Miralles Pilar, Berenguer Juan, Ribera Josep-Maria
Unidad de Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
Med Clin (Barc). 2010 Sep 18;135(9):417-22. doi: 10.1016/j.medcli.2009.04.047. Epub 2009 Jul 22.
With the widespread use of highly active antiretroviral therapy (HAART) the incidence of systemic non-Hodgkin lymphoma (NHL) in patients infected with the Human Immunodeficiency Virus (HIV) has declined. HAART has also modified the clinical manifestations of these tumors, with a lower frequency of involvement of the central nervous system (CNS). Currently, the frequency of meningeal involvement at the time of diagnosis of NHL in HIV-infected patients varies between 3% and 5%. These figures are similar to those observed among immunocompetent hosts. The diagnosis of meningeal lymphoma relies in clinical findings, imaging techniques, and cerebrospinal fluid (CSF) examination. Flow cytometry is a diagnostic technique with a higher sensitivity and specificity than conventional cytology for the diagnosis of meningeal lymphoma. However, flow cytometry is not yet considered to be the gold standard for this purpose. Until recently, most experts recommended neuromeningeal prophylaxis for all HIV-infected patients with aggressive NHL. However, at present this prophylaxis is recommended only in patients with higher risk of CNS relapse according to different sites of involvement, stage and histological subtype. There are different regimens of prophylaxis and treatment for meningeal lymphoma. The drugs most commonly used for this purpose are methotrexate and cytosine arabinoside. However, there are other alternatives such as liposomal cytosine arabinoside that requires fewer spinal taps for drug administration and whose results are very promising. In summary, in the context of an effective HAART, HIV infected patients with NHL have a frequency of CNS involvement by lymphoma similar to that found among immunocompetent hosts. Consequently, indications and regimens for CNS prophylaxis in HIV-infected patients with NHL should not be different than those employed in the general population. Universal CNS prophylaxis should be reserved for the few patients unable to receive an effective HAART.
随着高效抗逆转录病毒疗法（HAART）的广泛应用，感染人类免疫缺陷病毒（HIV）的患者中系统性非霍奇金淋巴瘤（NHL）的发病率有所下降。HAART也改变了这些肿瘤的临床表现，中枢神经系统（CNS）受累频率降低。目前，HIV感染患者诊断NHL时脑膜受累的频率在3%至5%之间。这些数字与免疫功能正常宿主中观察到的数字相似。脑膜淋巴瘤的诊断依赖于临床发现、影像学技术和脑脊液（CSF）检查。流式细胞术是一种诊断技术，对于脑膜淋巴瘤的诊断，其敏感性和特异性高于传统细胞学。然而，流式细胞术尚未被视为这一目的的金标准。直到最近，大多数专家建议对所有患有侵袭性NHL的HIV感染患者进行神经脑膜预防。然而，目前仅建议根据受累部位、分期和组织学亚型，对有较高CNS复发风险的患者进行这种预防。脑膜淋巴瘤有不同的预防和治疗方案。最常用于此目的的药物是甲氨蝶呤和阿糖胞苷。然而，还有其他替代药物，如脂质体阿糖胞苷，其给药时所需的腰椎穿刺次数较少，且效果非常有前景。总之，在有效的HAART背景下，感染HIV的NHL患者中淋巴瘤累及CNS的频率与免疫功能正常宿主中发现的频率相似。因此，感染HIV的NHL患者中CNS预防的指征和方案不应与普通人群中使用的不同。普遍的CNS预防应仅保留给少数无法接受有效HAART的患者。
