Influence of highly active anti-retroviral therapy on response to treatment and survival in patients with acquired immunodeficiency syndrome-related non-Hodgkin's lymphoma treated with cyclophosphamide, hydroxydoxorubicin, vincristine and prednisone

Double-Hit Diffuse Large B-Cell Lymphoma in AIDS

Diffuse large B-cell lymphoma (DLBCL) is the most common type of immunoblastic lymphoma associated with AIDS, with the stomach being the most frequent extranodal site of involvement. Despite the widespread use of combined antiretroviral therapy (cART), the incidence of systemic lymphomas remains relatively high. These lymphomas often present in the early stages of AIDS as high-grade malignancies. We report the case of a man in his early 30s who initially presented with chronic cough and weight loss, diagnosed with pulmonary tuberculosis and found to be HIV-positive. Within a few months, he returned with persistent abdominal pain and progressive weight loss. Imaging revealed a gastric ulcer, and biopsy confirmed the diagnosis of DLBCL. Although cART is now available and started early upon an HIV diagnosis, vigilant surveillance, early diagnosis, and prompt initiation of chemotherapy are critical for achieving an adequate response and remission.

The Management of Hematopoietic Stem Cell Transplant in People with HIV

Hematopoietic stem cell transplant (HSCT) is now recognized as a standard treatment option for people with HIV (PWH) who develop high-risk hematologic malignancies. However, the involved polypharmacy can lead to complications from drug interactions and toxicities, affecting the efficacy and safety of chemotherapy and antiretroviral therapy (ART). Managing these patients requires a personalized approach, including the careful selection of ART based on previous therapies and potential interactions, alongside risk assessment for infections. This discussion will address the history of HSCT in PWH and management considerations for this group.

Plasmablastic Lymphoma. A State-of-the-Art Review: Part 2-Focus on Therapy

The objective of this two-part review is to present a current and comprehensive understanding of the diagnosis and management of plasmablastic lymphoma. The first part, which was published previously, focused on the study of epidemiology, etiology, clinicopathological characteristics, differential diagnosis, prognostic variables, and the impact of plasmablastic lymphoma on specific populations. This second part addresses the difficult topic of the treatment of plasmablastic lymphoma, specifically examining both the conventional, consolidated approach and the novel therapeutic strategy.

Diffuse Large B-Cell Lymphoma in the HIV Setting

Despite the widespread use of combined antiretroviral therapy (cART) and the subsequent decrease in AIDS-defining cancers, HIV-related lymphomas remain a leading cause of morbidity and mortality in people with HIV (PWH). Diffuse large B-cell lymphoma (DLBCL) is the most common non-Hodgkin lymphoma (NHL) subtype in PWH. This lymphoma is a heterogeneous disease including morphological variants and molecular subtypes according to the cell of origin or the mutation profile. In the pre-cART era, treatment with standard-dose chemotherapy induced high rates of toxicity and outcomes were very poor. The introduction of cART and the incorporation of infection prophylaxis allowed the use of conventional intensive chemotherapy regimens used in the general population, such as R-CHOP or R-EPOCH. The use of cART during chemotherapy treatment was initially controversial due to the potential risk of adverse drug-drug interactions. However, the availability of current cART regimens with less potential to cause drug interactions and evidence that cART improves survival rates in NHL strongly support the use of cART in PWH with DLBCL. Consequently, interdisciplinary collaboration between HIV specialists and hemato-oncologists for the management of potential interactions and overlapping toxicities between antiretroviral and antineoplastic drugs is crucial for the optimal treatment of PWH with NHL.

Plasma Epstein-Barr Virus Load as an Early Biomarker and Prognostic Factor of Human Immunodeficiency Virus-related Lymphomas

BACKGROUND

Epstein-Barr virus (EBV) has been implicated in lymphomagenesis and can be found infecting tumor cells and in plasma at lymphoma diagnosis, especially in human immunodeficiency virus (HIV)-infected patients. Our aim was to evaluate the usefulness of plasma EBV load as biomarker and prognostic factor in HIV-positive patients with lymphomas.

METHODS

EBV loads were measured by polymerase chain reaction in plasma samples of 81 HIV-positive patients' lymphomas at different moments: within 1 year before lymphoma diagnosis, at diagnosis, and at complete response (CR). Control samples included HIV-negative patients with lymphomas and HIV-positive patients without neoplasia or opportunistic infections.

RESULTS

HIV-positive patients with lymphomas had more frequently-detectable EBV load at lymphoma diagnosis (53%) than either HIV-negative patients with the same lymphoma type (16%; P < .001) or HIV-positive individuals without neoplasia or opportunistic infection (1.2%; P < .001). HIV-positive lymphoma patients with detectable EBV load in plasma at lymphoma diagnosis had statistically significant decrease of EBV load at CR. High EBV load (>5000 copies/mL) at lymphoma diagnosis was an independent negative prognostic factor for overall survival and progression-free survival in HIV-positive patients with lymphomas. Detectable plasma EBV loads identified HIV-positive subjects that would eventually develop lymphoma (area under the curve, 82%; 95% CI: 0.67-0.96).

CONCLUSIONS

Plasma EBV load can be used as a biomarker and as a prognostic factor in HIV-positive patients with lymphomas. The presence of the EBV load in the plasma of an HIV-positive patient can be an early predictor of lymphoma development.

GESIDA/PETHEMA recommendations on the diagnosis and treatment of lymphomas in patients infected by the human immunodeficiency virus

The incidence of non-Hodgkin's lymphoma and Hodgkin's lymphoma is higher in patients with HIV infection than in the general population. Following the introduction of combination antiretroviral therapy (cART), the prognostic significance of HIV-related variables has decreased, and lymphoma-related factors have become more pronounced. Currently, treatments for lymphomas in HIV-infected patients do not differ from those used in the general population. However, differentiating characteristics of seropositive patients, such as the need for cART and specific prophylaxis and treatment of certain opportunistic infections, should be considered. This document updates recommendations on the diagnosis and treatment of lymphomas in HIV infected patients published by GESIDA/PETHEMA in 2008.

Evolution of HIV-Associated Lymphoma Over 3 Decades

INTRODUCTION

The emergence of combined antiretroviral therapy (cART) and improvements in the management of opportunistic infections have altered the HIV epidemic over the last 30 years. We aimed to assess changes to the biology and outcomes of HIV-associated lymphomas over this period at the national center for HIV oncology in the United Kingdom.

METHODS

Clinical characteristics at lymphoma diagnosis have been prospectively collected since 1986, along with details of lymphoma treatment and outcomes. The clinical features and outcomes were compared between 3 decades: pre-cART decade (1986-1995), early-cART decade (1996-2005), and late-cART decade (2006-2015).

