Intensive sequential chemotherapy with hematopoietic growth factor support for non-Hodgkin lymphoma in patients infected with the human immunodeficiency virus

AIDS-Related Non-Hodgkin's Lymphoma in the Era of Highly Active Antiretroviral Therapy

In economically developed countries, AIDS-related lymphoma (ARL) accounts for a large proportion of malignances in HIV-infected individuals. Since the introduction of highly active anti-retroviral therapy (HAART) in 1996, epidemiology and prognosis of ARL have changed. While there is a slight increase in the incidence of Hodgkin's lymphoma in HIV-infected individuals, use of HAART has contributed to a decline in the incidence of non-Hodgkin's lymphoma (NHL) and also a decrease in the overall incidence of ARL. Strategies that employ HAART, improved supportive care, and the use of Rituximab with multi-agent chemotherapy have contributed to improved rates of complete remission and survival of patients with ARL that rival those seen in stage and histology matched HIV negative NHL patients. Most recent clinical trials demonstrate better outcomes with the use of rituximab in ARL. Tumor histogenesis (germinal center vs. non-germinal center origin) is associated with lymphoma-specific outcomes in the setting of AIDS-related diffuse-large B cell lymphoma. High-dose chemotherapy (HDCT) and autologous stem cell rescue (ASCT) can be effective for a subset of patients with relapsed ARL. HIV sero-status alone should not preclude consideration of ASCT in the setting of ARL relapse. Clinical trials investigating the role of allogeneic hematopoietic stem cell transplant in ARL are currently underway.

Controversies in the treatment of Burkitt lymphoma in AIDS

PURPOSE OF REVIEW

The success of combined antiretroviral therapy (cART) has transformed HIV infection into a survivable chronic disease in developed countries. Increasingly then, the risks of HIV associated cancers become paramount. Burkitt lymphoma is one of the cancer subtypes highly disproportionately affecting HIV infected patients.

RECENT FINDINGS

Recent conference proceedings appear to corroborate early reports that intensive therapy of HIV-Burkitt lymphoma is feasible and effective. An optimal approach is not defined due to the small numbers of patients in current trials and the absence of comparison studies. Moreover, as breakthroughs in the pathogenesis of lymphoma in general and Burkitt lymphoma in particular suggest that HIV infection plays a significant role, the opportunity for targeted therapy based on differences in biology are wholly untapped.

SUMMARY

Advances are being made in HIV-Burkitt lymphoma, but future studies need to incorporate our expanding understanding of biology to improve efficacy and reduce toxicity, preferably by integrating a biologic approach to this curable disease.

GI-lymphomas in immunosuppressed patients (organ transplantation; HIV)

Gastrointestinal lymphoma plays a major role complicating different diseases presenting with immunosuppression, both primary and acquired immunodeficiency (incl. HIV, transplantation, immunosuppression following chemotherapy, or inflammatory bowel disease). Lymphoma in diseases with immunosuppression are clinically and pathologically heterogeneous, but share some features such as frequent involvement of extranodal sites, diffuse aggressive histology, B-cell lineage derivation, viral association with EBV and clinically aggressive courses. While gastrointestinal lymphoma in congenital immunodeficiency disorders seems to be a rare event inspite of higher prevalences, in post-transplant lymphoproliferative disorders (PTLD) the gastrointestinal tract is one of the most important organs of lymphoma. In HIV-associated non-Hodgkin's lymphoma, gastrointestinal lesions as the most frequent extranodal localisation occur in 30-50% of lymphoma patients, are late events of HIV infection with severe immunosuppression and are mainly diagnosed with advanced disease stages Ann Arbour III or IV. They are characterised by unusual, often multifocal localisation in the gastrontestinal tract, high rates of life-threatening complications (bleeding, perforation or obstruction) and high-grade B-cell histology. With the introduction of highly active antiretroviral therapy (HAART) in the therapeutic concept in AIDS, a decrease of AIDS-related GI lymphoma was noted with improved survival rates and prognosis of lymphoma. Therapy strategies including chemotherapy, immunotherapy and HAART will show promising results in response and survival rates.

Modern management of non-Hodgkin lymphoma in HIV-infected patients

Patients infected with human immunodeficiency virus (HIV) are at greater risk of developing non-Hodgkin lymphoma than the general population and aggressive B-cell lymphoma has become one of the most common of the initial acquired immunodeficiency syndrome (AIDS)-defining illnesses. This review considers the prognostic factors and new approaches to the treatment of patients with AIDS-related lymphoma (ARL). As highly active antiretroviral therapy (HAART) became available, the survival of many ARL patients has become comparable to that of HIV-negative patients. This is partly due to the decrease in the incidence of opportunistic infections and improved prognosis. Both developments can also be attributed to new treatment strategies for ARL, such as the use of effective infusional regimens, Rituximab combinations and high-dose therapy with autologous stem-cell transplantation for relapsed disease. However, unresolved issues persist, such as the optimal therapy for patients with Burkitt ARL or central nervous system involvement.

