Highly active antiretroviral therapy (HAART) improves survival in HIV-associated Hodgkin's disease: results of a multicenter study

Clinical features in Hodgkin lymphoma patients living with human immunodeficiency virus: A meta-analysis in the antiretroviral therapy era

OBJECTIVE

Evaluate the clinical features in people with Hodgkin's lymphoma living with HIV (HIV-HL) during the combination ART (cART) era.

DESIGN

Systematic review and meta-analysis.

METHODS

The study was conducted in accordance with the recommendations of 2020 PRISMA and MOOSE statements. The protocol was prospectively registered through the PROSPERO (CRD42021289520). Manuscripts published until July 2023 were systematically searched in the PubMed, EMBASE, Cochrane Library, and Web of Science databases, with no language and year of publication restriction. Meta-analysis was performed to estimate a pooled proportion of each outcome using a random-effect analysis. Quality assessment was performed by using New-Castle Ottawa scale. Certainty of evidence was graded using the GRADE.

RESULTS

Sixteen cohorts, representing 3.882 HIV-HL patients, were included in this review. Our findings indicate that HIV-HL patients showed a 2-year overall survival (OS) of 92% (95% CI 0.87, 0.95). However, the 5-year overall survival decreased to 79% (95% CI 0.74, 0.83), with a high certainty of evidence according to GRADE. Additionally, the 5-year progression-free survival declined to 79% and complete remission rate increased to 81%. Our meta-analysis indicates an increase for B symptoms (80%, 95% CI 0.75, 0.84) and extranodal involvement in bone marrow (43%, 95% CI 0.30, 0.47) among HIV-HL patients.

CONCLUSION

The HIV-HL patients showed a 2-year OS of 92%. However, the 5-year OS decreased to 79%. The reported main cause of mortality among HIV-HL patients was progression of HL. Our systematic review and meta-analysis suggest that cART is associated with improved short-term survival of HIV-HL patients.

Impact of the HIV infection in Hodgkin lymphoma individuals: A protocol for systematic review and meta analysis

BACKGROUND

Hodgkin lymphoma (HL) is a rare lymphoproliferative disorder that occurs in about 10% of all cancer cases. Human immunodeficiency virus (HIV) is associated with an increased occurrence of a wide range of cancers, including HL due to progressive immunosuppression and co-infection with oncogenic viruses. However, the aim of this systematic review is to obtain evidence about the impact of the HIV infection in HL individuals.

METHODS

We will obtain studies through PubMed, Embase, CINAHL, LILACS, CENTRAL, Web of Science, Scopus, Cochrane Library, and Google Scholar databases. The inclusion criteria will be observational studies (sectional, cohort, and case-control) that describe the impact of the HIV infection in HL individuals. Outcomes of interest include mortality, prevalence, causes of hospitalization, time between HIV diagnosis and HL diagnosis in days, comorbidities (systemic hypertension, diabetes mellitus, metabolic syndrome, others), T CD4 + cells/mm3 at HIV diagnosis and at HL diagnosis, viral load (log10 copies/mL) at HL diagnosis, and history of treatment abandon. Two reviewers, independently, will extract the data from each included study. Meta-analysis will then be carried out using fixed-effects or random-effects model, using the mean difference for continuous outcomes and the relative risk for dichotomous outcomes. Risk of bias will be assessed using the Newcastle-Ottawa Scale. The quality of evidence for each outcome will be assessed using Grading of Recommendations Assessment, Development and Evaluation methodology. Review Manager V.5.3.5 will be used for synthesis and subgroup analysis. To assess heterogeneity, we will compute the I2 statistics. Additionally, a quantitative synthesis will be performed if the included studies are sufficiently homogenous.

ETHICS AND DISSEMINATION

This study will be a review of the published data, and thus it is not necessary to obtain ethical approval. The findings of this systematic review will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021289520.

First Extensive Analysis of 18F-Labeled Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography in a Large Cohort of Patients With HIV-Associated Hodgkin Lymphoma: Baseline Total Metabolic Tumor Volume Affects Prognosis

PURPOSE

¹⁸F-labeled fluorodeoxyglucose positron emission tomography with computed tomography (¹⁸F-FDG PET-CT) data in HIV-associated Hodgkin lymphoma (HIV-HL) are scarcely reported. In addition to the description of the characteristics of both baseline and interim ¹⁸F-FDG PET-CT examinations (PET1 and iPET, respectively), the aim of this study was to assess the prognostic value of PET1 and previously identified clinical parameters in this population.

PATIENTS AND METHODS

PET1 of 109 patients with HIV-HL, treated with doxorubicin, bleomycin, vinblastine, and dacarbazine chemotherapy regimen since 2007, and 104 iPET were centrally reviewed. All the patients were enrolled in an ongoing prospective single-center cohort of HIV-associated lymphoma.

RESULTS

Most patients had a disseminated disease according to the Ann Arbor classification (30% stage III and 43% stage IV), with especially bone marrow and liver as extranodal localizations. After a median follow-up of 6.7 years, 12 patients relapsed (11%) and 13 died (12%). Five-year progression-free survival (PFS) was 75.1%, and 5-year overall survival was 86.1%. Median total metabolic tumor volume (TMTV) was 121.4 cm³. The optimal TMTV cutoff identified for prognostic analysis was 527 cm³, with a 2-year PFS of 71% in the 20 patients with TMTV > 527 cm³, compared with 91% in the 89 patients with TMTV ≤ 527 cm³ (P = .004). On multivariate analysis, a high TMTV was the only parameter independently associated with PFS.