RESULTS

A total of 615 patients with HIV-associated lymphoma were included in the study: 158 patients in the pre-cART era, 200 patients in the early-cART era, and 257 patients in the late-cART era. In more recent decades, patients were older (P < 0.0001) and had higher CD4 cell counts (P < 0.0001) at lymphoma diagnosis. Over time, there has also been a shift in lymphoma histological subtypes, with an increase in lymphoma subtypes associated with moderate immunosuppression. The overall survival for patients with HIV-associated lymphoma has dramatically improved over the 3 decades (P < 0.0001).

CONCLUSION

Over the last 30 years, the clinical demographic of HIV-associated lymphomas has evolved, and the outcomes have improved.

Non-Hodgkin’s lymphoma and the CNS: prophylaxis and therapy in immunocompetent and HIV-positive individuals

The involvement of the CNS in individuals with non-Hodgkin's lymphoma is a well-recognised complication. Despite the progress that has been made in controlling cancer at most sites in the body, the outcome of individuals affected by meningeal infiltration is dismal and few patients survive for more than a few months. There are few studies that have addressed the management of CNS disease in AIDS-associated non-Hodgkin's lymphoma, and treatment algorithms have been formulated secondary to protocols in immunocompetent individuals. The prevention and treatment of CNS disease is an important aspect of lymphoma management, and new medications, such as a sustained-release formulation of intrathecal cytarabine, will have an increasingly relevant role.

Characteristics and prognosis of B-cell lymphoma in HIV-infected children in the HAART era

Chronic HIV infection leads to increased risk of non-Hodgkin B-cell lymphoma. However, only few recent data are available about their current management and prognosis in HIV-infected children since the advent highly active antiretroviral therapy (HAART). This multicenter retrospective study describes the 12 cases of B-cell non-Hodgkin lymphoma diagnosed in HIV-infected children in France between 1996 and 2009. All children had moderate to severe immunosuppression and high viral load at the time of diagnosis. Nine children had extracerebral primary sites and 3 had a primary central nervous system lymphoma. Eight patients had Burkitt lymphoma; 4 had diffuse large B-cell lymphoma. Concomitantly with HAART, all children with extracerebral lymphoma received intensive chemotherapy according to LMB protocol, those with primary central nervous system lymphoma received high-dose methotrexate. No toxicity-related deaths occurred. Ten patients entered complete remission (CR), 2 died of tumor progression despite a second line of therapy. No relapses occurred after CR (median follow-up, 72 mo). Thus, prognosis of patients unresponsive to first-line lymphoma treatment remains poor, but relapse seems to be rare when CR is achieved. Children without severe comorbidities can tolerate intensive chemotherapy with a mandatory HAART treatment, taking into account drug interactions.

[Comparison of two initial mobilizing strategies of peripheral blood stem cells for autologous transplantation in patients with lymphoma and human immunodeficiency virus infection]

BACKGROUND AND OBJECTIVE

Several studies have demonstrated the feasibility of autologous stem cell transplantation (ASCT) in patients with lymphoma and human immunodeficiency virus (HIV) infection. HIV infection has been described as a risk factor for poor mobilization. The aim of this study was to compare the results of two mobilization strategies of peripheral blood stem cells (PBSC) in patients with lymphoma and HIV infection in seven Spanish hospitals.

PATIENTS AND METHODS

The following variables were collected: demographic, clinical and biological features, previous chemotherapies and outcomes, as well as mobilization's strategies (classified in two groups: 1) G-CSF, and 2) G-CSF + chemotherapy).

RESULTS

Between January 2000 and May 2010, 42 patients with lymphoma and HIV infection were referred for ASCT. The rate of successful mobilization (collection >1.60 × 10(6) CD34 cells/kg) with the first regimen was 67%, with no differences between those patients mobilized with G-CSF or with G-CSF + chemotherapy (16 [72%] and 12 [60%], respectively; p=0.382). The status of the lymphoma at the time of mobilization was the only factor for successful mobilization (20/22 patients [91%] in complete remission [CR] mobilized adequately versus 5/12 [58%] in partial remission [PR]; p=0.038).

CONCLUSIONS

In patients with lymphoma and HIV infection, mobilization with G-CSF was as effective as mobilization with chemotherapy followed by G-CSF. The stage of disease prior to the mobilization was the main risk factor for the success of mobilization, with better results in patients mobilized in remission of the lymphoma.

Paradigms and Controversies in the Treatment of HIV-Related Burkitt Lymphoma

Burkitt lymphoma (BL) is a very aggressive subtype of non-Hodgkin's lymphoma that occurs with higher frequency in patients with HIV/AIDS. Patients with HIV-related BL (HIV-BL) are usually treated with high-intensity, multi-agent chemotherapy regimens. The addition of the monoclonal antibody Rituximab to chemotherapy has also been studied in this setting. The potential risks and benefits of commonly used regimens are reviewed herein, along with a discussion of controversial issues in the practical management of HIV-BL, including concurrent anti-retroviral therapy, treatment of relapsed and/or refractory disease, and the role of stem cell transplantation.

Treatment of AIDS-related lymphomas: rituximab is beneficial even in severely immunosuppressed patients

OBJECTIVE

AIDS-related lymphomas (ARLs) significantly contribute to mortality in HIV-infected patients. Optimal chemotherapy treatment and the use of rituximab remain controversial. The aim of the present cohort study was to analyze the outcome of HIV-infected patients diagnosed with ARL, with regard to the use of rituximab, clinical characteristics and histopathological markers.

METHODS AND DESIGN

This observational uncontrolled multicenter cohort study included 163 HIV-infected patients with ARL diagnosed between January 2005 and December 2008 in Germany.

RESULTS

Patients with CD20-positive ARL had a significantly better overall survival (OS) and progression-free survival (PFS) than patients with CD20-negative ARL [hazard ratio 0.28, 95% confidence interval (CI) 0.15-0.53 and hazard ratio 0.29, 95% CI 0.16-0.53]. In CD20-positive cases, the use of rituximab was associated with better OS and PFS (n = 128, hazard ratio 0.48, 95% CI 0.25-0.93 and hazard ratio 0.47, 95% CI 0.26-0.86), even in patients with severe immune deficiency at ARL diagnosis (CD4 T-cell count<100 cells/μl, n = 33; OS: hazard ratio 0.25, 95% CI 0.07-0.90). In multivariate analysis, CD4 T-cell counts more than 100 cells/μl and the use of rituximab were associated with better OS and PFS. In total, there were 12 polychemotherapy-associated deaths, which were not related to specific therapy regimens or to the use of rituximab.

CONCLUSION

In patients with CD20-positive ARL, CD4 T-cell count at ARL diagnosis and the use of rituximab had strong impact on survival. Rituximab was beneficial in ARL even in the setting of severe immune deficiency and was not associated with an increased risk of fatal infections.

