Hodgkin's disease and human immunodeficiency virus infection: clinicopathologic and virologic features of 114 patients from the Italian Cooperative Group on AIDS and Tumors

Clinical aspects and management of Hodgkin's disease and other tumours in HIV-infected individuals

As the AIDS epidemic advances, the spectrum of malignancies encountered is expanding. Several non-AIDS defining cancers, i.e. Hodgkin's disease (HD), anal and testicular cancer, are increasing in incidence in HIV-infected patients. The widespread use of highly active antiretroviral therapy (HAART) in industrialised countries has resulted in substantial improvement in the survival of HIV-infected patients. It is likely that in the future, cancers associated with long-term mild immune suppression will occur at an increased rate in long-term survivors of HIV infection. The natural history of the majority of non-AIDS defining tumours differs from that of the general population. Unusual aspects of tumour localisation, growth behaviour and therapeutical responses distinguish tumours in patients with HIV infection from those without. This paper reviews the most relevant data on the epidemiology, pathology, clinical features and treatment of the most frequently reported non-AIDS defining tumours, i.e. HD, lung, testicular and skin cancers.

Adult Burkitt's lymphoma in patients with and without human immunodeficiency virus infection in Kenya

Prior to the acquired immunodeficiency syndrome (AIDS) epidemic, one or two cases of adult Burkitt's lymphoma (BL) were seen annually at the Kenyatta National Hospital, the national referral medical center in Nairobi, Kenya. To investigate the influence of human immunodeficiency virus (HIV) infection in adult BL in Kenya, we conducted a national prevalence survey of all patients 16 years of age and older with BL. A systematic review of medical records of all patients diagnosed with BL between 1992 and 1996 was performed. The diagnosis of BL was based and confirmed on review of pathological material from time of original diagnosis. HIV serology was confirmed by enzyme-linked immunosorbent assay (ELISA). Twenty-nine adult patients with BL were identified during the 5-year study period. Of these patients, 17 (59%) were males, 12 (41%) were females, and the median age was 26 years. Nineteen patients (66%) with BL were HIV-seropositive. The proportion of men was similar in HIV-seropositive and -seronegative patients (58% vs 60%). HIV-seropositive BL patients were significantly older than seronegatives (median 35 vs 19.5 years, p < 0.001). HIV-seropositive patients uniformly presented with constitutional or B symptoms and advanced BL accompanied by diffuse lymph node involvement, whereas the clinical presentation of HIV-seronegative patients during this time period was reminiscent of the "typical" endemic pattern of disease with complete sparing of peripheral lymph nodes. The overall survival of HIV-seropositive cases was significantly worse than that of the HIV-seronegative cases; median survival in the HIV-seropositive patients was 15 weeks. There is an approximate 3-fold increase in the incidence of adult BL during the time period of this study, which is attributable to the AIDS epidemic. In this setting, patients often present with disseminated disease, diffuse peripheral lymphadenopathy and fever, the latter two of which heretofore have been commonly associated with non-lymphoproliferative disorders such as Mycobacterium tuberculosis and sexually transmitted diseases in Kenya. These observations warrant inclusion of AIDS-related BL in the differential diagnosis of the adult patient with unexplained fever and lymphadenopathy in Kenya. The corollary is that HIV infection is virtually excluded in an adult patient without peripheral lymphadenopathy and biopsy-proven BL.

HIV-associated lymphomas

Intermediate and high-grade non-Hodgkin lymphomas (NHL) with a B-cell phenotype are AIDS-defining illnesses. The incidence of systemic NHL is over 100 times increased, primary central nervous system NHL is over 3000 times increased, and Hodgkin's disease is approximately 10 times increased in the HIV-infected population. Unusual extranodal presentations of NHL and Hodgkin's disease are seen in HIV-infected individuals. High-grade histologies are common for both NHL and Hodgkin's disease in the HIV setting. Treatment approaches may be changing with the advent of highly active antiretroviral therapy, which may allow patients to tolerate more intensive treatment.

Hodgkin's disease in patients infected with human immunodeficiency virus: frequency, presentation and clinical outcome

We report the frequency, presenting characteristics, progression-free survival, event-free survival, overall survival and AIDS-free survival of patients with previously untreated Hodgkin's disease (HD) in the setting of infection by human immunodeficiency virus (HIV). To accomplish this we retrospectively reviewed all untreated patients presenting to the University of Texas M.D. Anderson Cancer Center between July 1985 and August 1999 with HD and HIV infection. All available records were reviewed to determine presentation, clinical characteristics, treatment outcome, progression-free survival and overall survival. We identified 887 patients with HD and 3,500 with Non-Hodgkin's Lymphoma (NHL). The ratio of NHL to HD in HIV-negative versus HIV-positive patients was 3.9 versus 6.9, respectively. There were 14 HIV-positive patients with HD and 97 with NHL. The median age of the HIV-positive HD patients was 33 years, and 13 were male. Three patients had Acquired Immune Deficiency syndrome (AIDS) at the time of HD diagnosis, and seven had B-symptoms. Ann Arbor stage was I in one, II in three, III in four and IV in six patients. Mixed cellularity histology was seen in eight, bone marrow involvement in five and extranodal disease in seven patients. Four patients had elevated serum lactate dehydrogenase, three low serum albumin, and nine elevated serum beta2-microglobulin, The median CD4 count was 160/microl. Eleven patients received ABVD or equivalent regimens, followed by radiotherapy in five. One patient was treated with COPP and radiotherapy, one with NOVP and radiotherapy and one only with radiotherapy. All patients received some antiretroviral therapy, but it was variable over the years. With a median follow-up of 64 months for survivors, the projected 5-year progression-free survival was 64%, event-free survival 45%, overall survival 54% and AIDS-free survival 45%. Six patients died of complications arising from HIV infection, including one patient who had preexisting AIDS at HD presentation. Two patients died of HD, without developing other conditions diagnostic of AIDS. We conclude that in our referral patient population HIV infection is associated with preferential development of NHL rather than HD, which appears curable with standard treatment regimens. Since HIV-related deaths exceed those caused by HD, future investigation should focus on integration of chemotherapy and highly active antiretroviral therapy.

