Influence of highly active anti-retroviral therapy on response to treatment and survival in patients with acquired immunodeficiency syndrome-related non-Hodgkin's lymphoma treated with cyclophosphamide, hydroxydoxorubicin, vincristine and prednisone

Combined highly active anti-retroviral therapy (HAART) with protease and reverse transcriptase inhibitors has modified the natural history of opportunistic infections and neoplasms in human immunodeficiency virus (HIV)-infected patients. We analysed the influence of HAART on the response to treatment and survival in a series of 58 patients with acquired immune deficiency syndrome (AIDS)-related non-Hodgkin's lymphoma (NHL) treated with CHOP (cyclophosphamide, hydroxydoxorubicin, vincristine and prednisone). Two groups of patients were included: (i) forty-one patients diagnosed with NHL between 1988 and 1996 who were not treated with HAART; (ii) seventeen patients diagnosed since 1996, who were receiving or commenced HAART when NHL was diagnosed. The response rate to CHOP was higher in group 2 (13 out of 17 cases; 75%) than in group 1 (14 out of 41 cases; 34%) (P = 0.003). The 2-year probability of event-free survival (EFS) [95% confidence interval (CI)] for group 1 was 0.5 (0.24-0.74), whereas for group 2 it was 0.85 (0.61-0.90) (P = 0.024). The lymphoma-free survival (LFS) was also significantly different for both groups (2-year LFS probability 0.53 vs. 1.0, P = 0.04). The median (95% CI) overall survival (OS) for group 1 was 7 months (range, 3-10.8 months), whereas it was not reached in group 2 (P = 0.0015). In the multivariate analysis for remission attainment, the only variables with a higher probability to achieve complete remission (CR) were HAART (P = 0.01) and International Prognostic Index score 1 (P = 0.02). The only statistically significant variable in the multivariate analysis for EFS was HAART (P = 0.049) and the variables with prognostic value for OS in the multivariate analysis were B symptoms (P = 0.01) and HAART (P = 0.003). Patients with AIDS-related NHL treated with CHOP and HAART had a higher CR rate than those treated only with CHOP. In this study, HAART was an independent prognostic factor for CR, OS and EFS in patients with AIDS-related NHL.

[Hodgkin's disease in patients infected by the human immunodeficiency virus. Study of fifteen cases]

BACKGROUND

In spite of not being considered as an AIDS defining illness, Hodgkin's disease (HD) has specific clinical and biological features in HIV-infected patients.

PATIENTS AND METHODS

Study of clinicopathologic and analytic characteristics, Epstein-Barr virus (EBV) detection (polymerase chain reaction), and prognosis in 15 patients with HD and HIV infection.

RESULTS

Thirteen patients had B symptoms, 10 extranodal involvement and 12 advanced HD. The most frequent histologic subtypes were mixed cellularity (6) and lymphocyte depletion (6). The mean (SD) of CD4 lymphocytes was 0.10 (0.08) x 10(9)/l. The presence of EBV in lymph node biopsy was demonstrated in 3 out of 4 patients investigated. Complete remission (CR) was achieved in 7 out of 14 treated cases (50%), the median overall survival was 26 months and the 2 year event-free survival probability was 60%.

CONCLUSIONS

In HIV-infected patients, HD presents in advanced stages, unfavourable histologic subtypes, frequent extranodal involvement and B symptoms. The prognosis is poor, mainly because of a low CR rate.

[The usefulness of the bone marrow examination in the etiological diagnosis of prolonged fever in patients with HIV infection]

BACKGROUND

To analyze the usefulness of bone marrow (BM) study in the diagnosis of fever of unknown origin (FUO) in patients infected by the human immunodeficiency virus (HIV) in a single center during a period of 42 months.

PATIENTS AND METHODS

182 episodes of FUO in 162 patients p3th HIV infection were studied. Age, sex, risk factor for HIV infection, hemoglobin level, counts of leucocytes, neutrophils, lymphocytes, CD4 positive lymphocytes, platelets and levels of hepatic enzymes, albumin and beta 2-microglobulin were studied. BM aspirate was performed in all episodes for cytologic and microbiologic examination, and BM biopsy was done in 43. Analysis of factors related with the probability of diagnosis by BM examination was carried out.

