Neurosurgery

60 Gy (40 Gy to the whole brain, 20 Gy boost to the tumor and its margin) [23].

The optimal extent of radiation is also controversial. Radiation may be administered to the involved field, the whole brain or the entire cranio-spinal axis. Historically, whole-brain irradiation has been the standard treatment, even though its advantage relative to other protocols has never been definitively established [6,22]. In fact, one review reports a median survival of 40 months for local treatment and 25.3 months for whole-brain irradiation, although this difference may merely reflect selection bias [22]. Radiating the entire cranio-spinal axis prophylactically is not warranted. The potential for radiation toxicity and the fact that the survival of most patients with spinal disease is determined by control of cerebral tumor argue against using prophylactic spinal radiation. Spinal irradiation is reserved for patients with spinal disease, demonstrated radiographically or by CSF cytology.

Radiation therapy yields both clinical and radiographic response in AIDS-related primary CNS lymphoma, but the median survival in this population remains poor, ranging from 2 to 5.5 months [24]. Younger age and higher Karnofsky performance status at the time of treatment correlate with better outcome.

The complications of radiation therapy for primary CNS lymphoma are the same as those seen with radiation in any setting. The acute toxicities include headaches, nausea/vomiting and local skin reactions. Chronic complications include cognitive impairment and radiation necrosis of brain tissue. The risk of late neurologic sequelae increases with higher radiation dose and with age.

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