Epstein-Barr virus and survival after Hodgkin disease in a population-based series of women

BACKGROUND

Epstein-Barr virus (EBV) positive Hodgkin disease (HD), as defined by the presence of EBV genes or gene products in the malignant cells, differs epidemiologically from EBV negative HD. However, survival patterns for EBV-defined HD have not been well studied. To determine if EBV status influenced survival time after HD, the authors investigated a large, population-based series of female patients.

METHODS

For 311 female patients living in the Greater San Francisco Bay Area who were aged 19-79 years with HD diagnosed between mid-1988 and 1994, histopathologically rereviewed archived biopsy specimens were assayed for EBV with immunohistochemistry and in situ hybridization. The 53 subjects with EBV positive and the 258 with EBV negative HD were observed for vital status through 1998; overall survival was analyzed with Kaplan-Meier and Cox proportional hazards regression methods.

RESULTS

Epstein-Barr virus positive HD patients were older, received diagnosis at a later stage, and were less likely to have nodular sclerosis histology than EBV negative patients. Deaths were reported for 21 (40%) EBV positive and 37 (14%) EBV negative patients. No survival differences were observed between EBV positive and negative women aged 19-44 years, but survival was significantly poorer in women aged 45-79 years with EBV positive HD. Regression analysis confirmed this strong negative effect of EBV positive status on survival (hazard ratio for death, 3.0; 95% confidence interval, 1.5-6.2) as unrelated to age, stage at diagnosis, or tumor histology.

CONCLUSIONS

This study found a marked survival disadvantage for EBV positive HD in older but not young adult women. These findings suggest influences of both EBV status and age on HD survival, as well as pathogenesis.

Deletions within the epstein-barr virus latent membrane protein-1 oncogene in adult ordinary, HIV-associated and paediatric Hodgkin's disease

The aims of this study were the following: a) to perform Epstein-Barr virus (EBV) strain type assignment in three groups of Hodgkin's disease(HD): adult ordinary (39 cases), paediatric (24 cases), and HIV-associated (30 cases) and to compare the prevalence of type 1 and type 2 in each of the groups with that existing in two reference populations made up of 50 adults and 39 children; b) to assess the frequency of latent membrane protein-1 (LMP-1) 30-base pair (bp) deletions in the HD groups and in the healthy controls; and c) to relate the presence of LMP-1 deletions with EBV type. Type 2 EBV was observed in 12.8% of ordinary HD, in 26.7% of HIV-associated HD, in 25% of paediatric HD, in 4% of adult controls, and in none of the healthy children. The existence of double infections by type 1 and 2 EBV was also observed in 5.1% of ordinary HD, in 6.7% of HIV-associated HD, and in 10% of adult controls. The 30-bp deletion was identified overall in 33.3% of ordinary HD, in 83.3% of HIV-positive HD, 79.2% of paediatric HD, 34.7% of adult controls, and 36.4% of healthy children. Statistical analysis showed a significant association of the deleted strains with HD occurring in HIV-positive patients (P= 0.00003) and childhood HD (P= 0.006). On the other hand, the prevalence of the 30-bp deletion in the adult ordinary HD group reflects the prevalence of the deletion in the general population. Co-infections by deleted and non-deleted EBV strains were detected in 12.8% of ordinary HD, in 33.3% of HIV-associated HD, in 50% of paediatric HD, in 26.5% of adult controls, and in 27.3% of healthy children. Concerning the relationship between the deletion and the EBV typing, 26% of type 1 specimens carried the 30-bp deletion in an isolated manner compared with 64.7% of type 2. The statistical analysis showed that the deletion was associated with type 2 strains when coinfections were excluded and only the cases in which the deletion appeared alone were considered (P=0.003).

EBV-associated perianal Hodgkin's disease in an HIV-positive individual

Hodgkin's disease (HD) has a higher incidence in HIV-positive individuals. It tends to occur at extranodal sites, frequently exhibits an unfavorable histological type with large numbers of neoplastic cells, and almost invariably harbors Epstein-Barr Virus (EBV). We describe a case of a 33-year-old HIV-positive man who presented with anal pain from a 4-cm mass in the anorectal canal. He had no B symptoms or peripheral lymphadenopathy. A chest X-ray was within normal limits. A biopsy showed an ulcerated mass composed of a mixed infiltrate of lymphocytes, plasma cells, eosinophils, and Reed-Sternberg (RS) cells positive for CD15 and strongly positive for CD30. They were negative for CD45 and CD20. Numerous RS cells and lymphocytes were positive for EBV RNA using the EBER-1 probe. This highly unusual presentation of HD may reflect the greater incidence of anorectal lymphoma and of extranodal HD in the HIV-positive population.

AIDS oncology

Kaposi's sarcoma, non-Hodgkin's lymphoma, Hodgkin's disease, and squamous cell carcinoma are among the malignancies seen with increased frequency in patients infected with HIV. The outlook for patients with these malignancies has improved significantly with the utilization of highly active antiretroviral therapy (HAART) and more aggressive cytotoxic therapies. Novel biologic therapies with lesser side effects are currently being evaluated. This article reviews the current knowledge about HIV malignancies, their epidemiology, pathogenesis, clinical manifestations, and treatment.

