Hodgkin Lymphoma Among Patients Infected with HIV in Post-HAART Era

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.

CD4+ T cell count in HIV/TB co-infection and co-occurrence with HL: Case report and literature review

In the human immunodeficiency virus (HIV)-infected population, especially HIV with concomitant tuberculosis (TB) or Hodgkin's lymphoma (HL), numerous risk factors have been reported in recent years. Among them, the decreased CD4+ T cell count was recognized as the common risk factor. We report a case of a patient with HIV and TB and HL co-occurrence, in which patient's CD4+ T cell count was inconsistent with disease. A 58-year-old male presented with fever and shortness of breath that persisted for 2 months. The patient had a 4-year history of HIV infection and underwent antiretroviral therapy (ART) effectively. After blood test, computed tomography, bone biopsy, and lymphoma biopsy, the patient was diagnosed with skeletal TB and HL, underwent TB treatment and received ART, and underwent four cycles of chemotherapy. CD4+ T cell count was not decreased before diagnosed with TB/HL and increased in this case after the fourth cycle of chemotherapy. We collected and analyzed CD4+ T cell counts in our case and reviewed relevant literature. It is suggested that CD4+ T cell count may be insufficient to predict the risk of HIV-related disease, especially lymphoproliferative disorders.

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.

Hodgkin lymphoma in the elderly, pregnant, and HIV-infected

Hodgkin lymphoma (HL) presenting in patients with co-incidental advanced age, pregnancy, or human immunodeficiency virus (HIV) infection is uniquely challenging to manage. In this article we integrate recent evidence and clinical expertise to present recommendations for diagnosis and therapeutic management. Older patients with HL need to be carefully evaluated for comorbidies after which judicious choice of chemotherapy should minimize functional compromise. A pregnant patient with concurrent HL should be staged with minimal use of imaging requiring ionizing radiation and treated in an individualized manner optimally combining the strategies of treatment deferral when appropriate, use of single-agent vinblastine for symptomatic disease and reservation of multi-agent chemotherapy for the small minority of patients with aggressive clinical presentation. Treatment of HL coincident with HIV infection requires a combination of highly active anti-retroviral agents (HAART), standard multi-agent chemotherapy with meticulous attention to drug-drug interactions, and vigorous supportive care to ensure the best chance of cure.

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.

Decision-making in the management of adult classical Hodgkin's lymphoma: determining the optimal treatment

This review discusses promising new approaches in classical Hodgkin's lymphoma that have been recently evaluated. There is a focus on the fluorodeoxyglucose PET scanning that is now considered crucial for staging and treatment evaluation, including interim evaluation after two cycles. An up-front treatment strategy is discussed, with the place of radiation therapy and the difficult choice of chemotherapy intensity emphasized. Indications for frail patients are also reviewed, particularly elderly or HIV-positive patients. Emerging data on the antibody drug conjugate brentuximab vedotin and its future potential in the transplantation framework for relapsed/refractory Hodgkin's lymphoma is also discussed.

Cumulative HIV viremia and non-AIDS-defining malignancies among a sample of HIV-infected male veterans

BACKGROUND

Research suggests that cumulative measurement of HIV exposure is associated with mortality, AIDS, and AIDS-defining malignancies. However, the relationship between cumulative HIV and non-AIDS-defining malignancies (NADMs) remains unclear. The aim of this study was to evaluate the effect of different HIV measures on NADM hazard among HIV-infected male veterans.

METHODS

We performed a retrospective cohort study using Veterans Affairs HIV Clinical Case Registry data from 1985 to 2010. We analyzed the relationship between HIV exposure (recent HIV RNA, % undetectable HIV RNA, and HIV copy-years viremia) and NADM. To evaluate the effect of HIV, we calculated hazard ratios for 3 common virally associated NADM [ie, hepatocarcinoma (HCC), Hodgkin lymphoma (HL), and squamous cell carcinoma of the anus (SCCA)] in multivariable Cox regression models.

RESULTS

Among 31,576 HIV-infected male veterans, 383 HCC, 211 HL, and 373 SCCA cases were identified. In multivariable regression models, cross-sectional HIV measurement was not associated with NADM. However, compared with <20% undetectable HIV, individuals with ≥80% had decreased HL [adjusted hazard ratio (aHR) = 0.62; 95% confidence interval (CI): 0.37 to 1.02] and SCCA (aHR = 0.64; 95% CI: 0.44 to 0.93). Conversely, each log10 increase in HIV copy-years was associated with elevated HL (aHR = 1.22; 95% CI: 1.06 to 1.40) and SCCA (aHR = 1.36; 95% CI: 1.21 to 1.52). Model fit was best with HIV copy-years. Cumulative HIV was not associated with HCC.

CONCLUSIONS

Cumulative HIV was associated with certain virally associated NADM (ie, HL and SCCA), independent of measured covariates. Findings underline the importance of early treatment initiation and durable medication adherence to reduce cumulative HIV burden. Future research should prioritize how to best apply cumulative HIV measures in screening for these cancers.

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.

