Beneficial effect of highly active antiretroviral therapy on the prognosis of AIDS-related systemic non-Hodgkin lymphomas

Spontaneous Regression of Epstein-Barr Virus-Positive Diffuse Large B-cell Lymphoma in an HIV-Positive Patient: A Case Report and Literature Review

Individuals infected with human immunodeficiency virus (HIV) have a greater risk of developing malignancies, including both acquired immunodeficiency syndrome (AIDS)-defining malignancies as well as many non-AIDS-defining cancers. Several factors contribute to the increased incidence of malignancies in this population such as the direct effects of HIV itself, immune deficiency, co-infection with oncogenic viruses, environmental factors, and the effects of combination antiretroviral therapy (cART). The improvement of the immune response following the introduction of cART results in a better response to conventional therapies for malignancies, including chemotherapy, radiotherapy, and surgery. Significant disparities still exist in cancer treatment for people living with HIV and afflicted with cancers compared to those without HIV, with many in the former group not receiving any cancer treatment at all. We report a rare case whereby a newly diagnosed HIV-infected patient with Epstein-Barr virus-positive diffuse large B-cell lymphoma showed spontaneous regression of the lymphoma with the introduction of cART alone without any treatment of the cancer itself. We reviewed similar cases described in the literature and examined the possible explanations for this phenomenon.

Survival outcomes of primary cutaneous T-cell lymphoma in HIV-infected patients: a national population-based study

This study aimed to investigate clinical characteristics and survival outcomes of primary cutaneous T-cell lymphoma (CTCL) in HIV-infected and non-HIV-infected patients. All data were from the Surveillance, Epidemiology, and End Results program, 1973-2013, of the U.S. National Cancer Institute. Data of 318 HIV-infected patients and 1272 non-HIV-infected patients with primary CTCL were analyzed. Endpoints were overall survival and cancer-specific mortality. Independent variables included demographics, pre-existing malignancy, treatments, and environmental factors. Among 8823 patients with CTCL, 318 (3.60 per cent) were HIV-infected and 8505 (96.40 per cent) were not. 318 HIV-infected patients and 1272 non-HIV-infected patients selected by matching diagnosis dates were analyzed, including 941 (59.2 per cent) males and 649 (40.8 per cent) females with mean age 58.8 years. HIV-infected patients with CTCL had higher survival and significantly lower risk of overall mortality than non-HIV-infected patients (adjusted HR 0.37, 95 per cent CI 0.24 to 0.59, P<0.001). Non-HIV-infected, age and black race were significant risk factors for overall mortality. Age and race are independent risk factors for overall mortality in primary CTCL individuals, and HIV-infected status is an independent protective factor, suggesting that advanced antiretroviral therapy restores immunity and prolongs survival in HIV-infected patients with CTCL.

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.

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.

Radiation therapy for HIV-associated diffuse large cell non-Hodgkin lymphoma

PURPOSE

To report the clinical experience with external beam radiotherapy (RT) for AIDS-related lymphoma (ARL) with or without the involvement of the central nervous system (CNS) in HIV-infected patients.

PATIENTS AND METHODS

Clinical outcome of 24 HIV-seropositive patients with ARL treated with RT from 1995 to 2004 was reviewed, testing factors associated with outcome.

RESULTS

After 1 and 5 years, the overall survival was 65% and 35%, respectively. The mean RT dose was 31 Gy after normalization to fractions of daily 2 Gy (range, 7.8-47.2 Gy). Radiotherapy dose was associated with survival in univariate (P = .04) and multivariate analysis (P = .01). Other factors in univariate analysis associated with outcome were viral load (VL), highly active antiretroviral therapy (HAART), ARL stage, and CNS involvement. Patients with CNS involvement achieved complete response in 46% and improved clinical performance was seen in 73%.

CONCLUSIONS

After chemotherapy, RT in combination with HAART is highly active, and RT should be encouraged especially after suboptimal responses to induction treatment.

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.

Update on HIV lymphoma

In industrialized nations people infected with HIV remain at increased risk for malignancies despite highly active antiretroviral therapy. In these countries, lymphoma is the most common HIV-associated malignancy. This review summarizes progress from January 2005 to February 2007. The majority of investigation has been in diffuse large B cell lymphoma, with infusional therapy remaining promising but cumbersome. Rituximab likely improves complete response rates, and, possibly overall survival, but is likely associated with increased infections in a subset of patients with very low CD4 counts. Biologic insights have been attained in the spectrum of HIV-associated non-Hodgkin's lymphoma, Hodgkin's lymphoma, and virologic coinfections. Overall, the outcome for non-Hodgkin's lymphoma and Hodgkin's lymphoma in the setting of HIV continues to improve as insights into the pathophysiology and treatment advance.

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.

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.