AIDS-related non-Hodgkin lymphoma: final analysis of 485 patients treated with risk-adapted intensive chemotherapy

We aimed to compare AIDS risk–adapted intensive chemotherapy in AIDS-related lymphoma (ARL) patients before and after the advent of highly active antiretroviral therapy (HAART). A total of 485 patients aged from 18 to 67 years were randomly assigned to chemotherapy after stratification according to an HIV score based on performance status, prior AIDS, and CD4+ cell counts below 0.10 × 109/L (100/mm3). A total of 218 good-risk patients (HIV score 0) received ACVBP (doxorubicin, cyclophosphamide, vindesine, bleomycin, and prednisolone) or CHOP (doxorubicin, cyclophosphamide, vincristine, and prednisolone); 177 intermediate-risk patients (HIV score 1), CHOP or low-dose CHOP (Ld-CHOP); and 90 poor-risk patients (HIV score 2-3), Ld-CHOP or VS (vincristine and steroid). The 5-year overall survival (OS) in the good-risk group was 51% for ACVBP versus 47% for CHOP (P = .85); in the intermediate-risk group, 28% for CHOP versus 24% for Ld-CHOP (P = .19); and in the poor-risk group, 11% for Ld-CHOP versus 3% for VS (P = .14). The time-dependent Cox model demonstrated that the only significant factors for OS were HAART (relative risk [RR] 1.6, P < .001), HIV score (RR 1.7, P < .001), and the International Prognostic Index (IPI) score (RR 1.5, P < .001) but not chemotherapy regimen. Our findings indicate that in ARL patients, HIV score, IPI score, and HAART affect survival but not the intensity of the CHOP-based chemotherapy.

Current strategies for the treatment of diffuse large B cell lymphoma

PURPOSE OF REVIEW

This paper reviews the improvement in the treatment of patients with diffuse large B cell lymphoma.

RECENT FINDINGS

The outcome in these patients has become better with longer survival because of two major developments: (1) increasing the dose of active drugs and shortening the time between cycles, resulting in dose-dense or dose-intense regimens, and (2) combining rituximab with chemotherapy. Both strategies have been associated with higher response rates, longer event-free survival, and longer overall survival, particularly in patients without adverse prognostic parameters. A combination of both is currently being tested for these poor-risk patients.

SUMMARY

Although improvement has been made in low-risk patients, much work has to be done for patients with high-risk lymphoma. It may come with a better definition of genetic abnormalities specifically associated with refractoriness to chemotherapy.

AIDS-Related Burkitt's Lymphoma Versus Diffuse Large-Cell Lymphoma in the Pre–Highly Active Antiretroviral Therapy (HAART) and HAART Eras: Significant Differences in Survival With Standard Chemotherapy

Purpose

To compare outcomes of patients with HIV-Burkitt's lymphoma (HIV-BL) and HIV-diffuse large-cell lymphoma (HIV-DLCL) after treatment with CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) or M-BACOD (methotrexate, bleomycin, cyclophosphamide, etoposide) in pre–highly active antiretroviral therapy (HAART) versus HAART eras.

Patients and Methods

Three hundred sixty-three patients with AIDS-related lymphoma diagnosed from 1982 to 2003 were reviewed retrospectively, including 262 in the pre-HAART (HIV-BL, 117; HIV-DLCL, 145) and 101 in the HAART era (HIV-BL, 18; HIV-DLCL, 83). Pre-HAART included those who did not receive HAART, and HAART era included those diagnosed after January 1997 who received HAART.

Results

There were no significant differences between groups in terms of age, sex, history of injection drug use, prior AIDS, lactate dehydrogenase level, and disease stage at diagnosis. Compared with HIV-BL, HIV-DLCL was associated with significantly lower CD4 counts in the pre-HAART but not the HAART era. Although the overall median survival was similar for both groups in the pre-HAART era (HIV-BL, 6.4 months v HIV-DLCL, 8.3 months; P = .43), survival was significantly worse in patients with HIV-BL in the HAART era (HIV-BL, 5.7 months v HIV-DLCL, 43.2 months; P = .0003). Failure to attain complete remission and CD4 count less than 100 cells/mm3 independently predicted for poor survival in the pre-HAART era. In comparison, histology of HIV-BL and no attainment of complete remission were independent poor prognostic factors in the HAART era.

Conclusion

Survival of patients with HIV-DLCL has improved in the HAART era, along with CD4 count, whereas survival of similarly treated patients with HIV-BL remained poor. The current practice of using the same regimen for both groups of patients should be re-evaluated.

Update in HIV-associated lymphoma

PURPOSE OF REVIEW

Infection with human immunodeficiency virus (HIV) is associated with an increased risk of non-Hodgkin lymphoma and Hodgkin disease. This review summarizes developments within the past 18 months.

RECENT FINDINGS

Investigators continue to demonstrate that many standard therapies similar to those used in the non-HIV- infected population may be used in the HAART era for patients infected with HIV. Biologic differences do exist, however, and not all treatments and outcomes are directly translatable. Some treatments, such as rituximab in combination with CHOP, may have unforeseen toxicity. Nonetheless, high-dose therapy does appear feasible and may offer curative therapy for those with refractory and relapsed disease.

SUMMARY

HIV-infected persons appear to benefit from most, but not all standard treatments for lymphoma.