Human immunodeficiency virus infection and non-small cell lung cancer: survival and toxicity of antineoplastic chemotherapy in a cohort study

OBJECTIVES

To describe factors associated with survival in human immunodeficiency virus (HIV)-infected subjects with non-small cell lung cancer (NSCLC) and analyze toxicities induced by cytotoxic chemotherapy and antiretroviral compounds.

DESIGN

Retrospective analyses of HIV-infected subjects with NSCLC enrolled in the Dat'Aids cohort. A toxicity substudy included subjects treated by at least one cycle of cytotoxic chemotherapy.

METHODS

Survival was analyzed using Cox models. In the toxicity substudy, factors associated with grade 4 hematological toxicity of each episode of combination of antiretroviral drugs and cytotoxic chemotherapy were analyzed using marginal logistic regression models.

RESULTS

Fifty-two subjects were included in the study: 42 were men, median age was 48 years, 98% were smokers, with a median of 30 pack years, median CD4 was 300 cells/μl, and median survival time was 12 months. CD4 levels ≥200 cells/μl at NSCLC diagnosis (hazard ratio [HR] = 0.29, 95% confidence interval [CI] [0.10-0.89]), performance status less than 2 (HR = 0.32, 95% CI [0.15-0.68]) and highly active antiretroviral therapy (HR = 0.26, 95% CI [0.09-0.74]) were significantly associated with increased survival in the multivariable model. Forty subjects were included in the toxicity substudy, and 14 among 68 different combinations were complicated by a grade 4 hematological toxicity. Protease inhibitor use (odds ratio = 5.22, 95% CI [1.07-25.38]) was significantly associated with grade 4 hematological toxicity in the multivariable analyses.

CONCLUSIONS

In HIV-infected patients, CD4 levels at NSCLC diagnosis may be a predictive factor of survival. Use of highly active antiretroviral therapy during NSCLC chemotherapy is warranted, but protease inhibitors should be used with caution, as they may enhance severe hematological toxicities.

Emerging antiretroviral drug interactions

With HIV-infected patients living longer and recommendations to initiate antiretrovirals (ARVs) being made earlier, the likelihood for potential drug-drug interactions between ARVs and concurrent medications used to manage co-morbid conditions will increase. In order to maximize the clinical benefit and minimize potential toxicity of ARVs and co-administered medications, it is important for clinicians to recognize significant drug-drug interactions. This article highlights clinically significant drug-drug interactions with antituberculosis agents, antimalarials, anticoagulants, chemotherapeutic agents and pulmonary antihypertensive agents when they are co-administered with newer ARVs (e.g. darunavir, raltegravir, maraviroc and etravirine).

HIV-related lymphoma

Since the introduction of highly active antiretroviral therapy, the natural history of HIV infection has changed dramatically, and with it the epidemiology of HIV-related lymphoma. HIV-related lymphomas have increased as a percentage of first AIDS-defining illness. The most prevalent of the HIV-related lymphomas is diffuse large B-cell non-Hodgkin’s lymphoma, followed by Burkitt’s lymphoma. Although not considered an AIDS-defining illness, Hodgkin’s lymphoma is increasing in incidence in those with HIV infection. Treatment outcome and prognosis has improved significantly over the last decade. Paradigms of therapy have shifted, with approaches aimed at complete remission rather than palliation. This review discusses the biology and changes in epidemiology of HIV-related lymphoma and also reviews other key developments in the management of this disease.

Immunohistochemical expression profile and prognosis in patients with diffuse large B-cell lymphoma with or without human immunodeficiency virus infection

Diffuse large B-cell lymphoma (DLBCL) is the most common lymphoma subtype in non-immunosuppressed and in human immunodeficiency virus (HIV)-positive patients. The prognosis of DLBCL with germinal center (GC) phenotype is better than that of the non-germinal center (non-GC) phenotype by immunohistochemical expression profile (IHC) in some studies but not in others. The frequency and the prognosis of these phenotypic subtypes in DLBCL related to HIV infection is not well known. The objectives of this study were to characterize the IHC by tissue microarray in 98 patients with DLBCL, 34 of whom were HIV-positive, and to evaluate their prognosis. Patients with HIV-related DLBCL with a non-GC pattern had poorer prognosis than patients with non-HIV-related DLBCL with the same pattern, but this difference disappeared when we considered only patients receiving HAART.

Detrimental clinical interaction between ritonavir-boosted protease inhibitors and vinblastine in HIV-infected patients with Hodgkin's lymphoma

In order to analyze the clinical relevance of the pharmacokinetic interactions between vinblastine and antiretrovirals described in literature, we evaluated all HIV-infected patients with Hodgkin's lymphoma treated with vinblastine-containing regimens and combination antiretroviral therapy, in a single clinical center. The use of protease inhibitors was independently associated with WHO grade III-IV neutropenia. Moreover, an inverse correlation between dosage of ritonavir and mean nadir neutrophil count was found. The concomitant administration of vinblastine-containing chemotherapy regimens with protease inhibitors can lead to higher levels of neutropenia than those of different classes of drugs such as nonnucleoside reverse transcriptase inhibitors or integrase inhibitors.

GI-lymphomas in immunosuppressed patients (organ transplantation; HIV)

Gastrointestinal lymphoma plays a major role complicating different diseases presenting with immunosuppression, both primary and acquired immunodeficiency (incl. HIV, transplantation, immunosuppression following chemotherapy, or inflammatory bowel disease). Lymphoma in diseases with immunosuppression are clinically and pathologically heterogeneous, but share some features such as frequent involvement of extranodal sites, diffuse aggressive histology, B-cell lineage derivation, viral association with EBV and clinically aggressive courses. While gastrointestinal lymphoma in congenital immunodeficiency disorders seems to be a rare event inspite of higher prevalences, in post-transplant lymphoproliferative disorders (PTLD) the gastrointestinal tract is one of the most important organs of lymphoma. In HIV-associated non-Hodgkin's lymphoma, gastrointestinal lesions as the most frequent extranodal localisation occur in 30-50% of lymphoma patients, are late events of HIV infection with severe immunosuppression and are mainly diagnosed with advanced disease stages Ann Arbour III or IV. They are characterised by unusual, often multifocal localisation in the gastrontestinal tract, high rates of life-threatening complications (bleeding, perforation or obstruction) and high-grade B-cell histology. With the introduction of highly active antiretroviral therapy (HAART) in the therapeutic concept in AIDS, a decrease of AIDS-related GI lymphoma was noted with improved survival rates and prognosis of lymphoma. Therapy strategies including chemotherapy, immunotherapy and HAART will show promising results in response and survival rates.

Should we implement 'opt-out' HIV testing for patients with lymphoma?

