomography. The combination of PCR and neuroimaging techniques may obviate the need for brain biopsy in selected cases. However, stereotactic brain biopsy, which is associated with relatively low morbidity rates, remains the reference standard for diagnosis. Highly active antiretroviral therapy has improved the prognosis of several focal CNS processes, most notably toxoplasmosis, PML, and CMV encephalitis.
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Affiliation(s)
- Daniel J Skiest
- Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX 75390-9113 , USA.
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18
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Cohen K, Scadden DT. Non-Hodgkin's lymphoma: pathogenesis, clinical presentation, and treatment. Cancer Treat Res 2001; 104:201-30. [PMID: 11191128 DOI: 10.1007/978-1-4615-1601-9_7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
MESH Headings
- Acquired Immunodeficiency Syndrome/complications
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Antiretroviral Therapy, Highly Active
- Antiviral Agents/therapeutic use
- Bleomycin/therapeutic use
- California
- Clinical Trials as Topic
- Combined Modality Therapy
- Cyclophosphamide/therapeutic use
- Dexamethasone/therapeutic use
- Doxorubicin/therapeutic use
- Herpesvirus 4, Human/isolation & purification
- Herpesvirus 8, Human/isolation & purification
- Homosexuality, Male
- Humans
- Infusions, Intravenous
- Lymphoma, B-Cell/pathology
- Lymphoma, Non-Hodgkin/complications
- Lymphoma, Non-Hodgkin/drug therapy
- Lymphoma, Non-Hodgkin/pathology
- Lymphoma, T-Cell/pathology
- Male
- Prognosis
- Registries
- Vincristine/therapeutic use
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Affiliation(s)
- K Cohen
- Massachusetts General Hospital, Dana-Farber/Harvard Cancer Center, Partners AIDS Research Center, Harvard Medical School, USA
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Chow KU, Mitrou PS, Geduldig K, Helm EB, Hoelzer D, Brodt HR. Changing incidence and survival in patients with aids-related non-Hodgkin's lymphomas in the era of highly active antiretroviral therapy (HAART). Leuk Lymphoma 2001; 41:105-16. [PMID: 11342362 DOI: 10.3109/10428190109057959] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
To determine role of highly active antiretroviral therapy (HAART) and additional factors in incidence and outcome of patients with AIDS-related non-Hodgkin's lymphomas (NHL) we retrospectively analyzed 257 cases of AIDS-related NHL (24 low-grade, 168 high-grade B-cell, 6 high-grade T-cell, and 59 primary CNS lymphomas (PCNSL) among 2004 patients with HIV-infection treated at the University Hospital of Frankfurt, Germany from January 1983 to May 1999. Data were evaluated by univariate and multivariate analyses, using overall survival as end point. Patients received CHOP-like therapy as standard treatment. Until May 1999 incidence of all diagnosed cases of NHL was decreasing (1991-94: 14.2% versus 1995-5/99: 12.8%). Mainly, the incidence of low-grade NHL and PCNSL clearly decreased whereas the incidence of high-grade B-cell NHL increased compared to all diagnosed cases of NHL (1983-86: 53.3% versus 1995-5/99: 78.6%). One-year survival probability of all screened patients with AIDS related NHL was 54%, while 5-year survival rate remained 5%. We found age <25 years, development of NHL in the years before 1990, IVDU, CD4 counts <150/microl, PCNSL as well as NHL as the AIDS index disease, to be highly significant independent predictors of poor survival, including increased hazard ratios. In the era of HAART incidence of NHL is decreasing, mainly the incidence of low-grade NHL and PCNSL. Overall survival of patients has been prolonged with HAART. This development is mainly due to improvement of antiretroviral therapy, rather than to any fundamental changes in the chemotherapeutic treatment of NHL. Therefore, new treatment approaches for AIDS-related NHL should focus on more efficient antiretroviral therapy in association with combination chemotherapy.
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Affiliation(s)
- K U Chow
- Johann-Wolfgang Goethe University, Department of Internal Medicine III, Hematology/ Oncology and Infectious Diseases, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
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Changes in acquired immunodeficiency syndrome–related lymphoma since the introduction of highly active antiretroviral therapy. Blood 2000. [DOI: 10.1182/blood.v96.8.2730.h8002730_2730_2734] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Clinical data on 7840 HIV-positive patients, representing 43 745 patient-years of follow-up, has been collected. All patients with ARL since 1986 (n = 150) were assessed at presentation for prognostic factors and outcomes recorded. Comparisons are made between cases in the pre-HAART era (1988-1995), and the HAART era (1996-1999). Statistical models are used to calculate the incidence of ARL and factors predicting its development. The incidence of ARL has not changed over time (3 to 7 of 1000 patients per year,P = .933), but contributes to a greater percentage of first AIDS-defining illnesses (ADI) in the HAART era (P ≤ .0001). Older age, nadir CD4 count, and no prior HAART use, predict the development of ARL. There has been no change in stage at presentation, presence of B symptoms, performance status, or marrow involvement between the 2 time cohorts or between patients with or without prior HAART exposure. Similarly, there is no difference in survival duration between the pre-HAART and HAART era (log rankP = .15) or specifically in patients treated with HAART before ARL diagnosis (log rank P = .12). The use of HAART has not yet been shown to influence the incidence or survival of ARL. However, because nadir CD4 count and use of HAART are independent predictors of ARL development, this may translate into a future fall in new cases.
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Changes in acquired immunodeficiency syndrome–related lymphoma since the introduction of highly active antiretroviral therapy. Blood 2000. [DOI: 10.1182/blood.v96.8.2730] [Citation(s) in RCA: 157] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Clinical data on 7840 HIV-positive patients, representing 43 745 patient-years of follow-up, has been collected. All patients with ARL since 1986 (n = 150) were assessed at presentation for prognostic factors and outcomes recorded. Comparisons are made between cases in the pre-HAART era (1988-1995), and the HAART era (1996-1999). Statistical models are used to calculate the incidence of ARL and factors predicting its development. The incidence of ARL has not changed over time (3 to 7 of 1000 patients per year,P = .933), but contributes to a greater percentage of first AIDS-defining illnesses (ADI) in the HAART era (P ≤ .0001). Older age, nadir CD4 count, and no prior HAART use, predict the development of ARL. There has been no change in stage at presentation, presence of B symptoms, performance status, or marrow involvement between the 2 time cohorts or between patients with or without prior HAART exposure. Similarly, there is no difference in survival duration between the pre-HAART and HAART era (log rankP = .15) or specifically in patients treated with HAART before ARL diagnosis (log rank P = .12). The use of HAART has not yet been shown to influence the incidence or survival of ARL. However, because nadir CD4 count and use of HAART are independent predictors of ARL development, this may translate into a future fall in new cases.
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