Chemotherapy consisting of doxorubicin, bleomycin, vinblastine, and dacarbazine with granulocyte-colony-stimulating factor in HIV-infected patients with newly diagnosed Hodgkin's disease: a prospective, multi-institutional AIDS clinical trials group study (ACTG 149)

To ascertain the results of standard ABVD chemotherapy (doxorubicin, bleomycin, vinblastine, dacarbazine) in HIV-infected patients with newly diagnosed Hodgkin's disease (HD), a nonrandomized, prospective, multiinstitutional clinical trial was conducted by the AIDS Clinical Trials Group (ACTG), in HIV-infected patients with Hodgkin's disease. All patients received the standard ABVD regimen, with granulocyte-colony-stimulating factor (G-CSF). Antiretroviral therapy was not used. Between May, 1992 and August, 1996, 21 patients were added to the study and treated. The median CD4 count was 113 cells/mm3, and 29% had a history of a clinical AIDS-defining condition before diagnosis of HD. Systemic "B" symptoms were present in 90% at diagnosis. Stage IV HD was present in 67%, with bone marrow involvement in 12 (57%). Nodular sclerosis HD was present in 38%, with mixed cellular disease in 31%. Among all patients entered and treated, complete remission (CR) was attained in 9 (43%; 90% confidence interval [CI], 24%-63%), whereas partial response occurred in 4 (19%), leading to an overall objective response rate of 62% (90% CI, 42%-79%). Despite routine use of G-CSF, 10 patients (47.6%) experienced life-threatening neutropenia, with absolute neutrophil counts <500 cells/mm3. In all, nine opportunistic infections occurred in 6 patients (29%) during the study or shortly thereafter. Median survival was 1.5 years. Results of this study suggest that alternative treatment strategies should be explored, including use of chemotherapy together with antiretroviral therapy.

Current treatment of Hodgkin's disease

In spite of the fact that Hodgkin's disease (HD) remains still an enigma its management and treatment yield a cure rate of about 80% of all patients. However, this management has two limits: on one side favourable cases which should not be overtreated because of unacceptable side-effects, and on the other side very unfavourable cases which should be treated differently because of a very high rate of failure and/or relapse. Then it becomes necessary to precise as thoroughly as possible these two limits in order to choose the adequate treatment for the patient. Prognostic factors based on patient and disease characteristics allow a relatively exact classification of favourable and unfavourable cases. This distinction in two prognostic groups has therapeutic implications in terms of chemotherapy (regimen, duration) and radiotherapy (extension, doses). Other specific situations have to be considered, e.g. pediatric cases, pregnancy, old age and HIV-infected patients who need an adapted management according to very different situations.

Oral combination chemotherapy in the management of AIDS-related lymphoproliferative malignancies

An oral combination chemotherapy regimen initially developed for AIDS-related non-Hodgkin's lymphoma includes lomustine (CCNU), etoposide, cyclophosphamide, and procarbazine. This regimen takes advantage of oral administration, the in vitro synergy of these drugs and their first-line efficacy in lymphoma, and the ability of lomustine and procarbazine to cross the blood-brain barrier. This regimen was used to treat 38 patients with AIDS-related non-Hodgkin's lymphoma. The overall objective response rate was 66% (34% complete response rate) with a 5% CNS relapse rate, and a median survival duration of 7.0 months. One-third of the patients survived for 1 year, 11% for 2 years, and half of the patients survived free from progression of their lymphoma. On the basis of these results, this oral regimen was modified and administered to 5 patients with AIDS-related primary CNS lymphoma as part of a sequential combined-modality chemotherapy and radiation regimen. Rapid progression of CNS disease was observed in this group of patients, with a median survival duration of 1.0 month. The identical regimen was administered to 7 patients with AIDS-related Hodgkin's disease: we observed a 71% partial remission rate and a median survival duration of 7.0 months. Myelosuppression remains the most significant clinical toxicity. Our results with this oral regimen appear comparable to those of standard intravenous combination chemotherapy regimens in patients with AIDS-related non-Hodgkin's lymphoma.

Primary Hodgkin's disease of the vagina

We describe a patient with primary Hodgkin's disease (HD) of the vagina presenting with stage IEB. To our knowledge, this is the first case reported so far. Based on morphological and immunophenotypic features, the HD was classified as nodular sclerosis subtype, "syncytial" variant. The patient, a 64-year old woman, received chemotherapy followed by radiation therapy. She is still disease-free 14 months after diagnosis.

Epstein-barr virus-associated malignancies: epidemiologic patterns and etiologic implications

Epstein-Barr virus (EBV), a ubiquitous B-lymphotrophic herpesvirus, has been found in the tumor cells of a heterogeneous group of malignancies (Burkitt's lymphoma, lymphomas associated with immunosuppression, other non-Hodgkin's lymphomas, Hodgkin's disease, nasopharyngeal carcinoma, gastric adenocarcinoma, lymphoepithelioma-like carcinomas, and immunodeficiency-related leiomyosarcoma). As the epidemiologic characteristics of these cancers have not been considered together, this review seeks to relate their incidence patterns and risk factors to EBV biology and virus-host interaction in an attempt to help elucidate factors involved in EBV-related carcinogenesis. We include a brief review of EBV virology and primary infection to provide a biologic context for considering the epidemiology, summarize the most salient epidemiologic features of each malignancy, synthesize epidemiologic data by risk factor to uncover commonalities and informative contrasts across the diseases, and propose hypotheses regarding etiologic mechanisms, based on the possible effect of the risk factors at various stages in the viral life cycle.