Patients with HIV are dying due to late diagnosis and physicians are being encouraged to increase HIV testing. The uptake of opt-in HIV screening for 113 lymphoma patients was audited at University College London Hospital. Of the 113 patients, 46 were not tested (41%). Previous research in the antenatal setting suggests that adopting opt-out screening would increase testing rates.

Comparable survival between HIV+ and HIV− non-Hodgkin and Hodgkin lymphoma patients undergoing autologous peripheral blood stem cell transplantation

Autologous stem cell transplantation (ASCT) has been successfully used in HIV-related lymphoma (HIV-Ly) patients on highly active antiretroviral therapy. We report the first comparative analysis between HIV-Ly and a matched cohort of HIV− lymphoma patients. This retrospective European Group for Blood and Marrow Transplantation study included 53 patients (66% non-Hodgkin and 34% Hodgkin lymphoma) within each cohort. Both groups were comparable except for the higher proportion of males, mixed-cellularity Hodgkin lymphoma and patients receiving granulocyte colony-stimulating factor before engraftment and a smaller proportion receiving total body irradiation-based conditioning within the HIV-Ly cohort. Incidence of relapse, overall survival, and progression-free survival were similar in both cohorts. A higher nonrelapse mortality within the first year after ASCT was observed in the HIV-Ly group (8% vs 2%), predominantly because of early bacterial infections, although this was not statistically significant and did not influence survival. Thus, within the highly active antiretroviral therapy era, HIV patients should be considered for ASCT according to the same criteria adopted for HIV− lymphoma patients.

Autologous Stem-Cell Transplantation in Patients With HIV-Related Lymphoma

Purpose

Peripheral-blood autologous stem-cell transplantation (ASCT) in patients with HIV-related lymphoma (HIV-Ly) has been reported as a safe and useful procedure. Herein we report the European Group for Blood and Marrow Transplantation experience on patients with HIV-Ly undergoing ASCT.

Patients and Methods

This was a retrospective, multicentric, registry-based analysis.

Results

Since 1999, 68 patients from 20 institutions (median age, 41 years; range, 29 to 62 years) were included, diagnosed with non-Hodgkin's lymphoma (NHL; n = 50) or Hodgkin's lymphoma (n = 18). At the time of ASCT, 16 patients were in first complete remission (CR1); 44 patients were in CR more than 1, partial remission, or chemotherapy-sensitive relapse (chemo-S); and eight patients had chemotherapy-resistant disease. The median number of CD34+cells infused was 4.5 × 106/kg (range, 1.6 to 21.2 × 106/kg). Median time to neutrophil and platelet engraftment were 11 days (range, 8 to 36 days) and 14 days (range, 6 to 455 days), respectively, with a cumulative incidence (CI) at 1 year of 95.6% and 87%, respectively. CI of nonrelapse mortality (NRM) was 7.5% at 12 months after ASCT, mainly because of bacterial infections. CI of relapse was 30.4% at 24 months, statistically related with not being in CR at ASCT (relative risk [RR] = 3.6), NHL histology other than diffuse large B-cell lymphoma (RR = 3.4), and use of more than two previous treatment lines (RR = 3). At a median follow-up of 32 months (range, 2 to 81 months), progression-free survival (PFS) was 56%. Patients not in CR or with refractory disease at ASCT had poorer PFS (RR = 2.4 and 4.8, respectively).

Conclusion

Similarly to HIV-negative patients with lymphoma, ASCT is a useful treatment for patients with HIV-Ly and is associated with low NRM, mainly when performed in early stages and chemo-S disease.

Ongoing change in the treatment of HIV-associated malignancies in the HAART era

Implementation of highly active antiretroviral therapy (HAART) has changed the epidemiology, clinical outcome and therapeutic approach of HIV-associated malignancies. Whereas Kaposi sarcoma and primary CNS non-Hodgkin lymphoma have decreased dramatically, systemic non-Hodgkin lymphoma incidence seems unchanged, perhaps increasing as with other tumor incidence. Owing to HAART-induced immune function preservation, response rates to chemotherapy and survival times in patients with HIV-associated malignancies have neared those observed in their HIV-negative counterparts. Hence, intensive regimens have been more and more extensively used with promising results. This may also apply to other therapeutic options, such as biotherapy, and procedures, such as stem cell rescue following high-dose chemotherapy or heterologous stem cell transplant, which have so far been precluded to HIV-infected subjects as a matter of fact. A trend toward a full assimilation of HIV-infected people with cancer and the general population with the same pathology is ongoing.

Effect of highly active antiretroviral therapy on survival of HIV infected patients with non-small-cell lung cancer

OBJECTIVE

To evaluate the impact of highly active antiretroviral therapy (HAART) on survival in HIV infected patients with non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

All consecutive HIV infected patients with NSCLC diagnosed between 06/1996 and 03/2007 at two University hospitals in Paris (France) were prospectively followed until death. The association between survival and clinical and biological factors was analyzed by univariate and multivariate models. Survival analysis was performed by Kaplan-Meier estimates and the Cox proportional hazards regression model.

RESULTS

During the study period, NSCLC was diagnosed in 49 consecutive HIV infected patients (median age 46 years); 84% had advanced disease. Median survival was 8.1 months (range 5-10 months). In multivariate analysis, baseline parameters with significant positive impact on survival included performance status (PS) < or =1 (HR=0.2, 95%CI [0.09, 0.46], p=0.0001), stage I-II disease (HR=0.15, 95%CI [0.04, 0.53], p=0.003), and use of HAART (HR=0.4, 95%CI [0.2, 0.9], p=0.027).

CONCLUSION

HAART is a good prognostic factor for survival in HIV infected patients with NSCLC. Stage of disease and PS are two other valid survival prognostic factors.

Characteristics and outcome of AIDS-related Hodgkin lymphoma before and after the introduction of highly active antiretroviral therapy

OBJECTIVES

We analyzed survival, therapeutic response, and prognostic factors in patients with HIV-related Hodgkin lymphoma (HL) treated or not with highly active antiretroviral therapy (HAART).

METHODS

This study included 104 patients with HL, treated (n = 83) or not (n = 21) with HAART. Outcomes and prognostic factors of complete remission (CR), overall survival (OS), and disease-free survival (DFS) were assessed by an intention-to-treat analysis of all patients who received at least 1 chemotherapy course.