CONCLUSION

In this large series of HIV-HL patients with a homogeneous management, high TMTV on PET1 examination was associated with a poor prognosis.

Hodgkin Lymphoma in People Living with HIV

Simple Summary

Hodgkin lymphoma (HL) is a non-AIDS defining neoplasm, but people living with HIV (PLWH) have between a 5- and 26-fold higher risk of developing it than the general population. Epstein-Barr virus is present in almost all HIV-related HL cases, and plays an important role in its etiopathogenesis. Despite the aggressive characteristics, the prognosis of HL affecting PLWH is similar to that of the general population if patients are treated following the same recommendations. Administration of cART concomitantly with chemotherapy is highly recommended. However, this combination may be challenging due to drug–drug interactions and overlapping toxicity. Thus, interdisciplinary collaboration between hemato-oncologists and HIV specialists is crucial for the optimal treatment of both lymphoma and HIV infection.

Abstract

Despite widespread use of combined antiretroviral therapy (cART) and increased life expectancy in people living with HIV (PLWH), HIV-related lymphomas (HRL) remain a leading cause of cancer morbidity and mortality for PLWH, even in patients optimally treated with cART. While the incidence of aggressive forms of non-Hodgkin lymphoma decreased after the advent of cART, incidence of Hodgkin lymphoma (HL) has increased among PLWH in recent decades. The coinfection of Epstein–Barr virus plays a crucial role in the pathogenesis of HL in the HIV setting. Currently, PLWH with HRL, including HL, are treated similarly to HIV-negative patients and, importantly, the prognosis of HL in PLWH is approaching that of the general population. In this regard, effective cART during chemotherapy is strongly recommended since it has been shown to improve survival rates in all lymphoma subtypes, including HL. As a consequence, interdisciplinary collaboration between HIV specialists and hemato-oncologists for the management of potential drug–drug interactions and overlapping toxicities between antiretroviral and antineoplastic drugs is crucial for the optimal treatment of PLWH with HL. In this article the authors review and update the epidemiological, clinical and biological aspects of HL presenting in PLWH with special emphasis on advances in prognosis and the factors that have contributed to it.

Risk, Diagnostic and Predictor Factors for Classical Hodgkin Lymphoma in HIV-1-Infected Individuals: Role of Plasma Exosome-Derived miR-20a and miR-21

The incidence of classical Hodgkin lymphoma (cHL) in the HIV-1 setting has increased 5–25-fold compared to that observed in the general population. This study aimed to determine whether selected micro RNAs (miRs) and other soluble biomarkers and cellular subsets are dysregulated in cHL and could be used as biomarkers. This was a retrospective and longitudinal matched case-control study of 111 Caucasian, HIV-1-infected adult individuals, including 37 individuals with cHL and 74 with no type of cancer. Immunovirological data, plasma exosome-derived miR-16, miR-20a, miR-21, miR-221, miR-223, miR-106a, miR-185, miR-23, miR-30d, miR-222, miR-146a and miR-324, plasma IL-6, sCD14, sCD27, sCD30, sIL-2R, TNFR1, and cell phenotyping of T and B lymphocytes and natural killer (NK) cells were analyzed. Before cHL diagnosis, miR-20a, miR-21, and sCD30 were higher in cHL (p = 0.008, p = 0.009 and p = 0.042, respectively), while miR-16 was down-regulated (p = 0.040). miR-20a and miR-21 were independently associated with cHL (p = 0.049 and p = 0.035, respectively). The combination of miR-20a and miR-21 showed a good AUC value of 0.832 with a moderate likelihood ratio positive (LR+) value of 5.6 and a slight likelihood ratio negative (LR−) value of 0.23. At cHL diagnosis, miR-20a, miR-21 and miR-324 were overexpressed in cHL (p = 0.005, p = 0.024, and p = 0.001, respectively), while miR-223, miR-16, miR-185 and miR-106a were down regulated (p = 0.042, p = 0.007, p = 0.006, and p = 0.002, respectively). In addition, sCD14, sCD27, sCD30 and IL2R levels were higher in these individuals (p = 0.038, p = 0.010, p = 0.030, p = 0.006, respectively). miR-20a was independently associated with cHL (p = 0.011). The diagnostic value of miR-20a showed good AUC value of 0.754 (p = 0.074) with a slight LR+ value of 2 and a slight LR− of 0.25. After chemotherapy, miR-20a was higher in those individuals who had an adverse outcome (p < 0.001), while sCD14 and sCD30 were higher (p < 0.001). A specific signature of miRs and cytokines associated with a subsequent cHL diagnosis was found in this study, especially miR-20a and miR-21. Also, another biomarker signature was found at cHL diagnosis, with a relevant discriminant disease value for miR-20a. Of note, miR-20a expression was higher in those individuals who had an adverse clinical outcome after chemotherapy.

Patients With Malignant Lymphoma and HIV Infection Experiencing Remission After First-Line Treatment Have an Excellent Prognosis

BACKGROUND

Malignant lymphoma is still the leading cause of death among AIDS-related diseases.