Cancer risk among men with, or at risk of, HIV infection in southern Europe

OBJECTIVE

To evaluate the cancer risk in southern European men with, or at risk of, HIV infection.

DESIGN

An analysis of longitudinal data to assess time-dependent rare events.

METHODS

Data from a cohort of HIV seroconverters, and from two hospital-based HIV seroprevalent cohorts were combined and analysed. The number of cancer cases observed was compared with the expected number, obtained from cancer incidence rates among men in the general population. Age-standardized incidence ratios (SIR) and their 95% confidence intervals (CI) were computed.

RESULTS

A total of 19,609 person-years of observation were accumulated among HIV-positive men, and 7957 person-years among HIV-negative men. Among HIV-positive men, statistically significant increased SIR were seen for Hodgkin's disease (HD) (SIR = 8.7), liver cancer (SIR = 11.0), and cancer of the salivary glands (SIR = 33.6). An excess of lung cancer was seen among intravenous drug users (IDU), but not among homosexual men. When the risk of all non-AIDS-defining cancers was considered, HIV-positive men had a nearly twofold excess (95% CI: 1.2-2.8). A risk of similar magnitude emerged among HIV-negative IDU (95% CI: 1.0-4.5), largely attributable to lung cancer and HD.

CONCLUSION

These findings confirm that HIV infection increases the risk of HD, whereas they suggest that the risk of hepatocellular carcinoma may also be enhanced by HIV infection. The observation of an elevated risk of lung cancer in both HIV-positive and HIV-negative IDU points to personal behaviours unrelated to HIV infection.

[Hodgkin's disease in patients infected by the human immunodeficiency virus. Study of fifteen cases]

BACKGROUND

In spite of not being considered as an AIDS defining illness, Hodgkin's disease (HD) has specific clinical and biological features in HIV-infected patients.

PATIENTS AND METHODS

Study of clinicopathologic and analytic characteristics, Epstein-Barr virus (EBV) detection (polymerase chain reaction), and prognosis in 15 patients with HD and HIV infection.

RESULTS

Thirteen patients had B symptoms, 10 extranodal involvement and 12 advanced HD. The most frequent histologic subtypes were mixed cellularity (6) and lymphocyte depletion (6). The mean (SD) of CD4 lymphocytes was 0.10 (0.08) x 10(9)/l. The presence of EBV in lymph node biopsy was demonstrated in 3 out of 4 patients investigated. Complete remission (CR) was achieved in 7 out of 14 treated cases (50%), the median overall survival was 26 months and the 2 year event-free survival probability was 60%.

CONCLUSIONS

In HIV-infected patients, HD presents in advanced stages, unfavourable histologic subtypes, frequent extranodal involvement and B symptoms. The prognosis is poor, mainly because of a low CR rate.

Hodgkin's disease in HIV-infected individuals

The clinical and pathologic characteristics of Hodgkin's disease as they are diagnosed in patients with HIV infection differ from those of the general population. In fact, a higher frequency of unfavorable histologic subtypes, advanced stage, and poor therapeutic outcome have been reported in the HIV setting. Complete response rate after chemotherapy ranges from approximately 45% to 70%, although the disease-free survival is very short, and the median overall survival is only 18 months. The survival of these patients may be improved by the optimal combination of antineoplastic and antiretroviral treatment with the support of hematologic growth factors. However, new strategies of therapeutic intervention must be explored.

Increased incidence of Hodgkin's disease after allogeneic bone marrow transplantation

PURPOSE

Immune dysregulation associated with allogeneic bone marrow transplantation (BMT) is linked to an increased risk of posttransplant lymphoproliferative disorders (PTLD); however, reports of Hodgkin's disease (HD) after transplantation are rare.

PATIENTS AND METHODS

We evaluated the risk of HD among 18,531 persons receiving allogeneic BMT between 1964 and 1992 at 235 centers. The number of HD cases was compared with that expected in the general population. Risk factors were identified using Poisson regression and a nested case-control study.

RESULTS

Risk of HD was increased in the postBMT population compared with the general population with an observed-to-expected incidence ratio (O/E) of 6.2 (observed cases, n = 8; 95% confidence interval [CI], 2.7 to 12). A significantly increased risk of HD remained after excluding two human immunodeficiency virus-positive patients (observed cases, n = 6; O/E = 4.7, 95% CI, 1.7 to 10.3). Mixed cellularity subtype predominated (five of eight cases, 63%). Five of six assessable cases contained Epstein-Barr virus (EBV) genome. Posttransplant HD differed from PTLD by later onset (> 2.5 years) and lack of association with established risk factors (such as T-cell depletion and HLA disparity). Patients with HD were more likely than matched controls to have had grade 2 to 4 acute graft-versus-host disease (GVHD), required therapy for chronic GVHD, or both (P =.002), although analysis included small numbers of patients.

CONCLUSION

The increased incidence of HD among BMT recipients adds support to current theories which link overstimulation of cell-mediated immunity and exposure to EBV with various subtypes of HD. The long latency of HD after transplant and lack of association with risk factors for PTLD is noteworthy and should be explored further for possible insights into pathogenesis.

