AIDS-related central nervous system lymphomas.

PURPOSE: To evaluate combined radio-chemotherapy in patients with AIDS-related lymphomatous meningitis (LM) or primary central nervous system lymphoma (PCNSL). PATIENTS AND METHODS: Eighteen men and 2 women with AIDS had cytologically documented LM. Fifteen patients had systemic non-Hodgkin's lymphoma with LM and 5 patients had PCNSL with CSF dissemination. Standardized pre-treatment evaluations included contrast cranial MRI, placement of an intraventricular reservoir, contrast spine MRI, ophthalmologic evaluation and 111Indium-DTPA CSF flow studies. Regions of bulky or symptomatic disease were treated with limited-field irradiation. Concurrent systemic chemotherapy was administered in 18 patients. All patients were scheduled to receive intraventricular methotrexate (MTX) according to a concentration x time (C x T) drug schedule. In cytologic or clinical failures, patients were treated with salvage therapy using intraventricular ara-C and in a similar manner, patients were treated with intraventricular thio-TEPA following cytologic relapse or clinical failure intraventricular following intraventricular ara-C. Sixty-seven patients (63 men; 4 women) with PCNSL underwent a standardized pre-treatment evaluation as in patients with LM and were treated according to 3 schedules. In the first group (n = 15), comfort care was offered. In the second group (n = 45), whole brain radiotherapy was administered. In the third group (n = 7), patients were treated with combined radio- and chemotherapy using systemic procarbazine, CCNU and vincristine (PCV-3). The third group was selected based on a Karnofsky performance status > or =60, no evidence of disseminated PCNSL, a CD4 count >200, no concurrent opportunistic infection and a patient's desire for aggressive therapy.
RESULTS: In the LM patient group, 16 patients were evaluable as 4 patients subsequently withdrew consent for treatment. Median time to tumor progression/survival were as follows: not-treated (n = 4) 12 days/ month; treated non-responding (n = 6) 30 days/2 months; and treated responding (n = 10) 130 days/6 months. In the PCNSL patient group, median range survival were as follows: comfort care (n = 15) 1.5/0.5-3 months; whole brain radiotherapy (n = 45) 4/1.5-5 months; and combined radio-chemotherapy (n = 7) 13/10-18 months.
CONCLUSIONS: Combined radio- and chemotherapy is appropriate for a small subset of patients with AIDS and either LM or PCNSL. This approach results in meaningful palliation not strikingly dissimilar from that seen in non-AIDS patients.