RESULTS

The median age was 33 years (range, 22-70), and 123 were males. Drug abuse was the most frequent risk factor for HIV infection (63%). One hundred thirty patients had previous AIDS diagnosis before they were evaluated for unexplained fever. A specific diagnosis was achieved in 161 episodes (88%) and the most frequent diagnoses were Mycobacterium spp. (55%) and Leishmania spp. (14%) infections. Fifty-four episodes (30%) were diagnosed by BM examination, and in 36 (20%) BM study was the only diagnostic tool. Examination of the BM aspirate yielded the diagnosis in 40 out of the 178 episodes (13%), whereas BM biopsy was a diagnostic tool in 8 (19%); in 9 additional cases (21%) granulomas were observed. Microbiologic study of BM smears for mycobacterial infections was positive in 28 of the 143 episodes (19%), and the culture for Leishmania was positive in 2 out of the 42 cases. The presence of thrombocytopenia (< 75 x 10(9)/l) and elevated serum levels of aspartate-aminotransferase (AST) (> 100 U/l) were the factors associated with a high probability to obtain the diagnosis through BM study.

CONCLUSIONS

In patients infected by the HIV and unexplained fever, BM examination is an useful procedure for the diagnosis, particularly in areas where infections by Mycobacterium spp. and Leishmania are prevalent. So that, in our setting, systematic use of this procedure is justified for diagnosis of FUO in those patients.

[Changes in the long arm of chromosome 3 (3q) in malignant myeloid hemopathies. A study of 10 cases]

BACKGROUND

Abnormalities of the long arm of chromosome 3 (3q) involving bands 3q21 and/or 3q26 occur in 2-6% of myeloid malignancies. Trilineage myelodysplasia, especially in the megakaryocytic line, is a characteristic feature. Additional abnormalities of chromosomes 5 and 7 are usually present. The response to treatment and prognosis are poor.

PATIENTS AND METHODS

The main clinical, cytologic (bone marrow aspirate and biopsy) and cytogenetic characteristics as well as the response to the treatment in 10 patients with 3q abnormalities diagnosed in a single hospital in a period of 8 years are referred.

RESULTS

Eight patients had acute non-lymphoblastic leukemia, being de novo in five of them. The median value of hemoglobin was 87 g/l (range: 51-148), white blood cells count 5.8 x 10(9)/l (1.2-47.1) and platelet count 34 x 10(9)/l (5-182). The morphological findings in the study of the bone marrow were: dyserythropoietic features (7 patients), dysgranulopoietic abnormalities (5 patients) and small-sized megakaryocytes with hypolobulated nuclei (8 patients). Fibrosis was observed in the 4 cases in which a bone marrow biopsy was performed. In addition to the 3q alteration, abnormalities of chromosomes 7 (4 patients), 5q (2 patients) and +8 (2 patients) were present. Four patients received intensive chemotherapy and in two of them a complete remission was achieved, but relapse occurred at 3 and 5 months, respectively. All patients have died, the median survival being 7 months.

CONCLUSIONS

3q abnormalities define a subtype of myeloid malignancies with characteristic clinical and morphological features. The response to therapy and survival are poor.

[Primary gastrointestinal lymphoma in patients infected with HIV: study of 15 cases in a series of 76 patients with non-Hodgkin's lymphoma and HIV infection]

BACKGROUND

To analyze the main clinical and biological data and the response to therapy in 15 patients with primary gastrointestinal lymphoma (PGIL) from a series of 76 patients with HIV related non-Hodgkin's lymphoma (NHL) diagnosed in a single institution in a 13 years period.

PATIENTS AND METHODS

The main clinical, biological and evolutive data were recorded. Pathologic diagnosis of PGIL was made according to the REAL classification. Clinical stage was determined by the Ann Arbor system modified by Rohatiner et al. Response to therapy as well as overall survival (OS) were studied. Results were compared with non-PGIL HIV-related NHL patients.

RESULTS

Mean age of the series was 38 years. Thirteen patients were male, and 8 intravenous drug abusers. Then had bad performance status (ECOG 2-4) and 11 B symptoms. All patients had a high grade malignant PGIL and the localization was gastric in 10 cases. The most frequent symptoms were abdominal pain (11 cases), gastrointestinal bleeding (4) and dysphagia (3). Ten patients had advanced stages (IIE2-IV). The median CD4 cell count was lower in PGIL patients (92 x 10(6)/l vs 148 x 10(6)/l; p < 0.05). Thirteen patients received intensive chemotherapy with CHOP regimen (in 5 surgical procedures were previously made). Complete response (CR) was obtained in 4 patients (31%) and 1 of them relapsed. Median OS was 10 months vs 16 months non-PGIL HIV-related lymphoma patients (p < 0.05).

