Staging Workup Of The Patient With Aidslymphoma

Routine evaluation of the patient with AIDS-lymphoma must include an assessment of the HIV disease, as well as the lymphoma. Because the level of CD4 cells will predict prognosis in such patients (43,44), determination of CD4 and CD8 cell counts prior to therapy is indicated, as well as an assessment of HIV viral load. Because AIDS-related opportunistic infections are a common cause of death in patients with AIDS-lymphoma, every effort should be made to control the HIV infection.

Blood work is obtained at baseline, including assessment of renal and hepatic function, complete blood count, and level of lactate dehydrogenase (LDH). Elevated LDH levels have prognostic impact, portending a worse prognosis (45). Uric acid levels may be elevated, owing to spontaneous tumor cell lysis. Hypercalcemia may also occur.

Computerized axial tomographic (CAT) scans are routinely performed in patients with known or suspected lymphoma. Mass lesions are expected in the organ(s) of involvement. Abdominal CAT scans reveal evidence of focal lymphomatous insolvent, documented in 58 or 59 such patients who presented with predominant signs and symptoms related to the abdomen, and in 14 (26%) of 53 of those who had no specific abdominal symptoms (46). Focal hepatic lesions are expected with liver involvement, varying from solitary to innumerable, and ranging from relatively small (1 cm) nodules to large masses, > 15 cm in diameter. Mass lesions in other extranodal sites are also routinely encountered. Involvement of the lung is associated with interstitial infiltrates, pulmonary nodules, and/or alveolar lung disease; pleural effusions may also be present. Generalized or localized lymphadenopathy is also expected on CAT scan.

Gallium-67 scanning can be particularly useful in patients with AIDS-lymphoma, and may differentiate malignant lymphoma from reactive lymphadenopathy (47). High- and intermediate-grade lymphomas are almost always gallium avid, and the gallium scan may be useful in identifying lesions that have not yet caused specific organ or nodal enlargement on CAT scan. Aside from its known sensitivity and specificity in lymphoma, gallium-67 scanning may be particularly useful in the assessment of residual, stable masses after the completion of chemotherapy. These residual masses may occur in as many as 40% of patients with lymphoma who have been successfully treated, and are believed secondary to residual fibrosis in the area.

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