Management of AIDS-related non-Hodgkin's lymphomas

Burkitt lymphoma associated with human immunodeficiency virus infection and pulmonary tuberculosis: A case report

INTRODUCTION

The association of human immunodeficiency virus (HIV) infection with Burkitt lymphoma is related to the presence of Epstein Barr virus infection and the impact of the HIV antigen on the expansion of B-polyclonal cells. In Southeast Europe, the association is rare, and recognizing this is important in the therapeutic decision to increase patient survival rate. The association of HIV with Burkitt lymphoma and tuberculosis is even more rarely described in the literature.

PATIENT CONCERNS

We present the case of a 40-year-old patient who presented with a 3-week history of fever (max. 38.7 °C), painful axillary swelling on the right side, lumbar pain, gait disorders, headache, and night sweats. Clinical manifestations included marked weight loss (about 30 kg in the last 2 months before his admission).

DIAGNOSIS

A LyCD4 count of 38/μL and a HIV1 viral load of 384,000/mm3, classified the patient into a C3 stage. A biopsy of the right axillary lymph node was performed for suspected ganglionic tuberculosis due to immunodeficiency. Histopathological examination confirmed the diagnosis of Burkitt lymphoma. Cultures on Löwenstein-Jensen medium from sputum harvested at first admission were positive for Mycobacterium tuberculosis.

INTERVENTIONS

Highly active antiretroviral therapy, chemotherapeutic agents for Burkitt lymphoma, anti-tuberculous drug therapy, neurosurgical intervention of spinal cord decompression, and antibiotic therapy of the associated bacterial infection.

OUTCOME

Burkitt lymphoma disseminated rapidly, with central nervous system, spinal cord, osteomuscular, adrenal, and spleen involvement. The evolution under treatment was unfavorable, with patient death occurring 6 months after diagnosis.

CONCLUSIONS

The association of HIV infection with Burkitt lymphoma and tuberculosis is rare in the highly active antiretroviral therapy (HAART) era, posing prompt and multidisciplinary therapeutic management issues. Similar cases of HIV-TB and Burkitt lymphoma association have been described, but none of the other cases showed the involvement of the central nervous system or of the bilateral adrenal glands.

Serbian lymphoma study group (SLG): The prognosis of AIDS-related non-Hodgkin's lymphoma

BACKGROUND

The majority of patients with AIDS-related non-Hodgkin's lymphoma (ARL) present with advanced disease, aggressive histological type, B-symptoms, and often with an extranodal localization. The prognosis is generally poor. The use of highly active antiretroviral therapy (HAART), in combination with chemotherapy, has improved the outcome of ARL.

AIMS

The aims of this study were to detect prognostic factors for patients with ARL and estimate efficacy of concomitant chemotherapy and HAART on overall survival (OS) of these patients. Also, two different chemotherapy regimens have been tested: low dose (ld) mBACOD and CHOP.

METHODS

The study series involved 28 patients with ARL treated at the Clinical Center of Serbia in Belgrade during the period 1996-2006. Twenty-six patients had an aggressive type of lymphoma while 2 had an indolent type. Nineteen patients were treated with chemotherapy, 10 with ld mBACOD and 9 with CHOP. Concomitant HAART and chemotherapy were used in 14 patients.

RESULTS

This study demonstrated that significant factors for OS in patients with ARL were the high International Prognostic Index (P=0.019), previous AIDS event (P=0.04), aggressive histological type of NHL (P=0.007) and extranodal disease (P=0.04). The usage of concomitant HAART and chemotherapy had significant effect on median survival (90 months), compared with chemotherapy alone (10 months) (P=0.0002). The patients treated with CHOP had a better response than patients treated with ld mBACOD, but this difference was not significant.

CONCLUSIONS

Our data suggest that aggressive presentation of ARL implicates the need not only for more intensive chemotherapy regimens, but the concomitant usage of HAART, which should result in higher rates of OS in ARL patients.

Differential diagnosis of focal and diffuse neoplastic diseases of bone marrow in MRI

Magnetic resonance imaging (MRI) has become the preferred imaging modality for the evaluation of malignant disease in the bone marrow. Compared to bone marrow aspiration and biopsy, MRI is noninvasive and provides information by sampling a large volume of bone marrow. Due to disease-related alterations in the composition of bone marrow, MRI provides a very high sensitivity, but lacks specificity for most bone marrow disorders. However, MRI can be a very valuable diagnostic tool properly placed within the clinical context.

[Radiological diagnostics of Hodgkin- and non-Hodgkin lymphomas of the thorax]

Malignant lymphomas belong to the most important malignant diseases in western countries with an increasing incidence of Non-Hodgkin lymphoma. The thorax is the location of primary manifestation especially in patients with Hodgkin's disease. Progression of disease and therapy associated complications are frequently located in the chest. Based on morphological imaging criteria the two types of lymphoma cannot be differentiated, helpful for differentiation is, however, the way of disease spread. Primary and secondary thoracic lymphoma represent a diagnostic challenge in radiology: the patterns are variable in radiography as well as in computed tomography and alter under therapy. Radiological studies, especially CT, are an integral part of the staging process. MRI is considered advantageous for chest wall disease. PET as functional imaging technique has its proven role for staging of high grade lymphomas, the combination of functional and morphological information provided by PET-CT will become the first diagnostic standard in the future.

Response to highly active antiretroviral therapy strongly predicts outcome in patients with AIDS-related lymphoma

BACKGROUND

AIDS-related lymphoma (ARL) remains a frequent complication of HIV infection. We analyzed the outcome of patients with ARL with respect to the use and efficacy of highly active antiretroviral therapy (HAART) and to potential prognostic factors.

METHODS

This multicenter cohort study included patients with systemic ARL diagnosed between 1990-2001. We evaluated overall survival and the effects of several variables on overall survival using the Kaplan-Meier method and the extended Cox proportional hazards model. Response to HAART was used as a time-dependent variable and was defined as a CD4 cell count increase of >/= 100 x 106 cells/l and/or at least one viral load < 500 copies/ml during the first 2 years following diagnosis of ARL.

RESULTS

Among 203 patients with ARL, median overall survival was 9.0 months [95% confidence interval (CI), 7.6-12.4 months]. In the univariate analyses, age < 60 years, no previous AIDS, CD4 cell counts >/= 200 x 106 cells/l, hemoglobin > 11 g/dl, Ann Arbor stages I-II and A, no extranodal lesion, response to HAART, and complete remission showed statistically significant association with prolonged overall survival. In the multivariate Cox model, the only factors independently associated with overall survival were response to HAART [relative hazard (RH), 0.32; 95% CI, 0.16-0.62], complete remission (RH, 0.24; 95% CI, 0.15-0.36), previous AIDS (RH, 1.92; 95%CI, 1.23-3.01) and extranodal involvement (RH, 2.85; 95% CI, 1.47-5.51).

CONCLUSIONS

Efficacy of HAART was independently associated with prolonged survival in this large cohort of patients with ARL. Information on patient's response to HAART is crucial for the evaluation of future treatment strategies.