HIV-associated malignancies in children

The exact incidence of malignancies in HIV-infected children is not clear; however, an excess of non-Hodgkin's lymphomas (NHLs) and soft tissue tumors (leiomyosarcomas) is evident. The spectrum of diseases is slightly different in children compared to adults. For example, Kaposi's sarcoma (KS), although common in HIV-infected adults, is rare in children in industrialized countries. Preliminary results with brief, dose-intensive chemotherapeutic regimens have been encouraging. Such regimens may be complicated, however, by multiple HIV-associated organ dysfunctions, drug interactions, and infectious complications secondary to severe immunosuppression.

Meningioma in four patients with human immunodeficiency virus infection

We describe four patients infected with the human immunodeficiency virus (HIV) who had development of meningiomas. In contrast to those in the general population who have meningiomas, all our patients were young men; the mean age was 40 years (range, 32 to 50). Their risk behavior for HIV was homosexuality (three patients) and intravenous drug use (one patient). The CD4+ cell count in each of the three homosexual men was less than 50/microL and was 280/microL in the drug user. Imaging studies showed enhancing lesions in three of the patients. Although each of these meningiomas could have occurred in otherwise normal young to middle-aged men, we speculate that the meningiomas may have grown in these HIV-infected hosts because of either loss of immune function or dysregulation of cytokines.

Hodgkin's disease in 35 patients with HIV infection: an experience with epirubicin, bleomycin, vinblastine and prednisone chemotherapy in combination with antiretroviral therapy and primary use of G-CSF

BACKGROUND

The optimal therapeutic approach for patients with Hodgkin's disease and human immunodeficiency virus infection (HD-HIV) is unknown. In an attempt to improve the results previously obtained with EBV (epirubicin, bleomycin and vinblastine) without G-CSF (Cancer 1994; 73: 437-44), in January 1993 we started a trial using chemotherapy (CT) consisting of EBV plus prednisone (EBVP), concomitant antiretroviral therapy (zidovudine, AZT or dideoxinosyne, DDI), and G-CSF.

PATIENTS AND METHODS

Up to August, 1997, 35 (30 M/5 F) consecutive previously untreated patients (median age 34, range 21-53 years) with HD-HIV were enrolled in the European Intergroup Study HD-HIV. Their median performance status was 1 (range 1-3). At diagnosis of HD, 26% of the patients had AIDS, 90% had B symptoms at HD presentation and 83% had advanced-stage HD. Patients received E 70 mg/m2 i.v. on day 1, B 10 mg/m2 i.v. on day 1, V 6 mg/m2 i.v. on day 1 and P 40 mg/m2 p.o. from day 1 to day 5 (EBVP). Courses were repeated every 21 days for six cycles. AZT (250 mg x 2/day), or DDI (200 or 300 mg x 2/day) if AZT had been previously used, were given orally from the beginning of CT. G-CSF was given at the dose of 5 mcg/kg/day s.c. from day 6 to day 20 in all cycles.

RESULTS

An overall response rate of 91% was observed. There were 74% complete responses (CR) and 17% partial responses (PR). Toxicity was moderate, with grade 3-4 leukopenia and thrombocytopenia in 10 (32%) and three (10%) patients, respectively. The median number of administered cycles was 6 (range 3-6). Twenty-three of 35 patients received AZT and nine patients received DDI. Three (8%) patients had opportunistic infections (OI) during or immediately after CT. The median CD4+ cell count was 219/mm3 (6-812) at HD diagnosis and 220/mm3 (2-619) after the end of combined therapy, and these numbers remained unchanged. Ten of 26 (38%) patients who achieved CR relapsed. Twenty-three patients died of HD progression alone or in association with OI, being the cause of death in 48% and 9% of patients respectively. The median survival was 16 months, with a survival rate of 32% and a disease-free survival of 53% at 36 months.

CONCLUSIONS

The combined antineoplastic and antiretroviral treatment is feasible, but HD in HIV setting is associated with a more adverse prognosis than in the general population. Although the CR rate obtained was satisfactory, the relapse rate was high. Furthermore, comparison of the results of our two consecutive prospective studies demonstrated no overall improvement in the current trial with respect to the CR rate and survival.

Epstein-Barr virus in the pathogenesis of Hodgkin's disease

Epidemiologic and clinico-pathologic features of Hodgkin's disease suggest that an infectious agent may be involved in the pathogenesis of this puzzling disorder. Recently accumulated data provide direct evidence supporting a causal role of Epstein-Barr virus in a significant proportion of cases. In addition to allowing a better understanding of the complex pathogenesis of Hodgkin's disease, these virological advances, briefly reviewed herein, also constitute an important basis for the development of new therapeutic strategies.

Risk of cancer other than Kaposi's sarcoma and non-Hodgkin's lymphoma in persons with AIDS in Italy. Cancer and AIDS Registry Linkage Study

Record linkage was carried out between the national Registry of AIDS and 13 Cancer Registries (CRs) covering, in 1991, about 15% of the Italian population. Observed and expected numbers of cancers and standardized incidence ratios (SIRs) were assessed in 6067 persons with AIDS, for a total of 25,759 person-years. Significantly increased SIRs were found for Hodgkin's disease [8.9, 95% confidence interval (CI) 4.4-16.0], in which seven of 11 cases were of mixed cellularity type; invasive carcinoma of the cervix uteri (15.5; 95% CI 4.0-40.1); and non-melanomatous skin cancer (3.0, 95% CI 1.3-5.9), in which five of eight cases were basal cell carcinoma. An excess was also seen for brain tumours, but this may be partly due to misdiagnosis of brain non-Hodgkin's lymphoma or other brain diseases occurring near the time of the AIDS diagnosis. The risk for all cancer types, after exclusion of Kaposi's sarcoma (KS) and non-Hodgkin's lymphoma (NHL), was approximately twice the general population risk. An increased SIR for Hodgkin's disease in persons with AIDS is thus confirmed, though it is many times smaller than that for NHL. An association with invasive carcinoma of the cervix is also shown at a population level. The excess of non-melanomatous skin cancer seems to be lower than in transplant recipients.