CONCLUSIONS

PGIL in HIV patients often presented advanced stages and high grade of malignancy. The most common localization is the stomach, and these patients usually have bad performance status and a low CD4 lymphocyte count. Response to therapy is poor. In our series OS was worse in PGIL patients than in the rest of HIV-related NHL, possibly due to the high degree of immunosuppression in the formers.

Prophylactic platelet transfusion threshold during therapy for adult acute myeloid leukemia: 10,000/microL versus 20,000/microL

BACKGROUND AND OBJECTIVE

The threshold for prophylactic platelet transfusions has been classically established at 20,000/microL. In 48 patients with de novo acute myeloblastic leukemia (AML) we analyzed the effect of reducing the threshold for prophylactic platelet transfusion from 20,000/microL (group A) to 10,000/microL (group B) after induction and consolidation chemotherapy.

DESIGN AND METHODS

Forty-eight adult patients with de novo AML diagnosed in a single institution in a nine year period were enrolled in the study. Between January 1989 and December 1993 the patients received prophylactic platelet transfusions when their platelet count was below 20,000/microL (group A), and from January 1994 to March 1998 prophylactic platelet transfusions were indicated below 10,000/microL or between 10,000/microL and 20,000/microL if there was any consumption factor.

RESULTS

The mean number (SD) of platelet transfusions during induction was 8.4 (5.3) in group A and 8.5 (5.5) in group B; and during consolidation 4.7 (3.4) in group A and 4.6 (3.8) in group B (p = n.s.). Excluding the cases with consumption factors from the analysis, group B patients required 34% fewer transfusions during induction and 15.5% fewer during consolidation (p = 0.04). There were no differences between groups regarding major bleeding episodes.

INTERPRETATION AND CONCLUSIONS

Our data show that the threshold for prophylactic platelet transfusion can be safely set at 10,000 microL during induction and consolidation chemotherapy for adult patients with de novo AML.

The usefulness of the serum transferrin receptor in detecting iron deficiency in the anemia of chronic disorders

BACKGROUND AND OBJECTIVE

Recent studies have shown that the serum transferrin receptor (sTfR) is a sensitive, quantitative measurement of tissue iron deficiency. The objective of the study was to evaluate the diagnostic efficiency of some laboratory tests, including sTfR measurements, in the diagnosis of iron depletion in patients with anemia of chronic disorders.

DESIGN AND METHODS

The patient population consisted of 37 anemic patients: 10 hypoferritinemic patients (serum ferritin < 25 micrograms/L), and 27 anemic in-patients with hyperferritinemia (serum ferritin > 200 micrograms/L) and clinical/analytical criteria of anemia of chronic disorders, who were submitted to a bone marrow aspirate with iron stain. The sensitivity and specificity of serum TfR was evaluated according to the results of bone marrow iron status. Statistical analysis employed Student's t-test, one way analysis of variance and a logistic regression model using the Wald test.

RESULTS

Serum TfR was high in all the patients with hypoferritinemic anemia. In 12 patients with low bone marrow iron, the mean sTfR was 5.63 mg/L. In 6 of these 12 patients the sTfR was normal. On the other hand, sTfR was high in 4/15 patients with normal or increased iron stores. On multivariate analysis the most sensitive predictor of true iron deficiency was MCH (mean corpuscular hemoglobin). No other variables remained independently significant, including sTfR, after the inclusion of MCH in this model.

INTERPRETATION AND CONCLUSIONS

In our opinion, the iron status of patients with anemia of chronic diseases can not be accurately assessed by sTfR, as its sensitivity and specificity are low. In these patients, the gold standard for iron stores evaluation continues to be bone marrow aspirate and Perls stain.

International prognostic index is the best prognostic factor for survival in patients with AIDS-related non-Hodgkin's lymphoma treated with CHOP. A multivariate study of 46 patients

BACKGROUND AND OBJECTIVE

The management of non-Hodgkin's lymphomas (NHL) in AIDS is difficult because of the poor bone marrow reserve and immunosuppression of these patients. Combination chemotherapy is the treatment of choice in the subset of patients with good performance status and mild immunosuppression. Several combination chemotherapy regimens have been used in these patients but the results have been poor. We have studied the clinical and biological features, response to treatment, outcome and prognostic factors of 46 patients with NHL and HIV infection, diagnosed in a single institution between January 1988 and June 1997.