PATIENTS AND METHODS

We performed a retrospective analysis of 50 HIV-positive lymphoma patients. The median interval between HIV and malignant lymphoma diagnosis was 4 years. Eight patients (16%) had Hodgkin lymphoma and 42 (84%) non-Hodgkin lymphoma. Among non-Hodgkin lymphoma patients, diffuse large B-cell lymphoma (n = 18, 42%), Burkitt lymphoma (n = 11, 26%), and plasmoblastic lymphoma (n = 5, 12%) were the most frequent entities.

RESULTS

Lymphoma was treated according to standard protocols. Forty-four patients (88%) received combination antiretroviral therapy, 2 (4%) were not treated, and in 4 (8%) the HIV treatment status was not clarified. Response to first-line therapy was complete response (CR) in 24 (56%), partial response (PR) in 15 (35%), and stable disease in 1 (2%). Three patients (7%) developed progressive disease, and 9 (18%) experienced relapse after CR or PR. At a median observation period of 31 (range, 0.4-192) months, the 1-, 2-, and 5-year overall survival was 87%, 79%, and 76%, respectively. At univariate analysis, remission status after first-line treatment was predictive of outcome, as the 2-year overall survival was 95%, 66%, and 0 for patients with CR, with PR, and with progressive disease (P < .001). Results of the multivariate analysis revealed lactate dehydrogenase concentration at lymphoma diagnosis (P = .046) and relapse (P = .050) to be independent factors for overall survival.

CONCLUSION

First-line treatment of lymphoma in HIV positive patients is crucial. Patients who experienced and maintained a first CR had a favorable prognosis.

Hiv and Lymphoma: from Epidemiology to Clinical Management

Patients infected with human immunodeficiency virus (HIV) are at increased risk for developing both non-Hodgkin’s lymphoma (NHL) and Hodgkin’s lymphoma (HL). Even if this risk has decreased for NHL after the introduction of combination antiretroviral therapy (cART), they remain the most common acquired immune deficiency syndrome (AIDS)-related cancer in the developed world. They are almost always of B-cell origin, and some specific lymphoma types are more common than others. Some of these lymphoma types can occur in both HIV-uninfected and infected patients, while others preferentially develop in the context of AIDS. HIV-associated lymphoma differs from lymphoma in the HIV negative population in that they more often present with advanced disease, systemic symptoms, and extranodal involvement and are frequently associated with oncogenic viruses (Epstein-Barr virus and/or human herpesvirus-8). Before the introduction of cART, most of these patients could not tolerate the treatment strategies routinely employed in the HIV-negative population. The widespread use of cART has allowed for the delivery of full-dose and dose-intensive chemotherapy regimens with improved outcomes that nowadays can be compared to those seen in non-HIV infected patients. However, a great deal of attention should be paid to opportunistic infections and other infectious complications, cART-chemotherapy interactions, and potential cumulative toxicity. In the context of relatively sparse prospective and randomized trials, the optimal treatment of AIDS-related lymphomas remains a challenge, particularly in patients with severe immunosuppression. This paper will address epidemiology, pathogenesis, and therapeutic strategies in HIV-associated NHL and HL.

Outcome effects of antiretroviral drug combinations in HIV-positive patients with chemotherapy for lymphoma: a retrospective analysis

Background The combination of combined active antiretroviral therapy (cART) with chemotherapy in the treatment of lymphoma in human immunodeficiency virus (HIV)-positive patients has improved the overall survival of these patients. However, drug–drug interactions between antineoplastic agents and the antiretroviral agents non-nucleoside reverse transcriptase inhibitors (NNRTIs) and protease inhibitors (PIs) can occur by influencing the activity of the CYP3A4 enzyme. So far, little is known about the clinical relevance of this interaction: the effect on the efficacy and toxicity of the chemotherapy. Also, there is no general consensus which cART is preferable in combination with antineoplastic drugs. Objective To compare PI-based with NNRTI-based cART on the efficacy and toxicity of chemotherapy in lymphoma patients. Setting The Onze Lieve Vrouwe Gasthuis, located in Amsterdam, The Netherlands. Method A retrospective observational cohort study including all patients with HIV and lymphoma over a 10-year period. Clinical outcome (response to chemotherapy and survival) and toxicity of chemotherapy (renal, hepatic and bone marrow toxicity as well as dose reduction, treatment delay and discontinuation) was compared in patients with PI based and NNRTI-based cART. Main outcome measure: Response to chemotherapy and survival. Results Patients using PI-based cART (n = 22) had a significantly lower 1 year survival compared to NNRTI-based cART (n = 21). No significant differences were observed in reaching complete remission after chemotherapy. No overall significant differences in toxicity and discontinuation of the chemotherapy were observed. However, there was a trend towards more severe bone-marrow toxicity in patients with PI-based cART. In addition, patients with PI-based cART received earlier dose-reduction and treatment delay, indicating increased toxicity in PI-treated patients. Conclusion This retrospective study shows that PI-based cART is inferior in combination with chemotherapy to NNRTI-based cART: a lower 1 year survival is observed and dose-reduction and treatment delay occur earlier, possibly based on an earlier onset of toxicity.

HIV-infection has no prognostic impact on advanced-stage Hodgkin lymphoma

OBJECTIVE

Classical Hodgkin lymphoma (cHL) is a non-AIDS-defining cancer with a good response to chemotherapy in the combined antiretroviral therapy (cART) era. The aim of the present study was to compare the characteristics, the response to treatment and the survival of advanced-stage cHL treated with adriamycin, bleomycin, vinblastine and dacarbazine (ABVD) between cART-treated HIV-positive and HIV-negative patients.