Cancers in human immunodeficiency virus-infected children

Although the exact incidence of cancers in human immunodeficiency virus (HIV)-infected children is not clear, an excess of non-Hodgkin's lymphomas and soft tissue tumors as well as a multitude of otherwise rare tumors in childhood, such as cervical, thyroid, or pulmonary carcinoma, has been reported. In contrast to the findings in HIV-infected adults, Kaposi's sarcoma is rare in children in industrialized countries but not in children living in the sub-Saharan area. Treatment of the neoplastic disease is often complicated by multiple HIV-associated organ dysfunctions as well as drug interactions and infectious complications secondary to severe immunosuppression. Nonetheless, preliminary results with dose-intensive, but brief, chemotherapeutic regimens have been encouraging, and HIV-infected children who develop cancer are likely to benefit from aggressive treatment combined with adequate supportive care. Furthermore, insights gained from the study and treatment of this very challenging group of patients may benefit other immunocompromised hosts as well as increase our understanding of oncogenesis in general.

[Hodgkin's disease in patients infected with the human immunodeficiency virus]

INTRODUCTION

Hodgkin's disease in patients infected by the human immunodeficiency virus (HIV) is still not part of the definition of acquired immune deficiency syndrome. Nonetheless, this entity has a particular presentation when compared to the disease occurring in immune-competent patients.

CURRENT KNOWLEDGE AND KEY POINTS

Increased frequency (> 75%) of advanced anatomical stages and extranodular localizations (Ann Arbor system stages III and IV) has been outlined in HIV-infected patients. Mediastinal involvement is more unusual in immunocompromised than in immune-competent patients. The presence of B symptoms (fever, weight loss, nocturnal sweats) is very frequent. Finally, the predominance of mixed cellularity (type 3) characterizes Hodgkin's disease in immunocompromised patients. Due to either the immunodeficiency, antiretroviral treatments, poor hematological tolerance in response to chemotherapy, or to advanced anatomical stages, disease management may be hampered. Current therapeutical approaches often obtain complete remission; however, some deaths are still related to the disease progression to acquired immune deficiency syndrome.

FUTURE PROSPECTS AND PROJECTS

From these observations, Hodgkin's disease management in HIV-infected patients relies on therapeutical approaches similar to those used for non infected patients, with some specific recommendations. Chemotherapy should be conducted in the shortest time in order to minimize chemotherapy-induced immunosuppression. Simultaneous use of antiretroviral treatment and reinforced opportunistic infection prophylaxis are of pivotal importance. Finally, the use of hematopoietic growth factors appears to be safe regarding viral replication, but still requires further evaluation.

Epstein-Barr Virus Strains With Latent Membrane Protein-1 Deletions: Prevalence in the Italian Population and High Association With Human Immunodeficiency Virus–Related Hodgkin's Disease

Six Epstein-Barr virus (EBV)-related lymphoproliferative disorders were investigated to verify whether the EBV strain harbored by neoplastic cells had the same EBNA-2 and latent membrane protein-1 (LMP-1) DNA sequences of the virus carried by normal lymphocytes of the same patients. Within each case, the analysis of neoplastic lymph nodes, reactive lymphadenopathies, and/or EBV+ spontaneous lymphoblastoid cell lines gave concordant results with respect to type-specific EBNA-2 region and LMP-1 gene. In particular, five cases showed the same deletion in the 3′ end of the LMP-1 gene in both normal and neoplastic cells. We also determined the prevalence of LMP-1 deletions in a large series of normal peripheral blood mononucleated cells (PBMCs) from Italian individuals. The analysis showed that 50% (9 of 18) of PBMCs from human immunodeficiency virus (HIV)-seronegative donors carried a 30-bp deletion in the C-terminal portion of the LMP-1 gene, whereas a nondeleted fragment was amplified in about 44% (8 of 18) of the cases. Only one sample (5.6%) showed the amplification of a full-length LMP-1 band together with a deleted fragment. Similarly, PBMCs from HIV-infected patients showed an almost equivalent prevalence of full-length (17 of 37, 46%) and deleted (16 of 37, 43.2%) LMP-1 fragments, whereas about 11% of samples (4 of 37) showed evidence of double infections. Of note, deletions in the LMP-1 gene were detected with similar prevalence values in EBV+ Hodgkin's disease (HD) (13 of 30, 43.3%) and non-Hodgkin's lymphoma (NHL) (2 of 5, 40%) cases from HIV-seronegative patients and in HIV-related, EBV+ NHLs (4 of 7, 57.1%). Conversely, a 30-bp LMP-1 deletion was found in 10 of 12 HIV-associated HD cases (83%), a prevalence significantly higher than that detected in HIV-unrelated HD (P = .01). These findings indicate that: (1) the same EBV strain carrying LMP-1 deletions is harbored by normal and neoplastic cells of patients with EBV+ disorders, ruling out that these mutations might result from immunoselection phenomena; (2) in the Italian population, the prevalence of LMP-1 deletion mutants is comparable to that of EBV strains with full-length LMP-1; (3) HIV-induced immunosuppression is not associated with an increased prevalence of LMP-1 deletions in PBMCs; and (4) HIV-related HD cases, but not those of HIV-seronegative Italian patients, are closely correlated with the presence of LMP-1 deletions, suggesting that infection with these strains may increase the risk of developing HD in the HIV setting.