RESULTS

No differences were found between groups at baseline in the specific characteristics of HIV and HL. The proportion of patients receiving appropriate-for-stage therapy for HL was similar for both groups. The CR rates in the HAART (-) and HAART (+) groups were 14 (70%) of 20 versus 71 (91%) of 78 (P = 0.023). The median OS in the HAART (-) group was 39 months (95% confidence interval [CI]: 0 to 89) and was not reached in the HAART (+) group (P = 0.0089). The median DFS in the HAART (-) group was 85 months (95% CI: 73 to 97) and was not reached in the HAART (+) group (P = 0.129). Factors independently associated with CR by logistic regression analysis were appropriate-for-stage therapy of HL, HAART, and baseline CD4 count > or =100 cells/microL. CR was the only factor independently associated with OS by Cox regression analysis.

CONCLUSIONS

The achievement of CR was independently associated with appropriate-for-stage therapy for HL, with HAART, and with a baseline CD4 count > or =100 cells/microL. The only variable independently associated with OS was the achievement of CR.

Immunologic recovery in survivors following chemotherapy for AIDS-related non-Hodgkin lymphoma

The late effects of chemotherapy on immunologic parameters in AIDS-related non-Hodgkin lymphoma (NHL) have not been described. From a cohort of 105 consecutive patients treated with infusional chemotherapy and highly active antiretroviral therapy (HAART), 68 survived more than 3 months following the end of chemotherapy. Their lymphocyte subsets and plasma HIV viral loads were measured at regular intervals for 2 years and values compared with baseline. During chemotherapy, there were statistically significant falls in CD4 (helper T), CD8 (cytotoxic T), and CD19 (B) cell populations but no changes in the CD56 (natural killer [NK]) cell population. Among the 68 survivors, there were statistically significant increases in CD4, CD8, CD19, and CD56 cell populations during the first year of follow up, compared with the values at the start of chemotherapy. During the second year of follow up, there were further statistically significant rises in CD4 and CD19 cell populations, compared with the values at 12 months after chemotherapy. During 244 years of follow-up since chemotherapy in these 68 survivors, 7 second primary tumors and 8 opportunistic infections were diagnosed. Chemotherapy and concomitant HAART for AIDS-related NHL does not cause prolonged suppression of lymphocyte subsets. These data should provide reassurance regarding the long-term consequences of chemotherapy in these individuals.

Treatment and Prognosis of AIDS-Related Lymphoma in the Era of Highly Active Antiretroviral Therapy: Findings from the Swiss HIV Cohort Study

Objective

To assess the characteristics of combination antiretroviral therapy (cART) administered concomitantly with chemotherapy and to establish prognostic determinants of patients with AIDS-related non-Hodgkin's lymphoma.

Methods

The study included 91 patients with AIDS-related non-Hodgkin's lymphoma from the Swiss HIV Cohort Study enrolled between January 1997 and October 2003, excluding lymphomas of the brain. We extracted AIDS-related non-Hodgkin's lymphoma- and HIV-specific variables at the time of lymphoma diagnosis as well as treatment changes over time from charts and from the Swiss HIV Cohort Study database. Cox regression analyses were performed to study predictors of overall and progression-free survival.

Results

During a median follow up of 1.6 years, 57 patients died or progressed. Thirty-five patients stopped chemotherapy prematurely (before the sixth cycle) usually due to disease progression; these patients had a shorter median survival than those who completed six or more cycles (14 versus 28 months). Interruptions of cART decreased from 35% before chemotherapy to 5% during chemotherapy. Factors associated with overall survival were CD4+ T-cell count (<100 cells/μl) (hazard ratio [HR] 2.95 [95% confidence interval (CI) 1.53–5.67], hepatitis C seropositivity (HR 2.39 [95% CI 1.01–5.67]), the international prognostic index score (HR 1.98–3.62 across categories) and Burkitt histological subtypes (HR 2.56 [95% CI 1.13–5.78]).

Conclusions

Interruptions of cART were usually not induced by chemotherapy. The effect of cART interruptions on AIDS-related non-Hodgkin's lymphoma prognosis remains unclear, however, hepatitis C seropositivity emerged as a predictor of death beyond the well-known international prognostic index score and CD4+ T-cell count.

Lung cancer in HIV-infected patients in the era of highly active antiretroviral therapy

BACKGROUND

Infection with the human immunodeficiency virus (HIV) and lung cancer represent two problems beginning in the 20th century that are of epidemic proportions. By the end of the 20th century, therapeutic programs of modest efficacy had been developed for both. Because both HIV infection and lung cancer are common, it is not surprising that a number of patients would be afflicted with both diseases simultaneously. There is a very limited literature regarding the treatment and outcome of patients with both diseases, particularly since the advent of highly active antiretroviral therapy (HAART) for HIV infection.

METHODS

We retrospectively reviewed our tumor registry to ascertain cases with concurrent lung cancer and HIV diagnoses since 1996, at the advent of HAART. Twenty-nine patients were identified at the University of Maryland, and five additional cases from an affiliated institution were identified.

RESULTS

Thirty patients had non-small cell lung cancer, and four patients had small cell lung cancer. Of the 30 patients with non-small cell lung cancer, 27 had stage IIIb/IV disease and were analyzed for outcome on the basis of CD4 counts and HAART therapy. Patients with CD4 counts >200 or those on HAART had numerically, though not statistically, superior survival. Patients were able to receive standard chemotherapy regimens, and the overall survival was 5.2 months.

CONCLUSIONS

This single-institution analysis appears to indicate that there is an increasing incidence of patients with lung cancer and HIV infection. Patients with advanced NSCLC who are HIV positive with CD4 counts >200 can be treated with chemotherapy and demonstrate survival comparable to that of patients without HIV infection.

Prognosis of AIDS-related systemic non-Hodgkin lymphoma treated with chemotherapy and highly active antiretroviral therapy depends exclusively on tumor-related factors

OBJECTIVES

To assess complete remission (CR) and survival in patients with systemic AIDS-related non-Hodgkin lymphoma (ARL) receiving highly active antiretroviral therapy (HAART).

METHODS

We analyzed the Grupo de Estudio del SIDA register of systemic ARL, which started in Jan 1994, to collect cases diagnosed at 15 institutions prospectively and with active follow-up every 6 months. The date of censorship for this study was March 2005.

RESULTS

During the study period, 210 consecutive patients were diagnosed with ARL, with a median age 39 of years, 75.7% of whom were male, and with a median baseline CD4 count of 160 cells/microL. Histologic subtypes were diffuse large B-cell lymphoma (DLCL; n = 153 [72.9%]), Burkitt and atypical Burkitt/Burkitt-like lymphoma (BL; n = 40 [19.0%]), T-cell lymphoma (TC; n = 8 [3.8%]), and miscellaneous (n = 9 [4.3%]). Chemotherapy with or without other modalities was administered to 186 (88.6%) patients. In an intent-to-treat analysis of 184 patients who received at least 1 chemotherapy course with adequate follow-up to assess their response, 119 (64.7%) achieved CR, and the median length of survival (Kaplan-Meier analysis) was 52 months (95% confidence interval [CI]: 23 to 82 months). Factors independently associated with CR were histologic subtype and International Prognostic Index (IPI) score. Factors independently associated with improved overall length of survival (OS) were CR, low IPI score, and histologic subtype. The single factor independently associated with disease-free survival was Ann Arbor stage.