DESIGN AND METHODS

We retrospectively analyzed advanced-stage cHL patients from a single institution, uniformly treated with ABVD. All HIV-positive patients received cART concomitantly with ABVD.

RESULTS

A total of 69 patients were included in the study: 21 were HIV-positive and 48 were HIV-negative. HIV-positive patients had more aggressive features at cHL diagnosis, such as worse performance status, more frequent bone marrow involvement and mixed cellularity histologic subtype. There were no differences in complete response rate (89% in HIV-positive vs. 91% in HIV-negative), P = 1; disease-free survival (DFS) [10-year DFS probability (95% CI) 70% (41-99%) vs. 74% (57-91%)], P = 0.907 and overall survival (OS) [10-year OS probability (95% CI) 73% (52-94%) vs. 68% (51-85%)], P = 0.904. On multivariate analysis, HIV infection did not correlate with worse OS.

CONCLUSION

Although HIV-positive patients with cHL had more aggressive baseline features in this series, there were no differences in response rate or survival between HIV-positive and HIV-negative patients.

Targeting the rhesus macaque TRIM5α gene to enhance the susceptibility of CD4+ T cells to HIV-1 infection

The host range of human immunodeficiency virus type 1 (HIV-1) is extremely narrow, which has hampered the establishment of non-human primate models for HIV-1 infection. The species-specific innate immune factor tripartite motif 5 alpha (TRIM5α) is a key molecule that confers potent resistance against HIV-1 infection. In this study, we targeted the TRIM5α gene of rhesus macaques (rhTRIM5α) using the transcription activator-like effector nuclease (TALEN) to study the effect on HIV-1 infection. CD4⁺ T cells were separated from the peripheral blood of rhesus macaques by magnetic cell sorting, and the positive rate was greater than 99%. TALEN plasmids targeting rhTRIM5α were constructed and introduced into CD4⁺ T cells by electroporation, with a transfection efficiency of approximately 25%. The genome of the targeted cells was extracted, and the target efficiency was analyzed by T7E1 enzyme digestion. After sorting the positive transductants, the TALENs induced rhTRIM5α mutations at a rate of more than 40%. The ability of the HIV-1 virus to infect the targeted cells was demonstrated by ELISA. The results showed that targeting rhTRIM5α enhanced the susceptibility to HIV-1 infection. This finding will pave the way for further establishment of a new rhesus macaque model for HIV-1 studies.

New treatment strategies for HIV-positive cancer patients undergoing antiblastic chemotherapy

INTRODUCTION

The introduction of Highly Active Antiretroviral Therapy (HAART) into clinical practice has dramatically changed the outcome of HIV-infected patients by prolonging their survival. The increase in life expectancy has led to an increased risk of non-AIDS-related mortality and morbidity, including cardiovascular diseases, neurocognitive diseases, neuroendocrine dysfunctions and cancer. Areas covered: The GICAT (Italian Cooperation Group on AIDS and Tumors) has demonstrated that patients who receive a multidisciplinary approach with the combination of anticancer agents (AC) and HAART can achieve better responses and survival rates than patients who receive AC alone. The first obstacle for the oncologist to plan treatment for cancer HIV-patients is the preliminary evaluation of drug-drug interactions between AC and HAART. Recent progress in pharmacogenomics could provide a new approach for personalized treatments. The rationale of this review is to summarize the existing data on the impact of HAART on the clinical management of cancer patients with HIV/AIDS and DDIs between antiretrovirals and AC. In addition, to maximize the efficacy of both concomitant therapy and to minimize the risk of DDIs, a currently useful list of pharmacogenomic markers of key metabolic enzymes is provided. Expert opinion: In this scenario, the importance of cooperation between oncologists and other health specialists (i.e., infectivologists, pharmacists, genetics and lab specialists) must not be underestimated in the management of these patients with the aim of planning an individual treatment strategy.

Clinical features of AIDS patients with Hodgkin's lymphoma with isolated bone marrow involvement: report of 12 cases at a single institution

Objective

To study the main clinical and histopathological features of 12 patients with Hodgkin’s lymphoma (HL) diagnosed primarily from bone marrow (BM) involvement.

Methods

We included 12 acquired immunodeficiency syndrome (AIDS) patients with HL assisted in the F. J. Muñiz Infectious Diseases Hospital since January 2002 to December 2013. The diagnosis of HL with primary BM involvement in patients was confirmed by clinical, histopathological, and immunohistochemical findings.

Results

All patients presented “B” symptoms and pancytopenia. All of them had stage IV neoplasm disease because of BM infiltration. The median of CD4⁺ T-cell counts was 114 cells/μL, and mixed cellularity (MC) was the most frequent histopathological subtype of 92% cases.

Conclusion

When other causes are excluded, BM biopsy should be performed in AIDS patients with “B” symptoms and pancytopenia to evaluate BM infiltration by atypical lymphocytes.

