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6–82 | Clinical Manual for Management of the HIV-Infected Adult/2006
P: Plan
Diagnostic Evaluation
Definitive diagnosis of lymphoma requires identification
of lymphomatous cells, usually obtained by excisional
biopsy.
Biopsy of lymph node or other site
Rapidly expanding or otherwise abnormal lymph nodes
or masses should be biopsied. Fine needle aspiration
(FNA) biopsy may determine the diagnosis, but
excisional biopsy should be obtained if the FNA is
unrevealing. (Also, FNA may not yield enough cells for
definitive diagnosis). See chapter Lymphadenopathy for
more information.
Other that studies help to determine the extent of
involvement, rule out other diseases, and determine the
patient’s clinical status include complete blood count
(CBC) with differential, liver function tests, electrolyte
and lactate dehydrogenase (LDH) measurements,
and peripheral blood smear. (Otherwise-unexplained
cytopenias and peripheral blood smear abnormalities
may suggest bone marrow involvement. Elevated
LDH is nonspecific but may be seen in patients with
lymphoma.)
Perform blood cultures, MAC culture, tuberculosis
studies, serum cryptococcal antigen, or other laboratory
work as indicated by the patient’s symptoms.
Radiographic studies
Patients with unexplained CNS symptoms or signs
should receive brain imaging by computed tomography
(CT) scan with contrast or magnetic resonance imaging
(MRI); MRI is the more sensitive study. See chapter
Neurologic Symptoms for more information.
Perform chest x-ray and CT scans of other areas
as indicated by the patient’s presentation. Positron
emission tomography or gallium scanning also may be
used to assess the extent of the disease.
Cerebrospinal fluid studies
Lumbar puncture (LP) should be performed in all
persons diagnosed with NHL and in those suspected
of having CNS lymphoma (brain imaging should be
obtained first to rule out the presence of mass lesions
that might cause herniation upon LP). Studies should
include cytology, cell count, protein and glucose
measurements, and any studies needed to rule out
infections or other causes of the patient’s symptoms (eg,
bacterial, mycobacterial, and fungal cultures).
Bone marrow biopsy
This procedure may yield the diagnosis if other
studies are negative. It also should be performed for
patients with known NHL to assess for bone marrow
involvement.
Treatment
If possible, patients should be evaluated and treated by
an oncologist experienced in the treatment of HIVrelated
malignancies. Systemic chemotherapy is the
only curative treatment, but the optimal treatment for
AIDS-related NHL has not been defined. The standard
regimen for advanced disease is R-CHOP (rituximab,
cyclophosphamide, doxorubicin, vincristine, and
prednisone), though the specific treatment will depend
on the specific type of lymphoma and on patient
characteristics. In patients with very low CD4 cell
counts, rituximab may be withheld because of the risks
of further immunosuppression. Patients with meningeal
involvement should receive concomitant intrathecal
chemotherapy (medication given directly into the CNS
via a lumbar puncture or Ommaya reservoir) using
methotrexate and cytarabine.
Patients treated with ART in addition to chemotherapy
appear to have better survival rates than do those treated
with chemotherapy alone. Therefore, all patients should
receive ART, if possible, in addition to chemotherapy.
Prognosis is dependent on the type and stage of the
lymphoma and on the stage of HIV disease. A CD4
count of