AIDS-associated Burkitt or Burkitt-like lymphoma: Short intensive polychemotherapy is feasible and effective

Brentuximab vedotin as frontline treatment for HIV-related extracavitary primary effusion lymphoma

Primary effusion lymphoma (PEL) is a rare and aggressive herpesvirus-8 (HHV-8) driven B cell non-Hodgkin's lymphoma (NHL) that is usually associated with human immunodeficiency virus (HIV) infection, and has a poor prognosis. PEL is comprised of two clinically distinct but pathologically similar variants: classic and extracavitary PEL. Based on retrospective series, treatment options include combined antiretroviral therapy (cART) in conjunction with chemotherapy regimens used in other forms of NHLs. Treatment outcomes with this approach are usually dismal and there is no standard of care. We present a case of a patient with HIV associated CD30+ extracavitary PEL unfit for multi-agent chemotherapy, who achieved a durable complete response with single agent brentuximab-vedotin and cART.

Burkitt lymphoma in adolescents and young adults: management challenges

About one-half of all Burkitt lymphoma (BL) patients are younger than 40 years, and one-third belong to the adolescent and young adult (AYA) subset, defined by an age between 15 and 25-40 years, based on selection criteria used in different reports. BL is an aggressive B-cell neoplasm displaying highly characteristic clinico-diagnostic features, the biologic hallmark of which is a translocation involving immunoglobulin and c-MYC genes. It presents as sporadic, endemic, or epidemic disease. Endemicity is pathogenetically linked to an imbalance of the immune system which occurs in African children infected by malaria parasites and Epstein-Barr virus, while the epidemic form strictly follows the pattern of infection by HIV. BL shows propensity to extranodal involvement of abdominal organs, bone marrow, and central nervous system, and can cause severe metabolic and renal impairment. Nevertheless, BL is highly responsive to specifically designed short-intensive, rotational multiagent chemotherapy programs, empowered by the anti-CD20 monoclonal antibody rituximab. When carefully applied with appropriate supportive measures, these modern programs achieve a cure rate of approximately 90% in the average AYA patient, irrespective of clinical stage, which is the best result achievable in any aggressive lymphoid malignancy to date. The challenges ahead concern the following: optimization of management in underdeveloped countries, with reduction of diagnostic and referral-for-care intervals, and the applicability of currently curative regimens; the development of lower intensity but equally effective treatments for frail or immunocompromised patients at risk of death by complications; the identification of very high-risk patients through positron-emission tomography and minimal residual disease assays; and the assessment in these and the few refractory/relapsed ones of new monoclonals (ofatumumab, blinatumomab, inotuzumab ozogamicin) and new molecules targeting c-MYC and key proliferative steps of B-cell malignancies.

Burkitt's Lymphoma and B-Cell Lymphoma Unclassifiable With Features Intermediate Between Diffuse Large B-Cell Lymphoma and Burkitt's Lymphoma in Patients With HIV: Outcomes in a South African Public Hospital

Purpose

Burkitt’s lymphoma (BL) is a common HIV-associated lymphoma in South Africa. B-cell lymphoma unclassifiable with features intermediate between diffuse large B-cell lymphoma and Burkitt’s lymphoma (BL/DLBCL) also occurs in HIV infection. Outcomes of HIV-infected patients with BL or BL/DLBCL in a resource-constrained setting are not defined.

Methods

We performed a retrospective study of HIV-positive patients with BL or BL/DLBCL treated from 2004 to 2012 with curative intent at a publically funded academic medical center in South Africa. Differences between BL and BL/DLBCL, survival outcomes, and factors associated with survival were analyzed.

Results

There were 35 patients with either HIV-associated BL (24) or BL/DLBCL (11) who met study criteria. Median CD4⁺ T-lymphocyte count at lymphoma diagnosis was 188 cells/μL (range, 10 to 535 cells/μL). Patients with BL/DLBCL were significantly older and had less bone marrow involvement and lower baseline serum lactase dehydrogenase than patients with BL. Eighty-nine percent of patients presented with advanced disease, and 25% had baseline CNS involvement. Chemotherapy regimens consisted of cytoreduction with low-dose cyclophosphamide, vincristine, and prednisone followed by induction with vincristine, methotrexate, cyclophosphamide, doxorubicin and prednisone (LMB 86; 57%); hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone, methotrexate, and cytarabine (hyper-CVAD; 20%); cyclophosphamide, doxorubicin, vincristine, and prednisone and high-dose methotrexate with leucovorin rescue on day 10 with accompanying prophylactic IT chemotherapy (Stanford regimen; 14%); and cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP-like; 9%) regimens. Twenty-three patients received CNS treatment or prophylaxis, and 31 received concurrent combination antiretroviral therapy. Two-year overall survival was 38% (95% CI, 22% to 54%) and 2-year event-free survival was 23% (95% CI, 11% to 38%), with no difference between histologic subtypes. Common causes of death were infection (41%) and CNS disease progression or systemic relapse (41%).