Risk assessment in the management of newly diagnosed classical Hodgkin lymphoma

Treatment of Hodgkin lymphoma is associated with 2 major types of risk: that the treatment may fail to cure the disease or that the treatment will prove unacceptably toxic. Careful assessment of the amount of the lymphoma (tumor burden), its behavior (extent of invasion or specific organ compromise), and host related factors (age; coincident systemic infection; and organ dysfunction, especially hematopoietic, cardiac, or pulmonary) is essential to optimize outcome. Elaborately assembled prognostic scoring systems, such as the International Prognostic Factors Project score, have lost their accuracy and value as increasingly effective chemotherapy and supportive care have been developed. Identification of specific biomarkers derived from sophisticated exploration of Hodgkin lymphoma biology is bringing promise of further improvement in targeted therapy in which effectiveness is increased at the same time off-target toxicity is diminished. Parallel developments in functional imaging are providing additional potential to evaluate the efficacy of treatment while it is being delivered, allowing dynamic assessment of risk during chemotherapy and adaptation of the therapy in real time. Risk assessment in Hodgkin lymphoma is continuously evolving, promising ever greater precision and clinical relevance. This article explores the past usefulness and the emerging potential of risk assessment for this imminently curable malignancy.

Prognostic factors for advanced-stage human immunodeficiency virus-associated classical Hodgkin lymphoma treated with doxorubicin, bleomycin, vinblastine, and dacarbazine plus combined antiretroviral therapy: a multi-institutional retrospective study

BACKGROUND

The treatment and outcomes of patients with human immunodeficiency virus (HIV)-associated Hodgkin lymphoma (HL) continue to evolve. The International Prognostic Score (IPS) is used to predict the survival of patients with advanced-stage HL, but it has not been validated in patients with HIV infection.

METHODS

This was a multi-institutional, retrospective study of 229 patients with HIV-associated, advanced-stage, classical HL who received doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) plus combination antiretroviral therapy. Their clinical characteristics were presented descriptively, and multivariate analyses were performed to identify the factors that were predictive of response and prognostic of progression-free survival (PFS) and overall survival (OS).

RESULTS

The overall and complete response rates to ABVD in patients with HIV-associated HL were 91% and 83%, respectively. After a median follow-up of 5 years, the 5-year PFS and OS rates were 69% and 78%, respectively. In multivariate analyses, there was a trend toward an IPS score >3 as an adverse factor for PFS (hazard ratio [HR], 1.49; P=.15) and OS (HR, 1.84; P=.06). A cluster of differentiation 4 (CD4)-positive (T-helper) cell count <200 cells/μL was associated independently with both PFS (HR, 2.60; P=.002) and OS (HR, 2.04; P=.04). The CD4-positive cell count was associated with an increased incidence of death from other causes (HR, 2.64; P=.04) but not with death from HL-related causes (HR, 1.55; P=.32).

CONCLUSIONS

The current results indicate excellent response and survival rates in patients with HIV-associated, advanced-stage, classical HL who receive ABVD and combination antiretroviral therapy as well as the prognostic value of the CD4-positive cell count at the time of lymphoma diagnosis for PFS and OS.

Survival in HIV-infected patients after a cancer diagnosis in the cART Era: results of an italian multicenter study

OBJECTIVES

We studied survival and associated risk factors in an Italian nationwide cohort of HIV-infected individuals after an AIDS-defining cancer (ADC) or non-AIDS-defining cancer (NADC) diagnosis in the modern cART era.

METHODS

Multi-center, retrospective, observational study of HIV patients included in the MASTER Italian Cohort with a cancer diagnosis from January 1998 to September 2012. Malignancies were divided into ADC or NADC on the basis of the Centre for Disease Control-1993 classification. Recurrence of cancer and metastases were excluded. Survivals were estimated according to the Kaplan-Meier method and compared according to the log-rank test. Statistically significant variables at univariate analysis were entered in a multivariate Cox regression model.

RESULTS

Eight hundred and sixty-six cancer diagnoses were recorded among 13,388 subjects in the MASTER Database after 1998: 435 (51%) were ADCs and 431 (49%) were NADCs. Survival was more favorable after an ADC diagnosis than a NADC diagnosis (10-year survival: 62.7%±2.9% vs. 46%±4.2%; p = 0.017). Non-Hodgkin lymphoma had lower survival rates than patients with Kaposi sarcoma or cervical cancer (10-year survival: 48.2%±4.3% vs. 72.8%±4.0% vs. 78.5%±9.9%; p<0.001). Regarding NADCs, breast cancer showed better survival (10-year survival: 65.1%±14%) than lung cancer (1-year survival: 28%±8.7%), liver cancer (5-year survival: 31.9%±6.4%) or Hodgkin lymphoma (10-year survival: 24.8%±11.2%). Lower CD4+ count and intravenous drug use were significantly associated with decreased survival after ADCs or NADCs diagnosis. Exposure to cART was found to be associated with prolonged survival only in the case of ADCs.

CONCLUSIONS

cART has improved survival in patients with an ADC diagnosis, whereas the prognosis after a diagnosis of NADCs is poor. Low CD4+ counts and intravenous drug use are risk factors for survival following a diagnosis of ADCs and Hodgkin lymphoma in the NADC group.

HIV status does not influence outcome in patients with classical Hodgkin lymphoma treated with chemotherapy using doxorubicin, bleomycin, vinblastine, and dacarbazine in the highly active antiretroviral therapy era

PURPOSE

The prognosis of HIV-infected patients with non-Hodgkin lymphoma in the highly active antiretroviral therapy (HAART) era approaches that of the general population when they are treated with the same protocols. We analyzed the outcome of patients with Hodgkin lymphoma (HL) treated with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) in the HAART era according to HIV serostatus to establish whether this also holds true for HL.