Presentation and outcomes of systemic non-Hodgkin's lymphoma: a comparison between patients with acquired immunodeficiency syndrome (AIDS) treated with highly active antiretroviral therapy and patients without AIDS

We used the San Diego/Orange County cancer registry to identify 64 cases of systemic non-Hodgkin's lymphoma (NHL) with AIDS who received highly active antiretroviral therapy (HAART) at the time of NHL diagnosis or thereafter and 64 NHL controls without AIDS, matched on age, sex, race, time of NHL diagnosis (1994-1995 and 1996-1999), and hospital type (academic, large community, and small community). We compared cases and controls by chi-squared tests and Kaplan-Meier methods. Thirty-three percent of cases had high grade histology versus 11% of controls (p < 0.01); 69% had baseline hemoglobin <13 g/dL versus 35% controls (p < 0.001) and 21% had baseline neutrophils <2,000/mcl versus 4% of controls (p < 0.001). Overall median survival was 16 months for cases versus 99 months for controls (p < 0.01). Among 40 matched pairs of cases and controls who received chemotherapy, 32% of cases received reduced-dose chemotherapy versus 5% of controls (p < 0.01) and median survival was 33 months for cases and 99 months for controls (p < 0.44). Patients with AIDS-related NHL who received HAART had high grade histology and baseline cytopenia and received reduced-dose chemotherapy more often than patients without AIDS. However, AIDS patients who received HAART and chemotherapy had survival similar to NHL patients without AIDS, an improvement from the pre-HAART era. Appropriate hematologic support, through growth factors, transfusions, and avoidance of drugs with hematologic toxicity, might allow full dosing of chemotherapy, and perhaps would further improve outcomes among patients with AIDS and NHL.

Update in HIV lymphoma

PURPOSE OF REVIEW

Despite the control of HIV infection in industrialized nations, individuals infected with HIV remain at increased risk of malignancies. Lymphoma is the most common HIV-associated malignancy in these countries. This review summarizes progress from January 2005 to March 2006.

RECENT FINDINGS

Investigators continue to demonstrate that HIV-associated non-Hodgkin's lymphoma remains a significant problem, even in the era of highly active antiretroviral therapy. The majority of work has been in diffuse large B-cell lymphoma, with infusional therapy remaining promising, and rituximab an area of investigation. The latter improves complete response rates, but is associated with an increased incidence of infections. Biological insights have been gained into the spectrum of HIV-associated non-Hodgkin's lymphoma and Hodgkin's disease, and include further work on virological co-infections.

SUMMARY

The outcome for individuals infected with HIV and developing non-Hodgkin's lymphoma and Hodgkin's disease continues to improve as insights into the pathophysiology and treatment advance.

Management of advanced HIV disease: resistance, antiretroviral brain penetration and malignancies

Data from Italy, Spain and the USA all highlight the worrying fact that presentation with advanced HIV disease - defined as a cluster of differentiation 4 (CD4) count <50 cells/mm(3) or the presence of an acquired immunodeficiency syndrome-defining illness - is increasingly common. A review from 2003 showed that 31% of patients in the UK and Ireland presented late (<200 CD4 cells/mm(3)). Early diagnosis is vital to ensure that patients benefit from antiretroviral therapy, and when patients present late, they do not obtain the benefits of early treatment. The risk of death is lower when antiretroviral therapy is initiated at CD4 counts of 201-350 cells/mm(3) than at lower CD4 cell counts. In addition, the risk of unintentional infection of others is increased, which is particularly troubling in light of evidence that transmission of resistance can occur even in the absence of antiretroviral therapy. The management of patients with advanced disease and no complications is complex, but issues of transmitted resistance and comorbid conditions further confuse management decisions in the treatment of patients with higher CD4 counts. This article reviews recent evidence on transmitted resistance, the pharmacokinetics of antiretroviral drugs in patients with central nervous system disease and the management issues in patients with comorbid malignancies to offer practical advice on therapeutic options for treatment-naïve patients who present with advanced HIV disease.

Overview of non-Hodgkin's lymphoma

OBJECTIVES

To provide an overview of non-Hodgkin's lymphoma (NHL).

DATA SOURCES

Review and research articles.

CONCLUSION

NHLs are divided primarily into two main categories based on their rate of growth: aggressive and indolent. Within these two groups are various subtypes that have various clinical features. Prognostic features have been useful in determining the potential outcome of treatment of patients with NHL.

IMPLICATIONS FOR NURSING PRACTICE

Nurses play an important role in the education of patients regarding the type of lymphoma they have and the steps necessary to make an accurate diagnosis, which is important in determining the appropriate treatment.

AIDS-related malignancies: changing epidemiology and the impact of highly active antiretroviral therapy

PURPOSE OF REVIEW

Three cancers in people with HIV denote an AIDS diagnosis: Kaposi's sarcoma, high-grade B-cell non-Hodgkin's lymphoma and invasive cervical cancer. In addition a number of other cancers occur at increased frequency in this population group but are not AIDS-defining illnesses. This review discusses the impact of highly active antiretroviral therapy on the epidemiology and outcome of AIDS-defining cancers.

RECENT FINDINGS

The incidence of both Kaposi's sarcoma and non-Hodgkin's lymphoma has declined in the era of highly active antiretroviral therapy and the outcome of both tumours has improved. Moreover, highly active antiretroviral therapy alone produces a response in a majority of antiretroviral-naïve patients with Kaposi's sarcoma. In contrast, highly active antiretroviral therapy has had little impact on the incidence of human papilloma virus-associated tumours (cervical and anal cancer) in people with HIV, although it may improve survival by reducing opportunistic infection deaths. As people with HIV live longer with highly active antiretroviral therapy, an increased incidence of other non AIDS-defining cancers that have no known association with oncogenic infections is becoming apparent.

SUMMARY

For those with access to highly active antiretroviral therapy, the good news from the AIDS-defining cancers - particularly Kaposi's sarcoma and non-Hodgkin's lymphoma - may be balanced by the increasing numbers of non AIDS-defining cancers.

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.