Human immunodeficiency virus-associated lymphomas

Lymphomas associated with human immunodeficiency virus (HIV) will probably become an increasing problem with improved survivals of infected individuals in an immunosuppressed state because of the advances in antiretroviral treatment and the therapy of opportunistic infections. In an attempt to aid the understanding of the many aspects of the this growing problem, the current thinking about the epidemiology, pathology, biological and clinical features, and treatment of the systemic HIV-associated non-Hodgkin lymphomas is reviewed. The important features of the HIV-associated central nervous system lymphomas are also described. Finally, there is a discussion of Hodgkin's disease in HIV-infected individuals.

Epstein-Barr Virus Strains With Latent Membrane Protein-1 Deletions: Prevalence in the Italian Population and High Association With Human Immunodeficiency Virus–Related Hodgkin's Disease

Six Epstein-Barr virus (EBV)-related lymphoproliferative disorders were investigated to verify whether the EBV strain harbored by neoplastic cells had the same EBNA-2 and latent membrane protein-1 (LMP-1) DNA sequences of the virus carried by normal lymphocytes of the same patients. Within each case, the analysis of neoplastic lymph nodes, reactive lymphadenopathies, and/or EBV+ spontaneous lymphoblastoid cell lines gave concordant results with respect to type-specific EBNA-2 region and LMP-1 gene. In particular, five cases showed the same deletion in the 3′ end of the LMP-1 gene in both normal and neoplastic cells. We also determined the prevalence of LMP-1 deletions in a large series of normal peripheral blood mononucleated cells (PBMCs) from Italian individuals. The analysis showed that 50% (9 of 18) of PBMCs from human immunodeficiency virus (HIV)-seronegative donors carried a 30-bp deletion in the C-terminal portion of the LMP-1 gene, whereas a nondeleted fragment was amplified in about 44% (8 of 18) of the cases. Only one sample (5.6%) showed the amplification of a full-length LMP-1 band together with a deleted fragment. Similarly, PBMCs from HIV-infected patients showed an almost equivalent prevalence of full-length (17 of 37, 46%) and deleted (16 of 37, 43.2%) LMP-1 fragments, whereas about 11% of samples (4 of 37) showed evidence of double infections. Of note, deletions in the LMP-1 gene were detected with similar prevalence values in EBV+ Hodgkin's disease (HD) (13 of 30, 43.3%) and non-Hodgkin's lymphoma (NHL) (2 of 5, 40%) cases from HIV-seronegative patients and in HIV-related, EBV+ NHLs (4 of 7, 57.1%). Conversely, a 30-bp LMP-1 deletion was found in 10 of 12 HIV-associated HD cases (83%), a prevalence significantly higher than that detected in HIV-unrelated HD (P = .01). These findings indicate that: (1) the same EBV strain carrying LMP-1 deletions is harbored by normal and neoplastic cells of patients with EBV+ disorders, ruling out that these mutations might result from immunoselection phenomena; (2) in the Italian population, the prevalence of LMP-1 deletion mutants is comparable to that of EBV strains with full-length LMP-1; (3) HIV-induced immunosuppression is not associated with an increased prevalence of LMP-1 deletions in PBMCs; and (4) HIV-related HD cases, but not those of HIV-seronegative Italian patients, are closely correlated with the presence of LMP-1 deletions, suggesting that infection with these strains may increase the risk of developing HD in the HIV setting.

Epstein-Barr virus-associated Hodgkin's disease: epidemiologic characteristics in international data

Hodgkin's disease (HD) has long been suspected to have an infectious precursor, and indirect evidence has implicated Epstein-Barr virus (EBV), a ubiquitous herpesvirus, as a causal agent. Recent molecular studies using EBER in situ hybridization or latency membrane protein-I (LMP-I) immunohistochemistry have identified EBV latent infection in up to 50% of HD tumors. However, the epidemiologic features of these cases have not been examined in detail. To explore the epidemiology of EBV-positive HD so as to understand the role of EBV in HD etiology more clearly, this project accumulated patient data from 14 studies that had applied these EBV assays to HD tumors. With information on age at diagnosis, sex, ethnicity, histologic subtype, country of residence, clinical stage and EBV tumor status from 1,546 HD patients, we examined risk for EBV-positive disease using logistic regression. Forty percent of subjects had EBV-positive tumors, and EBV prevalence varied significantly across groups defined by the study variables. Odds ratios (OR) for EBV-associated HD were significantly elevated for Hispanics vs. whites (OR = 4.1), mixed cellularity vs. nodular sclerosis histologic subtypes (OR = 7.3, 13.4, 4.9 for ages 0-14, 15-49, 50+ years), children from economically less-developed vs. more-developed regions and young adult males vs. females (OR = 2.5). These findings suggest that age, sex, ethnicity and the physiologic effects of poverty may represent biologic modifiers of the EBV association and confirm that this association is strongly but variably linked to histologic subtype. The data augment biologic evidence that EBV is actively involved in HD pathogenesis in some cases but describe epidemiologic complexity in this process.