Conclusion

Cure of HIV-associated BL and BL/DLBCL with intensive regimens is possible in resource-limited settings, but lower toxicity regimens, improved CNS prophylaxis, and increased resources for supportive care are required.

Update on the treatment of HIV-associated hematologic malignancies

HIV is associated with an excess cancer risk, particularly of lymphoid malignancies. Modern therapeutics has changed the landscape of HIV disease and typical opportunistic complications of AIDS are now largely avoided. Although the risk of lymphoma has decreased, it still remains high. Nevertheless, treatment outcomes have improved due both to improvements in HIV medicine and in cancer therapeutics for the common lymphomas occurring in those with HIV infection. Other hematologic malignancies are rarely seen in HIV-infected patients, but the standardized risk ratio for many of these cancers is higher than in the background population. Principles of cancer care and appreciation for HIV infection as a comorbid condition can guide physicians in setting realistic goals and treatment for this patient population. In many cases, expected outcomes are very similar to the HIV-unrelated patients and therapeutic planning should be based on this understanding. Treatment tolerance can be predicted based on the status of the HIV disease and the cancer therapy being administered. For those hematologic cancers in which transplantation is part of standard care, this modality should be considered an option in those with HIV infection.

Burkitt post-transplantation lymphoma in adult solid organ transplant recipients: sequential immunochemotherapy with rituximab (R) followed by cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) or R-CHOP is safe and effective in an analysis of 8 patients

BACKGROUND

Burkitt lymphoma post-transplantation lymphoproliferative disorder (Burkitt-PTLD) is a rare form of monomorphic B-cell PTLD for which no standard treatment has been established. Currently, the treatment of Burkitt lymphoma outside the post-transplantation setting involves high doses of alkylating agents, frequent dosing, and intrathecal and/or systemic central nervous system prophylaxis. In PTLD, however, such protocols are associated with considerable toxicity and mortality.

METHODS

The authors present a retrospective series of 8 adult patients with Burkitt-PTLD. Six patients were reported to the prospective German PTLD registry or were enrolled in the PTLD-1 trial, and 2 patients had received treatment before 2000, thus allowing for comparison with the pre-rituximab era.

RESULTS

Seven of the 8 patients were men. The median age at presentation was 38 years, and the median time since transplantation was 5.7 years. Five of 8 patients had histologically established, Epstein-Barr virus-associated disease, and 7 of 7 patients were positive for a MYC translocation. Five of 8 patients received sequential immunochemotherapy (4 courses of rituximab [R] followed by 4 cycles of cyclophosphamide, doxorubicin, vincristine, and prednisolone [CHOP] or R plus CHOP [R-CHOP]). In this group, 5 of 5 patients reached complete remission (CR), and their overall survival (OS) was significantly longer (P = .008) compared with the OS for 2 of 8 patients who received first-line CHOP and did not respond. One of 8 patients (who had stage IV disease with meningiosis) received combination therapy (cyclophosphamide pretreatment, rituximab, intrathecal chemotherapy, whole-brain irradiation, and radioimmunotherapy) and reached CR. Overall, 6 of 8 patients reached CR; and, after a median follow-up of 4.7 years (range, 1.7-4.8 years), the median OS was 36.7 months. There was no treatment-related mortality under first-line therapy.

CONCLUSIONS

In the largest adult case series in Burkitt-PTLD to date, sequential immunochemotherapy with rituximab followed by standard CHOP or R-CHOP was a both safe and effective treatment.

HIV and cancer in Germany

BACKGROUND

Cancer is now the leading cause of death in persons with HIV. In this study, we gathered current epidemiological data on Aids-defining (AD) and non-Aids-defining (NAD) malignancies among HIV-positive patients in Germany.

METHODS

From 2000 to 2007, all 35 specialized HIV outpatient clinics and 189 HIV ambulatory care centers in Germany were contacted and asked to fill out a structured questionnaire on the incidence of malignancies in HIV-positive patients during multiple periods of observation.

