Intensive chemotherapy with cyclophosphamide, doxorubicin, high-dose methotrexate/ifosfamide, etoposide, and high-dose cytarabine (CODOX-M/IVAC) for human immunodeficiency virus-associated Burkitt lymphoma

Advances in the management of HIV-related non-Hodgkin lymphoma

PURPOSE OF REVIEW

Human immunodeficiency virus infection is associated with an increased risk of non-Hodgkin lymphoma. Even with a decrease in AIDS-defining illnesses after the advent of highly active antiretroviral therapy, HIV-associated non-Hodgkin lymphoma remains an important problem.

RECENT FINDINGS

Low CD4+ T-lymphocyte count, disease stage, performance status, serum lactate dehydrogenase, and number of extranodal sites of disease are all important prognostic factors for HIV-non-Hodgkin lymphoma. Recent studies have examined the role of infusional chemotherapy, as well as immunotherapy, in the treatment of aggressive HIV-non-Hodgkin lymphoma, and autologous stem cell transplantation for relapsed or refractory HIV-non-Hodgkin lymphoma. New developments in the association of viral infection and pathogenesis of certain subtypes of HIV-non-Hodgkin lymphoma have also recently been reported.

SUMMARY

Outcomes of HIV-non-Hodgkin lymphoma are improving with the routine use of highly active antiretroviral therapy and combination chemotherapy. For aggressive HIV-non-Hodgkin lymphoma, infusional chemotherapy regimens are well tolerated and lead to complete response in about 50-75% of cases and a 2-3 years overall survival of 40-60%. The potential benefit of adding rituximab to combination chemotherapy may be offset by infectious complications in severely immunosuppressed patients. HIV-associated Burkitt lymphoma should be treated with an intensive regimen rather than standard cyclophosphamide, doxorubicin, vincristine, prednisone-like chemotherapy. Autologous stem cell transplantation should be considered for selected patients with relapsed or refractory HIV-non-Hodgkin lymphoma.

AIDS-related non-Hodgkin lymphoma: final analysis of 485 patients treated with risk-adapted intensive chemotherapy

We aimed to compare AIDS risk–adapted intensive chemotherapy in AIDS-related lymphoma (ARL) patients before and after the advent of highly active antiretroviral therapy (HAART). A total of 485 patients aged from 18 to 67 years were randomly assigned to chemotherapy after stratification according to an HIV score based on performance status, prior AIDS, and CD4+ cell counts below 0.10 × 109/L (100/mm3). A total of 218 good-risk patients (HIV score 0) received ACVBP (doxorubicin, cyclophosphamide, vindesine, bleomycin, and prednisolone) or CHOP (doxorubicin, cyclophosphamide, vincristine, and prednisolone); 177 intermediate-risk patients (HIV score 1), CHOP or low-dose CHOP (Ld-CHOP); and 90 poor-risk patients (HIV score 2-3), Ld-CHOP or VS (vincristine and steroid). The 5-year overall survival (OS) in the good-risk group was 51% for ACVBP versus 47% for CHOP (P = .85); in the intermediate-risk group, 28% for CHOP versus 24% for Ld-CHOP (P = .19); and in the poor-risk group, 11% for Ld-CHOP versus 3% for VS (P = .14). The time-dependent Cox model demonstrated that the only significant factors for OS were HAART (relative risk [RR] 1.6, P < .001), HIV score (RR 1.7, P < .001), and the International Prognostic Index (IPI) score (RR 1.5, P < .001) but not chemotherapy regimen. Our findings indicate that in ARL patients, HIV score, IPI score, and HAART affect survival but not the intensity of the CHOP-based chemotherapy.

AIDS-related malignancies: emerging challenges in the era of highly active antiretroviral therapy

Human immunodeficiency virus (HIV)-infected patients are at increased risk of developing cancer, particularly in the later stages of acquired immune deficiency syndrome (AIDS). Despite the advent of highly active anti-retroviral therapy (HAART), malignancy in this population is a leading cause of morbidity and mortality. Kaposi's sarcoma (KS) and AIDS-related non-Hodgkin's lymphoma (ARL) are the most common AIDS-defining malignancies. AIDS-related KS varies from minimal to fulminant disease. Treatment decisions for AIDS-related KS are guided largely by the presence and extent of symptomatic disease. In addition to HAART, excellent treatments exist for both localized disease (topical gel, radiotherapy, and intralesional therapy) and advanced disease (liposomal anthracyclines, paclitaxel). Novel therapies that have become available to treat AIDS-related KS include angiogenesis inhibitors and antiviral agents. ARL comprises a heterogeneous group of malignancies. With the immune restoration afforded by HAART, standard-dose chemotherapies now can be safely administered to treat ARL with curative intent. The role of analogous treatments used in HIV-negative patients, including monoclonal antibodies and autologous stem cell transplantation, requires further clarification in HIV-positive patients. HIV-infected patients also appear to be at increased risk for developing certain non-AIDS-defining cancers, such as Hodgkin's lymphoma and multiple myeloma. Although the optimal treatment of these neoplasms is at present uncertain, recent advances in chemotherapy, antiretroviral drugs, and supportive care protocols are allowing for more aggressive management of many of the AIDS-related cancers. This article provides an up-to-date review of the epidemiology, pathogenesis, clinical features, and treatment of various AIDS-related malignancies that are likely to be encountered by an oncologist practicing in the current HAART era.

