Treatment

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Treatment of any lymphoma is based on its stage and grade and the patient's ability to withstand the rigors of treatment. For AIDS patients with their high-stage, high-grade disease this means chemotherapy. When faced with patients who are immunosuppressed and have poor bone marrow reserve before treatment the oncologist must make a balanced choice between reduced doses, which may compromise benefit, and quality of life. CHOP combination chemotherapy giving cyclophosphamide, vincristine and doxorubicin with oral prednisolone is delivered three weekly. Alternatively m-BACOD (methotrexate, Bleomycin, Adrianycin, Cyclophosphamide, Vincristine, Dexamethasone), another combination regimen, can be given. These regimens are toxic to bone marrow and in order to allow second and subsequent courses to be given on time patients may require GCSF. Prophylaxis against Pneumocystis carinii pneumonia should be considered. Allopurinol should be given to patients with bulky disease to prevent gout occurring when uric acid levels rise as the tumour breaks down. Patients with positive cytology or EBV DNA detected in their cerebrospinal fluid and those with meningeal or extensive sinus or base of skull disease require concomitant intrathecal methotrexate and cytosine arabinoside. Alternative chemotherapy regimens are undergoing trials but few have proved superior to CHOP and often result in worse immunosuppression and opportunistic infections.

For patients who have poor performance status, low CD4 counts and other AIDS diseases, palliative chemotherapy of vincristine plus prednisolone can be given. Radiotherapy is also useful for the palliation of symptoms caused by bulky disease. In the rare cases where NHL in AIDS presents as Stage I or II disease radiotherapy can be used as first-line treatment, avoiding the toxicity of chemotherapy.

Median survival is better in patients obtaining a complete response initially. In most studies half the patient deaths have been due to the lymphoma with remaining deaths being due to

. r . Figure 5.10 Lymphadenopathy due to lymphoma opportunistic infections.

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