CONCLUSIONS

In patients with ARL treated with HAART, CR was associated exclusively with tumor-related factors. The CR rate was poorer in patients with BL and TC subtypes and was inversely correlated with IPI score. OS was independently associated with CR, IPI score, and the histologic subtype.

Oncologic Complications of Human Immunodeficiency Virus Infection: Changing Epidemiology, Treatments, and Special Considerations in the Era of Highly Active Antiretroviral Therapy

Although highly active antiretroviral therapy (HAART) has revolutionized the treatment of human immunodeficiency virus (HIV)-positive patients, malignancies in the setting of HIV infection remain an appreciable problem. We evaluated the changing epidemiology of HIV-related malignancies, optimal neoplastics and their effect on viral dynamics, and evidence regarding drug interactions between chemotherapy and antiretrovirals. A MEDLINE search (January 1966-June 2006) was performed to identify clinical trials, review articles, and meta-analyses; abstracts from HIV conferences were also searched. Survival of patients with HIV-related malignancies has substantially improved since the advent of HAART. Chemotherapy for malignancies in the HIV-positive population generally resembles that for the HIV-negative population, with trials revealing an elevated frequency of toxicities in HIV-positive patients. Studies of antineoplastics have shown no long-term adverse effects on viral dynamics in terms of immunologic or virologic HIV markers. Limited pharmacokinetic data with antineoplastics and antiretrovirals suggest possible changes in some pharmacokinetic parameters, but these results should be interpreted cautiously because of the small numbers of patients enrolled in the trials. Researchers also report an increased frequency of chemotherapy-related toxicities when HAART was coadministered with antineoplastics. This increase was likely due to impairment of cytochrome P450 metabolism of antineoplastics by protease inhibitors. Because of the survival benefits of HAART, the integration of antiretrovirals with chemotherapy is now preferred for patients with HIV-related malignancies. However, because the metabolic pathways of many of these agents are similar, the effectiveness of antineoplastic therapy and its related toxicities should be vigilantly monitored in this patient population.

A prospective, non-randomised phase 1-2 trial of VACOP-B with filgrastim support for HIV-related non-Hodgkin's lymphoma

Non-Hodgkin's lymphoma (NHL) remains an important complication of associated HIV infection despite advances in antiretroviral therapy (ART), and the optimum chemotherapy regimen for this disease remains to be defined. A dose-escalation trial was performed to determine the maximum tolerated doses of etoposide and doxorubicin as part of the 12-week VACOP-B regimen, supported by filgrastim (r-metHuG-CSF). Patients with aggressive histology HIV-related NHL who were previously untreated with chemotherapy, and who had no active opportunistic infection were eligible for the study. Chemotherapy consisted of cyclophosphamide 350 mg/m2, vincristine 2 mg, bleomycin 10 U/m2; and prednisone 100 mg q2 days x 12 weeks, with increasing doses of doxorubicin 25-50 mg/m2 and etoposide 25-50 mg/m2 intravenously and 50-100 mg/m2 orally. Central nervous system prophylaxis (intrathecal cytarabine 50 mg x 4 doses), antifungal, and Pneumocystis carinii prophylaxis were used, and filgrastim was administered to prevent neutropenic complications. One dose level was expanded to permit the concomitant use of ART. Endpoints were determination of maximum tolerated dose of doxorubicin and etoposide, treatment tolerability, and survival. Forty-seven patients were enrolled, most with diffuse large-cell or immunoblastic NHL. Protocol-defined maximum tolerated dose was not reached and the limits of dose-limiting toxicity were not exceeded, even in patients receiving ART. Thirty-two cycles (4.9%) were delayed >6 days because of toxicity; 30 patients (64%) completed all 12 weeks of treatment. After completion of therapy, 14 patients had a complete response (30%), and 4 had a partial response (8%). Median time to progression was 9 months. At 42 months, progression-free survival was 25% and overall survival was 28%.

Update on extranodal lymphomas. Conclusions of the Workshop held by the EAHP and the SH in Thessaloniki, Greece

Classification and proper treatment of extranodal lymphoma is hindered by the diversity of lymphoma types and the relative rarity of many of these tumour types. In order to review controversial issues in extranodal lymphoma diagnosis, a joint Workshop of the European Haematopathology Association (EAHP) and the Society for Hematopathology (SH) was held, where 99 selected cases were reviewed and discussed. This Workshop summary is focused on the most controversial aspect of cutaneous B-cell lymphoma, other extranodal B-cell lymphomas, plasmablastic lymphoma and anaplastic large-cell lymphoma in extranodal sites, and makes practical recommendations about diagnosis and therapeutic approaches.

Diffuse large B-cell lymphomas with plasmablastic differentiation

Recent evidence suggests that diffuse large B-cell lymphoma (DLBCL) with plasmablastic differentiation represents a clinically heterogeneous spectrum with different clinicopathologic characteristics representing distinct entities. Subtypes of DLBCL with plasmablastic features and terminal B-cell differentiation include plasmablastic lymphoma (PBL) of oral mucosa type; PBL with plasmacytic differentiation; primary effusion lymphoma (PEL); KSHV-positive solid lymphoma/extracavitary PEL/HHV-8 associated DLBCL; and DLBCL expressing ALK. In contrast, PBL associated with multicentric Castleman disease, DLBCL with secretory differentiation, pyothorax-associated lymphoma, and atypical Burkitt lymphoma with plasmacytoid differentiation have morphologic appearances of plasma cell differentiation but maintain a mature B-cell (CD20 positive) phenotype. These tumors as well as extramedullary plasmablastic tumors secondary to multiple myeloma or plasmacytomas are included in the differential diagnosis. In this review, we discuss recently described clinicopathologic insights, case observations, and recently reported molecules involved in terminal B-cell or plasma cell differentiation and their possible roles in disease pathogenesis.

The changing face of HIV-associated lymphoma: what can we learn about optimal therapy inl the post highly active antiretroviral therapy era?