DESIGN AND METHODS

Forty-six patients with NHL and HIV infection were treated with CHOP. Patients with previously treated systemic NHL, primary CNS NHL, performance status > 2 and active AIDS-defining opportunistic or neoplastic diseases were excluded. The parameters evaluated were: age, sex, risk activity, basic hematologic and biochemical parameters, CD4 lymphocyte count, B symptoms, stage (Ann Arbor), histologic subtype (REAL classification), International Prognostic Index (IPI), response to treatment, relative dose intensity (RDI), relapse free survival (RFS) and overall survival (OS). Uni- and multivariate analyses of prognostic factors were performed.

RESULTS

Median age was 35 years and 40 patients were male. CD4 lymphocyte count was lower than 0.1 x 10(9)/L in 18 out of 38 cases, hypoalbuminemia was registered in 24 (52%), serum LDH was higher than 400 U/L in 20 (43%) and beta 2-microglobulin was higher than the normal range in 9 out of 20 patients (45%). Complete response was achieved in 18 patients (40%). Twenty-six patients received G-CSF after chemotherapy. Grade 4 neutropenia and fever were significantly more frequent in patients who did not receive G-CSF. Serum LDH > 400 U/L and hypoalbuminemia were the only parameters associated with a lower probability to achieve complete response (p = 0.015 and p = 0.025, respectively). The median RFS was 26 (6-47) months and no variable was found to have statistically significant influence on it. The median OS was 9.2 (4.5-14) months, and IPI score 1 and ESR < 60 mm/h were the only parameters identified as good prognostic factors in the multivariate analysis (p = 0.03 and 0.049, respectively).

INTERPRETATION AND CONCLUSIONS

In spite of patient selection, the response to CHOP treatment in patients with NHL and HIV infection remains poor. Episodes of neutropenic fever are less frequent when G-CSF is administered after CHOP. The IPI score 1 is the most important favorable prognostic factor for survival.

[Acute lymphoblastic leukemia in adults. Comparative study of clinicobiologic characteristics and of response to treatment in terms of age in a group of 41 patients]

BACKGROUND

The aim of this study was to analyze the influence of age on the clinical and biological features as well as the results of treatment in 41 adult patients with acute lymphoblastic leukemia (ALL).

PATIENTS AND METHODS

The patients diagnosed with ALL from January 1989 to October 1995 in a single center were studied. Two groups of patients were analyzed based on age. The main clinical, hematologic and biochemical parameters, morphologic subtype and immunologic phenotype and the results of the cytogenetic study were analyzed. Likewise, the attainment of complete remission (CR), its duration and overall survival (OS) were also studied. Comparison of the cited variables and the results of treatment among the two groups of patients was performed.

RESULTS

Group I was made of 19 (11 males, 8 females) patients > or = 50 years of age (mean age 65 +/- 9 years). Group II included 22 patients (11 males and 11 females) with a mean age of 28 +/- 11 years. Significant differences were only observed between the two groups in regard to the proportion of peripheral blood blasts (p < 0.02), serum LDH values (p = 0.05) and the performance status at the time of diagnosis ( p < 0.00007). In the patients in group 1 cytogenetic alterations were more frequent (10/16 vs 4/20, p < 0.02), being mainly pseudodiploid. Complete remission was achieved in 7/16 patients in group I and in 17/22 in group II (p < 0.02). The median duration of CR was 34 and 18 months, respectively. The median OS was 7 months in group 1 and 15 months in group II with an estimated survival at 5 years of 0% in group I and 38% in group II (p < 0.05).

CONCLUSIONS

Patients with acute lymphoblastic leukemia over the age of 50 years have a worse general status and more cytogenetic alterations (particularly structural) than younger adult patients, presenting a lower probability of achieving complete remission and a shorter survival.