PATIENTS AND METHODS

From 1997 to 2010, 224 patients newly diagnosed with HL, of whom 93 were HIV positive, were consecutively treated with ABVD chemotherapy. HIV-positive patients had more high-risk disease according to the International Prognostic Score (IPS) than HIV-negative patients (IPS≥3: 68% v 26%, respectively; P<.001). Forty-seven HIV-positive patients had a CD4 count less than 200/μL, and 92 patients received HAART during chemotherapy.

RESULTS

The complete response rate was 74% for HIV-positive patients and 79% for HIV-negative patients (P=not significant). After a median follow-up of 60 months (range, 8 to 174 months), 23 patients (16 HIV-negative and seven HIV-positive patients) have experienced relapse at a median time of 6 months (range, 1 to 106 months). Five-year event-free survival (EFS) was 59% (95% CI, 47% to 70%) for HIV-positive patients and 66% (95% CI, 57% to 74%) for HIV-negative patients (P=not significant). Five-year overall survival (OS) was 81% (95% CI, 69% to 89%) and 88% (95% CI, 80% to 93%) for HIV-positive and HIV-negative patients, respectively (P=not significant). HIV status did not predict OS or EFS on multivariate analysis including IPS and HIV status.

CONCLUSION

This mature study demonstrates that HIV-positive patients with HL have more extensive disease with more adverse prognostic factors than HIV-negative patients, but when treated with ABVD, HIV infection does not adversely affect OS or EFS.

Stage-adapted treatment of HIV-associated Hodgkin lymphoma: results of a prospective multicenter study

PURPOSE

Although the outcome of patients with HIV-related Hodgkin lymphoma (HIV-HL) has markedly improved since the introduction of combined antiretroviral therapy, standard therapy is still poorly defined. This prospective study investigates a stage- and risk-adapted treatment strategy in patients with HIV-HL.

PATIENTS AND METHODS

Patients with early favorable HIV-HL received two to four cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) followed by 30 Gy of involved-field (IF) radiation. In patients with early unfavorable HIV-HL, four cycles of bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone (BEACOPP baseline) or four cycles of ABVD + 30 Gy of IF radiation were administered. Six to eight cycles of BEACOPP baseline were given in patients with advanced-stage HIV-HL. In patients with advanced HIV infection, BEACOPP was replaced with ABVD.

RESULTS

Of 108 patients (including eight female patients) included in the study, 23 (21%) had early favorable HL, 14 (13%) had early unfavorable HL, and 71 (66%) had advanced-stage HL. The median CD4 count at HL diagnosis was 240/μL. The complete remission rates for patients with early favorable, early unfavorable, and advanced-stage HL were 96%, 100%, and 86%, respectively. The 2-year progression-free survival of the entire study population was 91.7%. Eleven patients (11%) have died, and treatment-related mortality was 5.6%. The 2-year overall survival rate was 90.7% with no significant difference between early favorable (95.7%), early unfavorable (100%), and advanced-stage HL (86.8%).

CONCLUSION

In patients with HIV-HL, stage- and risk-adapted treatment is feasible and effective. The prognosis for patients with HIV-HL may approach that of HIV-negative patients with HL.

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.

Ten-year survival among HIV-1-infected subjects with AIDS or non-AIDS-defining malignancies

Few data are available regarding the 10-year survival among subjects with HIV and cancer. The aim of this study was to evaluate the 10-year survival of HIV-infected subjects with AIDS-defining malignancies (ADM) or non-AIDS-defining malignancies (NADM). This was a single center, retrospective, observational study of subjects with HIV infection and a subsequent cancer diagnosis; the data were collected from January 1991 to April 2010. Malignancies were divided into ADM or NADM on the basis of the Centre of Diseases Control-1993 classification. Survival curves were estimated using Kaplan-Meyer method and compared by the log-rank test. Six hundred and fifteen (9.5%) of the 6,495 subjects recorded in the San Raffaele Infectious Diseases Database developed a malignancy: 431 (70%) an ADM and 184 (30%) a NADM. In the case of ADM, survival was more favorable when cancer was diagnosed during post-highly active antiretroviral therapy (HAART) era (10-year survival: 43.2% ± 4.4%) than when diagnosed during the pre-HAART era (10-year survival: 16.4% ± 2.7%; log-rank test: p < 0.001). The same was true in the case of NADM (10-year survival: 44.7% ± 5.5% vs. 33.3 ± 9.6%; log-rank test: p = 0.03). An evaluation of survival probability by cancer type showed higher survival rates during the post-HAART era in the case of non-Hodgkin lymphoma (10-year survival: 42.1% ± 5.3% vs. 11.4% ± 3.3%; log-rank test: p = <0.001), Kaposi's sarcoma (10-year survival: 44.0% ± 8.4% vs. 23.5% ± 3.9%; log-rank test: p < 0.001) and Hodgkin's disease (10-year survival: 49.5% ± 14.5% vs. 40.0% ± 12.7%; log-rank test: p = 0.005). Despite the better cancer prognosis during the post-HAART era, the 10-year survival of HIV-infected subjects with an ADM or NADM is poor.