RESULTS

552 evaluable data sets were reported. 253 (45.8%) of the reported malignancies were AD. Among the 299 cases (54.2%) of NAD malignancies, there were 214 solid tumors, including 71 anal carcinomas (23.7% of all NAD malignancies), and 85 hematopoietic malignancies, including 29 cases of Hodgkin`s lymphoma (9.7% of all NAD malignancies). The high percentage of NAD malignancy remained constant throughout the entire period of the study. Only a single case of primary cerebral lymphoma was reported after 2001. The number of patients with Hodgkin`s lymphoma rose steadily from 2000 to 2007.

CONCLUSION

The spectrum of HIV-associated malignancies has changed since the early days of the HIV epidemic. In Germany, NAD malignancies have become more common than AD malignancies. In particular, anal carcinoma and Hodgkin's lymphoma are much more common among persons with HIV than in the general population. Persons with HIV need more intensive preventive care for cancer than non-infected persons do.

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.

Molecular profiling of pediatric mature B-cell lymphoma treated in population-based prospective clinical trials

The spectrum of entities, the therapeutic strategy, and the outcome of mature aggressive B-cell non-Hodgkin lymphomas (maB-NHLs) differs between children and adolescents on the one hand and adult patients on the other. Whereas adult maB-NHLs have been studied in detail, data on molecular profiling of pediatric maB-NHLs are hitherto lacking. We analyzed 65 cases of maB-NHL from patients up to 18 years of age by gene expression profiling, matrix comparative genomic hybridization (CGH), fluorescent in situ hybridization (FISH), and immunohistochemistry. The majority of the analyzed pediatric patients were treated within prospective trials (n = 49). We compared this group to a series of 182 previously published cases of adult maB-NHL. Gene expression profiling reclassified 31% of morphologically defined diffuse large B-cell lymphomas as molecular Burkitt lymphoma (mBL). The subgroups obtained by molecular reclassification did not show any difference in outcome in children treated with the NHL-Berlin-Frankfurt-Muenster (BFM) protocols. No differences were detectable between pediatric and adult mBL with regard to gene expression or chromosomal imbalances. This is the first report on molecular profiling of pediatric B-NHL showing mBL to be much more prominent in children than suggested by morphologic assessment. Based on molecular profiling mBL is a molecularly homogeneous disease across children and adults.

Burkitt lymphoma in adults

This review will begin with a detail of the revision of the WHO classification, and pathological definitions of Burkitt lymphoma. Over the past several years, molecular understanding of Burkitt lymphoma has improved significantly. Using gene expression profiling, a genomic "signature" of Burkitt lymphoma may be identified, that has fidelity beyond c-myc expression, and the presence of the classical t(8;14). Then, evaluation and therapy of the adult patient with Burkitt lymphoma will be reviewed. Relatively few data exist on optimal therapy of the adult patient with Burkitt lymphoma. Principles of therapy should include high doses of alkylating agents, frequent administration of chemotherapy, and attention to central nervous system (CNS) prophylaxis with high doses of systemic chemotherapy, intrathecal therapy, or both. The outcome of adult patients with Burkitt lymphoma, particularly those over 40 years of age, is inferior to the outcome of younger patients, but may be improving over the past few years. Results from an international collaborative effort, which are helpful in evaluating results of Burkitt lymphoma therapy in adults, will be presented. HIV-associated Burkitt lymphoma, and elderly patients with Burkitt lymphoma, comprise special clinical situations that will be also covered in this review.

HIV-associated lymphoma: the evidence for treating aggressively but with caution

PURPOSE OF THE REVIEW

The aim of this article is to review key reports regarding the biology and management of HIV-associated lymphoma during the past year.

RECENT FINDINGS

The use of highly active antiretroviral therapy (HAART) has been associated with a reduced risk of primary cerebral and systemic non-Hodgkin's lymphoma, a stable or slightly increased risk of Hodgkin's lymphoma, and improved prognosis for those who develop HIV-associated non-Hodgkin's lymphoma or Hodgkin's lymphoma. Emerging evidence suggests that patients with HIV-associated lymphoma should be treated in a similar manner as immunocompetent patients with the same disease, especially if the CD4 count is 50-100 cells/mul or higher. Use of the anti-CD20 monoclonal antibody rituximab in combination with chemotherapy appears to result in improved control of B-cell lymphoma, but may come at the expense of an increased risk of bacterial and viral infections.

SUMMARY

Although the evidence currently supports an aggressive and curative approach for the management of HIV-associated lymphoma, clinicians must be vigilant about implementing infection prophylaxis and promptly recognizing, diagnosing, and treating bacterial, parasitic, fungal, and viral infections that may occur as a consequence of therapy.