Epidemiological data indicate that the risk of developing non-Hodgkin lymphoma (NHL) in HIV positive individuals is related to age and CD4 count (i.e. degree of immunosuppression). The prognosis of patients with HIV-NHL has been shown to be linked to several features including age, stage, modified IPI, prior AIDS diagnosis, CD4 count, immunoblastic pathology, LDH, and HAART use. These features are, as would be expected, a mixture of prognostic factors relating to both the HIV, and to the NHL. Population studies indicate that the incidence of associated (HIV-NHL) may be reducing with the advent of HAART, although not all studies concur. However, most population-based studies have not as yet shown a significant improvement in the survival of patients with HIV-NHL with HAART. The optimal chemotherapy for these patients is unknown, although it is generally accepted that CNS prophylaxis is mandatory. There is currently no good evidence of any survival benefit with increased dose intensity from large RCT. However, it must be borne in mind that the large randomised studies comparing differing dose intensities were undertaken before the advent of effective HAART. There is some evidence that there may be a subset of good prognosis patients who may benefit from more intensive therapy. Given that the prognosis of patients with HIV can now be considerably improved with HAART, we cannot necessarily assume that the same results would apply with regard to chemotherapy dose intensity. There is some evidence that there is a survival benefit from the addition of HAART to chemotherapy, although this is retrospective. It is likely, however, that the reason for this is that the HAART improves the prognosis of the patients from their HIV, and therefore reduces the number of patients dying from other HIV-related illnesses whilst in remission from their lymphoma, as was seen in large numbers of patients in the earlier chemotherapy trials. It must not be forgotten that the prognosis of the patient's NHL is intimately linked to their prognosis with respect to the HIV. Although the number of patients with HIV-NHL is currently few, there is a need for more trials of chemotherapy, particularly now in the HAART era, when the prognosis from the point of view of the HIV has improved so much. In particular, the issue of dose intensity needs revisiting for patients whose overall prognosis can be improved by commencing HAART. Patients with HIV-NHL should be managed at specialist centres, and where possible should be managed as part of RCT.

HIV-associated lymphoma successfully treated with peripheral blood stem cell transplantation

OBJECTIVE

To evaluate feasibility, safety, and efficacy of peripheral blood stem cell collection (PBSCC) and autologous stem cell transplantation (ASCT), to treat patients diagnosed of high-risk or relapsed HIV-associated lymphoma (HIV+ Ly), responding to highly active antiretroviral therapy (HAART).

METHODS

Prospective and multicentric study in patients with high-risk or relapsed chemosensitive HIV+ Ly, candidate for consolidation with ASCT. Eligibility criteria were similar to those of HIV- lymphoma. HAART was aimed to be maintained during the procedure.

RESULTS

Fourteen patients were admitted. Adequate PBSCC was obtained from all patients (median CD34+ cells was 4.7 x 10(6)/kg). Three patients died before ASCT; two had disease progression and one died from VHC-liver failure. Eleven transplanted patients showed neutrophil engraftment after a median time of 16 days (range, 9-33 days), and nine patients showed platelet engraftment after a median time of 20 days (range, 11-36 days). CD4+ cell counts and HIV viral load (VL) were appropriately preserved along the procedure. No patients died from treatment-related complications. One patient died from lymphoma progression (day +19), and another died in complete remission (CR) with undetectable VL, 15 months after transplant, due to infection. One patient relapsed at 32 months after ASCT. The remaining eight patients are alive in CR with an event-free survival of 65% and a median follow-up of 30 months after ASCT (range, 7-36 months).

CONCLUSIONS

These results show that feasibility, safety, and efficacy of PBSCC and ASCT in HIV+ Ly patients responding to HAART are similar to those observed in the HIV- lymphoma setting.

CD20-negative large-cell lymphoma with plasmablastic features: a clinically heterogenous spectrum in both HIV-positive and -negative patients

BACKGROUND

Plasmablastic lymphoma (PBL) has been described as a rapidly progressive and almost invariably fatal CD20- VS38c+ diffuse large-cell lymphoma with plasmablastic features, almost exclusively involving the jaw and oral mucosa in HIV-positive patients.

METHODS

From 2001 to 2003 we evaluated 12 men with PBL, and report the pathology, clinical findings, treatment and outcome. Six of 12 were HIV-positive while among the others, one was post-renal transplant, one had ulcerative colitis and four had no known immunodeficiency.

RESULTS

Tumor growth pattern, in general, showed cohesiveness and a starry-sky pattern; the morphology varied from typical plasmablastic to centroblastic cells. Partial immunophenotypes were (+/total): CD138, 11 of 12 (91.7%); MIB1 10 of 11 (4+, range 75-95%); p63/VS38c, nine of 10 (90%); EBV, eight of 11 (73%); LCA(CD45), two of 12 (16.7%); HHV8/LANA, zero of 10; ALK, zero of seven; and CD20, zero of 12. Three had stage IE and nine stage IV disease. Nine of 12 had an intermediate/high International Prognostic Index or high-risk disease. Computed tomography and positron emission tomography scan in four of 12 revealed extensive bone metastases. Eight of 12 are alive after treatment, with a median follow-up of 11+ months (range 1-24). Of the HIV-positive patients, five of six are alive with a median follow-up of 17 months.

CONCLUSIONS

It appears that PBL are heterogenous in terms of clinical presentation and morphology. The outcome presented here is superior to that originally reported.

Cytologic features of plasmablastic lymphoma

BACKGROUND

Plasmablastic lymphomas (PBLs) were originally described exclusively in human immunodeficiency virus (HIV)-positive patients who presented with jaw or oral mucosa involvement. Recent studies have reported this neoplasm also in patients without HIV infection and involving sites other than head and neck. This lymphoma has a heterogeneous morphologic presentation but distinct phenotype.

METHODS

Cytologic features from four cases of histologically confirmed PBL were evaluated. The cytology specimens were evaluated for criteria as follow: cellularity, cell size and shape, pleomorphism, cytoplasmic characteristics, chromatin pattern, nucleolar features, and mitotic figures.

RESULTS

Specimens evaluated were two head and neck fine needle aspiration specimens, one anal smear, and one cerebrospinal fluid specimen. Atypical lymphocytes ranged from intermediate to large in size and demonstrated slight nuclear pleomorphism. The cytoplasm varied from scant to moderate in the alcohol-fixed slides. Nuclei were round with vesicular chromatin. Nucleoli varied from a prominent one to multiple small ones. Multinucleated cells and mitotic figures were easily identified in three of four cases. Tingible-body histiocytes were seen in one case. Ancillary studies in two cases demonstrated expression of CD138 with lack of CD20 expression.

CONCLUSION

PBL is a variant of large cell lymphoma with heterogeneous cytologic findings but distinct immunophenotype. Knowledge of the cytomorphologic spectrum of PBLs and detection of CD138 expression by flow cytometry can be helpful in achieving a correct diagnosis.