HIV-1–related Hodgkin lymphoma in the era of combination antiretroviral therapy: incidence and evolution of CD4+ T-cell lymphocytes

The risk of Hodgkin lymphoma (HL) is increased in patients infected with HIV-1. We studied the incidence and outcomes of HL, and compared CD4+ T-cell trajectories in HL patients and controls matched for duration of combination antiretroviral therapy (cART). A total of 40 168 adult HIV-1–infected patients (median age, 36 years; 70% male; median CD4 cell count, 234 cells/μL) from 16 European cohorts were observed during 159 133 person-years; 78 patients developed HL. The incidence was 49.0 (95% confidence interval [CI], 39.3-61.2) per 100 000 person-years, and similar on cART and not on cART (P = .96). The risk of HL declined as the most recent (time-updated) CD4 count increased: the adjusted hazard ratio comparing more than 350 with less than 50 cells/μL was 0.27 (95% CI, 0.08-0.86). Sixty-one HL cases diagnosed on cART were matched to 1652 controls: during the year before diagnosis, cases lost 98 CD4 cells (95% CI, −159 to −36 cells), whereas controls gained 35 cells (95% CI, 24-46 cells; P < .0001). The incidence of HL is not reduced by cART, and patients whose CD4 cell counts decline despite suppression of HIV-1 replication on cART may harbor HL.

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.

Human Immunodeficiency Virus Infection and Hodgkin's Lymphoma in South Africa: An Emerging Problem

Hodgkin's lymphoma (HL) occurs with increasing frequency in human-immunodeficiency-virus-(HIV-) infected individuals. The natural history and behaviour of HIV-HL is different, being more atypical and aggressive. The association between HIV and HL appears to be primarily EBV driven. HAART use does not significantly impact on the incidence of HL. Indeed, the risk of HL has increased in the post-HAART era. However, the advent of HAART has brought renewed hope, allowing standard therapeutic options to be used more optimally, with better treatment outcomes. Despite the renewed optimism, the overall survival of HIV-HL patients remains less favourable than that in HIV-seronegative patients. This is particularly true in sub-Saharan Africa, where there is a significant burden of HIV/AIDS and where more than half the patients are HAART naive at diagnosis of HL. The similarities and differences of a South African cohort of HIV-HL are presented in this paper.

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).

Ten years later: a single hospital experience with malignancy in HIV/AIDS

BACKGROUND AND OBJECTIVE

We present our experience in the era of HAART with 5,112 patients having HIV infection or AIDS, treated between 2002 and 2006 in our hospital, 182 of whom had malignancies (3.56%). We compared our findings to those from a similar cohort of patients studied 10 years earlier.

METHODS

The charts were reviewed and data was electronically collected as in our 1993-1998 study. Similar statistical analyses were performed in both studies and the results were compared.

RESULTS

For the current study the average patient age increased by 9 years. A decrease in AIDS-defining cancers (ADC), from 63.6% to 37.3% and a higher incidence of non-AIDS-defining cancers (NADC), 62.7 as opposed to 37.9% was found. No decrease in the incidence of non-Hodgkin's B cell lymphoma (NHL) was noted. There was an increase in the number of opportunistic infections notably hepatitis C virus (HCV) and hepatitis B virus (HBV).

CONCLUSIONS

HIV/AIDS patients on HAART are older, have lower rates of AIDS related Kaposi's sarcoma and a higher incidence of NADCs than did patients in the early HAART era. No decrease in the proportion of NHL was observed.

The challenge of AIDS-related malignancies in sub-Saharan Africa

BACKGROUND

With the lengthening of life expectancy among HIV-positive subjects related to the use of highly active antiretroviral treatments, an increased risk of cancer has been described in industrialized countries. The question is to determine what occurs now and will happen in the future in the low income countries and particularly in sub-Saharan Africa where more than two-thirds of all HIV-positive people live in the world. The objective of our paper is to review the link between HIV and cancer in sub-Saharan Africa, putting it in perspective with what is already known in Western countries.

METHODS AND FINDINGS

Studies for this review were identified from several bibliographical databases including Pubmed, Scopus, Cochrane, Pascal, Web of Science and using keywords "HIV, neoplasia, epidemiology and Africa" and related MesH terms. A clear association was found between HIV infection and AIDS-classifying cancers. In case-referent studies, odds ratios (OR) were ranging from 21.9 (95% Confidence Interval (CI) 12.5-38.6) to 47.1 (31.9-69.8) for Kaposi sarcoma and from 5.0 (2.7-9.5) to 12.6 (2.2-54.4) for non Hodgkin lymphoma. The association was less strong for invasive cervical cancer with ORs ranging from 1.1 (0.7-1.2) to 1.6 (1.1-2.3), whereas ORs for squamous intraepithelial lesions were higher, from 4.4 (2.3-8.4) to 17.0 (2.2-134.1). For non AIDS-classifying cancers, squamous cell conjunctival carcinoma of the eye was associated with HIV in many case-referent studies with ORs from 2.6 (1.4-4.9) to 13.0 (4.5-39.4). A record-linkage study conducted in Uganda showed an association between Hodgkin lymphoma and HIV infection with a standardized incidence ratio of 5.7 (1.2-17) although OR in case-referent studies ranged from 1.4 (0.7-2.8) to 1.6 (1.0-2.7). Other cancer sites found positively associated with HIV include lung, liver, anus, penis, vulva, kidney, thyroid and uterus and a decreased risk of female breast cancer. These results so far based on a relatively small number of studies warrant further epidemiological investigations, taking into account other known risk factors for these tumors.