Cancers in children with HIV infection

Malignancies in children with HIV infection have not been as frequent as expected, but they still constitute a fertile area for clinical and basic research. Non-Hodgkin's lymphomas are the most frequent malignancies of children with AIDS and are curable diseases with standard chemotherapy. Leiomyomas and leiomyosarcomas have become the second leading cancer of children with HIV infection and are clearly associated with EBV infection. Treatment for these lesions has not been as successful as that for lymphomas. Other infrequent atypical lymphoproliferative lesions of these patients can often be categorized in the MALT group. Some of these are low-grade lymphomas, whereas others can progress to high grade. The diagnosis of Kaposi's sarcoma in children with AIDS should be carefully reviewed by pathologists experienced with these cases. The diagnosis of KS in children must be made with special care, because some other lesions of HIV-infected children (such as prominent vascularity in lymph nodes) can be confused with KS. Other tumors of these patients are rare and probably are no more frequent than would be expected in the normal population. Because malignancies in children with AIDS are rare, it is important that each one be studied completely with regard to type and incidence, risk factors, and biologic features. To this end, the Pediatric Oncology Group (POG) has established a national registry and treatment protocols. Patient information as well as fresh, frozen, and fixed specimen studies are coordinated through the POG Statistical Office in Gainesville, Florida (telephone, 904-392-5198; FAX, 904-392-8162). The collaborative efforts of all physicians treating children with AIDS and malignancies will be needed to advance our knowledge and efficacy in treating these diseases.

The epidemiology of AIDS--related neoplasms

The magnitude for and risk factors of the two most important AIDS neoplasm, Kaposi's sarcoma and non-Hodgkin's lymphoma, are reviewed in detail. The association between AIDS and other cancers is mostly speculative because surveillance biases tend to favor detecting associations that may be spurious. The overall relative risk of other cancers appears, however, to be only twofold above that in the general population, with associations being most convincing for anal (but not cervical) cancer and leiomyosarcoma and possible also for Hodgkin's disease, testicular cancer, and conjunctival cancers.

The epidemiology of Hodgkin's disease

Much of the epidemiological heterogeneity of HD incidence reflects the behaviour of the NS subtype, at least in the USA. Incidence variation across races (except Asians) and time periods is most marked in this subtype. In young adults with HD, there is compelling evidence for social class modification of risk consistent with an infectious aetiology; limited data suggest that this effect occurs within the NS subtype, but considerable evidence indicates that it does not primarily involve EBV infection. Findings from familial aggregation studies and HLA associations point to inherited susceptibility to this subtype. Despite little sex difference for NS in young adulthood in the latest incidence data, parity nevertheless appears to be protective against this subtype for women. Therefore, the greater increase for females than males in the incidence of young-adult NS in recent years may reflect the impact of population trends towards later childbearing and lower parity. This change, as well as the concomitant smaller family sizes and growing affluence, could explain part of the burgeoning incidence of NS in young adults in the USA. These observations suggest that NS in young adults constitutes a separate disease, probably of infectious origin. The incongruous occurrence of this subtype in older adults, and the presence of EBV in some NS cases, could reflect heterogeneity within NS, for example, representing features of the cellular phase of NS (Cozen et al, 1992; Medeiros and Greiner, 1995). For the non-NS subtypes, many of the factors that predict risk of NS may also be relevant. Patterns of social class determinants in children and older adults, the age groups at risk for MC, support involvement of an infectious precursor given intense exposure, and EBV is a likely candidate, based on its high prevalence in these groups. However, little aetiological research has been directed explicitly at the non-NS subtypes. Considerable effort has gone into exploring an infectious aetiology of HD. Recently, this line of investigation has moved beyond social class determinants to molecular epidemiological studies of EBV and, to a lesser degree, other potentially involved viruses. The roles of genetic susceptibility and sex hormones also represent promising areas for exploration, particularly in their possible interaction with infectious agents and other environmental factors. Ultimately, clearer epidemiological understanding of HD will be aided by more precise classification of this disease at the molecular level.

Hodgkin's disease: old and recent clinical concepts

The diagnosis of Hodgkin's disease (HD) is still primarily based on the histopathologic criteria presented by Lukes et al in 1965. Over the past three decades, however, advances in immunohistochemistry, molecular studies, and virologic findings have provided evidence that HD exhibits significant heterogeneity. Whereas the nodular sclerosis subtype is the major subset of the "classic" disease, it has become evident that the nodular, lymphocytic predominance subtype may represent a minor distinct subset, and possibly a distinct disease entity. Furthermore, there is strong evidence that the mixed cellularity subtype may be an Epstein-Barr virus-related disorder. Finally, based on phenotypic and genotypic features, the existence of a "continuum" between a fraction of HD cases, including the lymphocytic depletion subtype, and CD30-positive anaplastic large cell lymphomas has been suggested.

Malignant lymphomas in patients with HIV infection

During the last two decades, the occurrence of non-Hodgkin's lymphoma (NHLs) has been increasing both in the general population, in which their incidence doubled, and in people with human immunodeficiency virus (HIV) infection, in whom a 100-fold increase has been observed since the onset of the AIDS epidemic. HIV infected patients are living longer owing to advances in antiretroviral therapy and treatment of prophylaxis against opportunistic infections but because of their immunodeficiency they are at high risk of cancers, especially NHL. The natural history of cancers in patients with HIV infection differs from that of the general population. Unusual aspects of tumor localization, growth behaviour and therapeutical response, distinguish tumors in patients with from those without HIV infection. The pathologic and virological aspects of HIV-related tumors are peculiar and a pathological classification of HIV associated systemic lymphomas based on the morphological features of the two main types, i.e. blastic and anaplastic cell lymphomas has been formulated. The treatment of HIV-related neoplasms is controversial as it is not clear whether conventional therapy and in particular chemotherapy is able to modify the natural history of these malignancies in HIV setting. Moreover the treatment of HIV-related tumors presents several problems, due to the aggressive behaviours of tumors and because of immunosuppressive chemotherapy employed in patients with immunodeficiency.