Interactions Between Antiretrovirals and Antineoplastic Drug Therapy

Despite the established impact of highly active antiretroviral therapy (HAART) in reducing HIV-related morbidity and mortality, malignancy remains an important cause of death. Patients who receive the combination of cancer chemotherapy and HAART may achieve better response rates and higher rates of survival than patients who receive antineoplastic therapy alone. However, the likelihood of drug interactions with combined therapy is high, since protease inhibitors (PIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs) are substrates and potent inhibitors or inducers of the cytochrome P450 (CYP) system. Since many antineoplastic drugs are also metabolised by the CYP system, coadministration with HAART could result in either drug accumulation and possible toxicity, or decreased efficacy of one or both classes of drugs. Although formal, prospective pharmacokinetic interaction studies are not available in most instances, it is possible to infer the nature of drug interactions based on the metabolic fates of these agents. Paclitaxel and docetaxel are both metabolised by the CYP system, although differences exist in the nature of the isoenzymes involved. Case reports describing adverse consequences of concomitant taxane-antiretroviral therapy exist. Although other confounding factors may have been present, these cases serve as reminders of the vigilant monitoring necessary when taxanes and HAART are coadministered. Similarly, vinca alkaloids are substrates of CYP3A4 and are, thus, vulnerable to PI- or NNRTI-mediated changes in their pharmacokinetics. Interactions with the alkylating agents cyclophosphamide and ifosfamide are complicated as a result of the involvement of the CYP3A4 and CYP2B6 isoenzymes in both the metabolic activation of these drugs and the generation of potentially neurotoxic metabolites. Existing data regarding the metabolic fate of the anthracyclines doxorubicin and daunorubicin suggest that clinically detrimental interactions would not be expected with coadministered HAART. Commonly used endocrine therapies are largely substrates of the CYP system and may, therefore, be amenable to modulation by concomitant HAART. In addition, tamoxifen itself has been associated with reduced concentrations of both anastrozole and letrozole, raising the concern that similar inducing properties may adversely affect the outcome of PI- or NNRTI-based therapy. Similarly, dexamethasone is both a substrate and concentration-dependent inducer of CYP3A4; enhanced corticosteroid pharmacodynamics may result with CYP3A4 inhibitors, while the efficacy of concomitant HAART may be compromised with prolonged dexamethasone coadministration. Since PIs and NNRTIs may also induce or inhibit the expression of P-glycoprotein, the potential for additional interactions to arise via modulation of this transporter also exists. Further research delineating the combined safety and pharmacokinetics of antiretrovirals and antineoplastic therapy is necessary.

AIDS-related cancer in the era of highly active antiretroviral therapy (HAART): a model of the interplay of the immune system, virus, and cancer. "On the offensive--the Trojan Horse is being destroyed"--Part B: Malignant lymphoma

The impact of highly active antiretroviral therapy (HAART) on the incidence of non-Hodgkin's lymphoma was less obvious initially, although primary central nervous system lymphoma (PCNSL) has dropped precipitously since the introduction of HAART. The pathogenesis of acquired immunodeficiency syndrome-related lymphoma is multifactorial. Epstein-Barr virus plays a significant role in these diseases, especially Burkitt lymphoma and PCNSL. Data regarding the effect of HAART on the natural history and treatment outcomes of these malignancies are emerging. The possibility of direct and indirect roles of human immunodeficiency virus in the carcinogenesis suggests that antiretroviral therapy may be an important component of the treatment for these malignancies. The simultaneous administration of HAART and chemotherapy does not appear to significantly alter the toxicity profile, although the information with respect to the interaction of HAART and chemotherapy is limited. The use of biological agents, for example, monoclonal antibody against CD-20, is being explored to improve the clinical outcome of this disease.

Durable remissions with autologous stem cell transplantation for high-risk HIV-associated lymphomas

The treatment of HIV-associated lymphoma has changed since the widespread use of highly active antiretroviral therapy. HIV-infected individuals can tolerate more intensive chemotherapy, as they have better hematologic reserves and fewer infections. This has led to higher response rates in patients with HIV-associated Hodgkin disease (HD) or non-Hodgkin lymphoma (NHL) treated with chemotherapy in conjunction with antiretroviral therapy. However, for patients with refractory or relapsed disease, salvage chemotherapy still offers little chance of long-term survival. In the non-HIV setting, patients with relapsed Hodgkin disease (HD) or non-Hodgkin lymphoma (NHL) have a better chance of long-term remission with high-dose chemotherapy with autologous stem cell rescue (ASCT) compared with conventional salvage chemotherapy. In a prior report we demonstrated that this approach is well tolerated in patients with underlying immunodeficiency from HIV infection. Furthermore, similar engraftment to the non-HIV setting and low infectious risks have been observed. Herein, we expand upon this early experience with the largest single institution series of 20 patients. With long-term follow-up we demonstrate that ASCT can lead to an 85% progression-free survival, which suggests that this approach may be potentially curative in select patients with relapsed HIV-associated HD or NHL.

Clinical features and predictors of survival of AIDS-related non-Hodgkin's lymphoma in a population-based case series in Sydney, Australia

OBJECTIVES

To analyse clinical features and predictors of survival for AIDS-related non-Hodgkin's lymphoma (NHL) in the era of highly active antiretroviral therapy (HAART), compared to earlier in the HIV epidemic.

METHODS

All AIDS-NHL cases diagnosed at three inner Sydney hospitals caring for people with AIDS during 1985-2001 were identified through medical record searches. Demographic, clinical, immunological and histopathological information was recorded. Year of NHL diagnosis was grouped into three periods, corresponding to whether monotherapy (1985-1991), dual therapy (1992-1995) or HAART (1996-2001) was the main treatment for HIV infection. Statistical comparisons were made between the pre-HAART and post-HAART eras.

RESULTS

Three hundred cases of AIDS-NHL were identified. Divergent trends were identified for systemic and primary central nervous system (CNS) NHL. For systemic NHL, the CD4 count at NHL diagnosis increased markedly to 208 cells/microL in the post-HAART era (P=0.014) and there was a trend towards presentation as the first AIDS-defining illness (69%, P=0.053), and as earlier stage NHL disease (42%, P=0.048). Median survival time increased from 4.2 months in 1985-1991 to 19 months in the post-HAART era (P<0.001). In a multivariate model, predictors of poor survival from systemic NHL included: NHL diagnosis after another AIDS-defining illness (P<0.001), stage 4 NHL (P<0.001), presentation at extra lymphatic sites (P=0.001), and nonreceipt of chemotherapy (P=0.002). After adjusting for the factors, those diagnosed in the era of HAART had a significant 56% reduction in rate of death (P<0.001). In contrast, for CNS NHL, clinical features were little changed and survival did not improve in the era of HAART.

CONCLUSIONS

Systemic NHL is presenting earlier in the course of HIV disease, and at a less advanced NHL stage. There has been a marked improvement in survival in the era of HAART even after adjustment for other prognostic variables. In contrast, primary CNS NHL remains a disease which presents late in the course of HIV infection and is associated with a very poor prognosis.