CONCLUSION

Studies conducted in sub-Saharan Africa show that HIV infection is not only strongly associated with AIDS-classifying cancers but also provided some evidence of association for other neoplasia. African countries need now to implement well designed population-based studies in order to better describe the spectrum of AIDS-associated malignancies and the most effective strategies for their prevention, screening and treatment.

Case report of human immunodeficiency virus infection, Hodgkin lymphoma, and pregnancy

As the incidence of human immunodeficiency virus (HIV) infection in women of child bearing age continues to increase in the era of highly active antiretroviral therapy and Hodgkin lymphoma (HL) is the most common non-acquired immunodeficiency syndrome defining malignancy, we anticipate that the number of cases of HIV-associated HL in pregnant women will increase in the near future. Herein, we describe the case of a pregnant 30-year-old HIV-infected Ethiopian woman with a CD4 count of 254 cells/microL and an HIV viral load of 1200 copies/mL who presented to medical attention with progressive neck adenopathy. Subsequent histopathology and radiographic findings revealed clinical stage IIIA Classical HL. After a spontaneous miscarriage of 10 weeks into her pregnancy, the patient began highly active antiretroviral therapy and chemotherapy. Thirty months later, she remained in complete remission. Through a literature review, we identified 2 additional case reports involving HIV, HL and pregnancy. One patient received 3 cycles of chemotherapy, refused further treatment, delivered an HIV-seropositive girl, and died shortly after from complications of presumed pneumocystis jiroveci pneumonia. The second patient received both active antiretroviral therapy and chemotherapy, delivered an HIV-seronegative boy, and remained in complete remission at 9 months follow-up. We conclude by offering recommendations for the staging and treatment of pregnant, HIV-infected patients with HL.

Clinical manifestations and natural history of Hodgkin's lymphoma

Hodgkin's lymphoma usually presents with typical lymphadenopathy that has been detected either incidentally by the patient or by imaging procedures performed for assessment of other conditions. Occasionally, it may be detected when investigation of nonspecific symptoms, such as fever, fatigue, or unexplained pain prompt assessment that, in turn reveals a mass lesion. The diagnosis must be confirmed with an appropriate biopsy. Nowadays, clinicians usually have little difficulty making the diagnosis of Hodgkin's lymphoma. Knowledge of the usual pattern of spread of this lymphoma, with its orderly progression through lymph node groups and its typical forms of extranodal involvement, facilitates timely diagnosis, staging, and treatment planning. Rare manifestations due to involvement of unusual sites or presentation with paraneoplastic organ dysfunction can prove challenging but a search for mass lesions and an appreciation of these uncommonly encountered findings as potential clues to the presence of Hodgkin's lymphoma usually prompts appropriate investigation and correct diagnosis. Finally, an understanding of the usual pattern and timing of relapse and knowledge of the typical types of late toxicity expected after successful eradication of the lymphoma allow the patient's physicians to detect recurrence in a timely fashion and to identify or prevent secondary complications enabling appropriate management plans to be developed.

Malignancies in women with HIV infection

Women with HIV infection have an increased risk of developing certain malignancies. These malignancies are commonly human papillomavirus (HPV)-related, reflecting the high rate of coinfection with HPV in women with underlying HIV infection. These women also have a high incidence of premalignant HPV-related changes, such as high-grade squamous intraepithelial lesions as diagnosed on Pap smears and cervical intraepithelial neoplasia on cervical biopsy. Screening recommendations for HIV-infected women reflect the need for vigilance in detecting and treating these lesions early. In addition, recent interest has focused on the use of cervical cancer screening, employing HPV-testing techniques, and on HPV vaccination in younger women to prevent initial infection and the subsequent development of cervical and other HPV-related cancers. The incidence of other types of malignancies, such as Hodgkin's and non-Hodgkin's lymphoma, is also increased in HIV-infected individuals. When these lymphomas occur, they tend to be of advanced stage and high-grade histologies. The advent of highly active antiretroviral therapy has been associated with a marked decrease in the incidence of some of these cancers. The use of therapy has been associated with marked improvement in response rates and overall survival of affected patients.

Challenging Problems: Coincident Pregnancy, HIV Infection, and Older Age

With the application of modern chemotherapy and radiation techniques, most patients with Hodgkin lymphoma can be cured, regardless of initial extent of disease. However, the lymphoma sometimes presents coincident with certain other major conditions, including pregnancy, infection with human immunodeficiency virus (HIV) or older age, which complicate treatment and make management considerably more challenging. Specially crafted approaches to staging and treatment, including the addition of specific supportive care measures, are required in these situations. Pregnant patients with coincident Hodgkin lymphoma should be staged without the use of imaging requiring radiation and treated with an approach that includes initial treatment deferral when appropriate, single agent vinblastine and reservation of multi-agent chemotherapy for the small minority with very aggressive lymphoma. Patients with Hodgkin lymphoma and HIV infection can be given standard anti-lymphoma treatment but require intensive supportive care with highly active anti-retroviral treatment (HAART) and prophylactic anti-fungal and anti-Pneumocystis antibiotics plus neutrophil growth factors. Standard staging and full dose multi-agent chemotherapy are necessary if older patients with Hodgkin lymphoma are to be afforded the best chance of cure but the final choice of the individual elements of treatment must respect co-morbid conditions and age- or other disease-related organ compromise. If appropriately chosen, these special measures permit delivery of safe, effective treatment and frequent cure of the Hodgkin lymphoma despite complicating pregnancy, HIV infection or older age.

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.