Hodgkin's lymphoma in adults

Management of Hodgkin's lymphoma continues to develop. Outcomes for patients with favourable-risk, early-stage disease are excellent, and serial reductions in intensity of treatment have been made to retain the excellent prognosis while reducing the late effects of treatment. Prognosis is also very good in advanced-stage disease but the rate of relapse is higher than in early-stage disease, and the optimum first-line treatment is unclear. Workers are investigating the role of functional imaging to assess whether treatment can be tailored according to response, with the most intensive therapies reserved for patients predicted to have poor outcomes. In this Seminar we critically appraise the management of Hodgkin's lymphoma in early-stage disease, advanced-stage disease, and at relapse, with a focus on late effects of treatment.

The rising challenge of non-AIDS-defining cancers in HIV-infected patients

Since the advent of HAART, patients with HIV infection have seen a significant improvement in their morbidity, mortality, and life expectancy. The incidence of AIDS-defining illnesses, including AIDS-defining malignancies, has been on the decline. However, deaths due to non-AIDS-defining illnesses have been on the rise. These so-called non-AIDS-defining cancers (NADCs) include cancers of the lung, liver, kidney, anus, head and neck, and skin, as well as Hodgkin's lymphoma. It is poorly understood why this higher rate of NADCs is occurring. The key challenge facing oncologists is how to administer chemotherapy effectively and safely to patients on antiretroviral therapy. The challenge to clinicians caring for HIV-infected patients is to develop and implement effective means to screen, treat, and prevent NADCs in the future. This review presents data on the epidemiology and etiology of NADCs, as well as ongoing research into this evolving aspect of the HIV epidemic.

Characterization of HIV-associated Hodgkin's lymphoma in HIV-infected patients: a single-center experience

INTRODUCTION

Although the incidence and prevalence of AIDS-defining malignancies has decreased in the era of highly active antiretroviral therapy (HAART), the incidence and prevalence of Hodgkin's lymphoma (HL) in the HIV-infected population continues to rise. Compared with the general population, HIV-infected patients exhibit a 5-10-fold increased risk for developing HL.

METHODS

A retrospective review of charts and electronic records from 2000-2010 at the HIV outpatient clinic (HOP)-Louisiana State University in New Orleans was conducted, and pathologically confirmed cases of HIV-HL were identified within this cohort.

RESULTS

We found a prevalence of 6.3 cases per 1,000 patients per year of HIV-HL over a period of 10 years in our HIV outpatient clinic. The mean absolute CD4 count before treatment was 284 cells/mm(3) and after treatment was 194 cells/mm(3). The average time from the diagnosis of HIV infection to the diagnosis of HIV-HL was 7.6 years. The most common histopathologic type was mixed cellularity followed by lymphocytic predominance. The majority of patients had 6 cycles delivered. In terms of HL staging 87% presented with advanced stages (III B or IV). To the best of our knowledge 5 out of the 14 patients remain alive.

CONCLUSIONS

Patients in our cohort were older than most patients identified in other cohorts. All of our patients had coexisting chronic illnesses associated with inflammation, as well as detectable HIV viral loads and CD4 count >200, suggesting a role for both HIV- and non-HIV-associated inflammation in HIV-HL pathogenesis in this population. The role of HIV virus and other oncogenic viruses (EBV, HPV, and others) in the pathogenesis of Hodgkin's lymphoma in this group of patients needs to be elucidated.

Human immunodeficiency and Hodgkin lymphoma

Presentation of Hodgkin lymphoma (HL) is distinctive in the infected individual being more advanced, accompanied by B symptoms and the presence of extranodal disease particularly lymphadenopathy of the head and neck. Bone marrow involvement may be found in over 50% of cases. Virtually all co express gamma-herpesvirus. Phenotypically there is prominence of the mixed-cellularity and lymphocyte depleted histopathologic subtypes that define an aggressive clinical course in comparison to other variants. Prior to the induction of cART, median survival was only 1-2 years. Notably the first chemotherapy trial using ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) in 21 patients, without treating the viral infection, resulted in a 43% complete remission rate accompanied by severe haematological toxicities but did not extend median survival with this being 1.5 years matching the negative cases. Significant change accompanied concomitant anti-retroviral therapy that could be given safely even with dose intensive regimens exemplified by BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone) in 12 patients or the Stanford V regimen (doxorubicin, vinblastine, mechlorethamine, etoposide, vincristine, bleomycin, prednisone) coupled with involved-field radiation for bulky disease studied in 59 patients. BEACOPP extended overall survival (OS) to 83% at 2 years. A similar trend was seen when using the Stanford V regimen with an OS rate of 51% at 3 years, disease-free survival (DFS) of 68% and freedom from progression (FFP) in 60%. Additional benefits accrued from supportive care with stimulatory peptides such as G-CSF and when combined with bacterial prophylaxis results approached that found in the uninfected reference group. Current consensus holds this particular lymphoma as still among the non-AIDS defining cancers being lung, stomach, liver or anal despite these having recently gained more attention as several of these neoplasms may be occurring more commonly in the era of cART. While the relative risk of developing a non-AIDS-defining neoplasm in HIV-infected persons on the average is 2-3 times, the risk for developing HL in HIV-infected cases impressively ranges between 5 and 25 times when compared to the general population. Based on the precedent in which Kaposi sarcoma and the non-Hodgkin lymphomas distinctively alter the course of this retroviral infection in a way indistinguishable from concurrent Hodgkin lymphoma we propose that this entity be similarly regarded and the hypothesis tested in large randomised prospective study.

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.

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.

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.