AIDS-Related Burkitt's Lymphoma Versus Diffuse Large-Cell Lymphoma in the Pre–Highly Active Antiretroviral Therapy (HAART) and HAART Eras: Significant Differences in Survival With Standard Chemotherapy

Purpose

To compare outcomes of patients with HIV-Burkitt's lymphoma (HIV-BL) and HIV-diffuse large-cell lymphoma (HIV-DLCL) after treatment with CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) or M-BACOD (methotrexate, bleomycin, cyclophosphamide, etoposide) in pre–highly active antiretroviral therapy (HAART) versus HAART eras.

Patients and Methods

Three hundred sixty-three patients with AIDS-related lymphoma diagnosed from 1982 to 2003 were reviewed retrospectively, including 262 in the pre-HAART (HIV-BL, 117; HIV-DLCL, 145) and 101 in the HAART era (HIV-BL, 18; HIV-DLCL, 83). Pre-HAART included those who did not receive HAART, and HAART era included those diagnosed after January 1997 who received HAART.

Results

There were no significant differences between groups in terms of age, sex, history of injection drug use, prior AIDS, lactate dehydrogenase level, and disease stage at diagnosis. Compared with HIV-BL, HIV-DLCL was associated with significantly lower CD4 counts in the pre-HAART but not the HAART era. Although the overall median survival was similar for both groups in the pre-HAART era (HIV-BL, 6.4 months v HIV-DLCL, 8.3 months; P = .43), survival was significantly worse in patients with HIV-BL in the HAART era (HIV-BL, 5.7 months v HIV-DLCL, 43.2 months; P = .0003). Failure to attain complete remission and CD4 count less than 100 cells/mm3 independently predicted for poor survival in the pre-HAART era. In comparison, histology of HIV-BL and no attainment of complete remission were independent poor prognostic factors in the HAART era.

Conclusion

Survival of patients with HIV-DLCL has improved in the HAART era, along with CD4 count, whereas survival of similarly treated patients with HIV-BL remained poor. The current practice of using the same regimen for both groups of patients should be re-evaluated.

Adult Burkitt's Lymphoma

Burkitt's lymphoma is a mature B-cell lymphoma that is characterized by a rapid proliferative rate and propensity for extranodal sites of involvement such as the gastrointestinal tract and central nervous system. This subtype of non-Hodgkin's lymphoma is associated with unique cytogenetic translocations involving the c-MYC oncogene on chromosome 8, which appears to be involved in the pathogenesis of this disease. Although current literature is limited by a lack of randomized trials, Burkitt's lymphoma appears to be curable in a high proportion of cases if treated with aggressive multiagent chemotherapy regimens. The use of autologous stem cell transplantation appears to benefit patients who have had chemotherapy-sensitive relapses. The role of allogeneic stem cell transplantation for this disease remains uncertain. Patients with HIV-associated Burkitt's lymphoma appear to have a better prognosis today, which is likely a result of more effective antiretroviral therapy and the ability to treat selected patients with more aggressive chemotherapeutic regimens than before. This article will review the epidemiologic, biologic, diagnostic, and therapeutic aspects of Burkitt's lymphoma in adults.

Successful administration of aggressive chemotherapy concomitant to tuberculostatic and highly active antiretroviral therapy in a patient with AIDS-related Burkitt's lymphoma

Treatment of AIDS-related malignant lymphoma (ARL) remains a therapeutic challenge. There are concerns not only about infectious and haematological complications in HIV-infected patients during intensive chemotherapy, but also about potential interactions between chemotherapy and highly active antiretroviral therapy (HAART). Current data on patients treated concomitantly with intensive chemotherapy and HAART are limited, and no data exist on patients with ARL suffering from active opportunistic infections. We report the case of a 38-year-old man with advanced HIV-1 infection, pulmonary tuberculosis and Burkitt's lymphoma. Intensive chemotherapy was administered in parallel with tuberculostatic therapy and HAART. Six months later, the patient achieved not only a complete remission of Burkitt's lymphoma and sustained viral suppression, but also a full recovery from tuberculosis. This case report provides some useful observations on the successful application of intensive chemotherapy in addition to tuberculostatic therapy and HAART in HIV-infected patients.

Update in HIV-associated lymphoma

PURPOSE OF REVIEW

Infection with human immunodeficiency virus (HIV) is associated with an increased risk of non-Hodgkin lymphoma and Hodgkin disease. This review summarizes developments within the past 18 months.

RECENT FINDINGS

Investigators continue to demonstrate that many standard therapies similar to those used in the non-HIV- infected population may be used in the HAART era for patients infected with HIV. Biologic differences do exist, however, and not all treatments and outcomes are directly translatable. Some treatments, such as rituximab in combination with CHOP, may have unforeseen toxicity. Nonetheless, high-dose therapy does appear feasible and may offer curative therapy for those with refractory and relapsed disease.

SUMMARY

HIV-infected persons appear to benefit from most, but not all standard treatments for lymphoma.

Treatment advances in adult Burkitt lymphoma and leukemia

PURPOSE OF REVIEW

Despite significant improvements in the treatment of Burkitt lymphoma, outcomes of adults are generally inferior to those of children. This review summarizes the most recent developments in the management of Burkitt lymphoma and leukemia in adults.

RECENT FINDINGS

Current regimens have largely been derived from pediatric protocols. High complete remission rates are typically achieved, but relapse remains a problem. Recent trials have validated or built upon findings from older studies.

SUMMARY

The adoption of aggressive, multiagent, short-course therapy has markedly improved outcomes, but relapse rates remain relatively high in poorer-risk cohorts. New approaches are particularly needed in older patients to improve survival rates while minimizing toxicities.