[Disseminated histoplasmosis and AIDS. Report of 4 cases]

Disseminated histoplasmosis is frequent in patients with HIV infection from endemic zones of Africa and South America. It is infrequent in Europe. Four cases diagnosed as disseminated histoplasmosis among a total of 1,100 AIDS cases reported from 1984 to 1994 were reviewed. Four males with a mean age of 40 years were reviewed. Two were from Argentina, one from Gambia with HIV-2 infection and the remaining case was a Spanish man who had made numerous travels to endemic zones. Prolonged fever without an apparent focci in the previous weeks was the clinical manifestation at the onset in all the cases. Diagnosis was performed by bone marrow aspirate (1 case), histologic study of the cutaneous lesions (1 case) and on autopsy with the diagnosis not being suspected during life (2 cases). Tracheal ulcers and hyperferritinemia are the main peculiarities of the two cases presented. Antifungal treatment with amphotericin B and secondary prophylaxis with itraconazole were effective in one of the cases. It is important to take histoplasmosis into account in the differential diagnosis of prolonged fever in patients with HIV infection from endemic zones.

[Pseudotumorous cardiac infiltration in a patient with acute monoblastic leukemia]

Although cardiac infiltration is common in advanced stage of acute leukaemia, it is not usually diagnosed at life and it is extremely rare for it to become pseudotumoral. A 25-years-old patient with an acute monoblastic leukaemia who had a leukaemic infiltration which affected the main part of the left ventricle at the time of diagnosis, is referred. The heart infiltration was detected by a two dimension echocardiography. In spite of a massive infiltration, heart failure was not present and the left ventricle's ejection fraction was 50%. Even though chemotherapy was administered, the patient died four days after diagnosis due to septic shock of respiratory origin. The most relevant autopsy finding was a widespread pseudotumoral infiltration of the left ventricle, the back side of the right ventricle and the interventricular wall. The pseudotumoral infiltration of the heart by acute leukaemia is uncommon and must be differentiated from granulocytic sarcoma. The usefulness of the different diagnostic procedures is discussed.

[Lymphoma of the marginal zone of the spleen. A case study]

Lymphomas of the marginal spleen zone are an entity recently considered as separate by the International Lymphoma Study Group. There are B-cell non Hodgkin's lymphomas (NHL) of low grade malignancy with a characteristic phenotype that allows to differentiate from mantle lymphomas and other B-cell lymphoproliferative syndromes. The case of a 69-year-old female patient admitted for abdominal pain due to large splenomegaly is reported. Pancytopenia and the presence of atypical large-sized lymphocytes with extensive cytoplasm and a rounded nucleus with indentations, reticulated appearing chromatin and one or several nucleoli were of note in the hemogram. Microscopic examination of the bone marrow demonstrated moderate-degree lymphocytary infiltration with grade I reticulin fibrosis. Laparotomy with splenectomy was performed. White pulp invasion with multifocal infiltration of the red pulp by lymphocytes of the same characteristics as those observed in the peripheral blood and bone marrow were observed on microscopic bone marrow examination. Immunophenotypic study of these lymphocytes was positive for CD19, CD20 and CD22 while being negative for CD5, CD10, CD23, CD25, CD11c and FMC7, the phenotype belonging to the lymphocytes of marginal spleen zone. Following splenectomy the patient recovered hemoperipheral counts and did not undergo additional treatment. The patient died due to septic shock of respiratory origin 4 months later. The clinical, morphologic and immunophenotypic features of marginal spleen zone lymphomas are reported with emphasis on the differences with other B-cell non Hodgkin's lymphomas of low malignancy.

[Pseudotumorous hyperplasia of the caudate lobe of the liver in a patient with Alagille syndrome]

The Alagille's syndrome consists in hypoplasia of the intrahepatic biliary ducts associated to congenital abnormalities of different organs. It is usually diagnosed in infancy due to cholestasis with good prognosis. The case of a 31-year old women who presented prominent chin, micrognathia, flattening of the nasal bone, infundibular stenosis of the pulmonary artery and cholestasis is reported. Ultrasonography demonstrated a lesion in the space of the hepatic caudate lobe with punction showing sinusoidal dilatation and infiltration of some portal spaces by lymphocytes, eosinophils and neutrophils. Samples of liver tissue obtained during laparotomy showed an absence of intrahepatic biliary ducts in the right and left lobes and preservation of those of the caudate lobe, which was also increased in size with a pseudotumoral appearance. The patients was asymptomatic with slight anicteric cholestasis at 16 months of diagnosis. The rarity of these forms of Alagille's syndrome with areas free of hypoplasia of the intrahepatic biliary ducts are of note.

[Non-Hodgkin's lymphomas in patients with human immunodeficiency virus infections. Clinicopathologic characteristics, treatment response and prognosis in 40 patients]

BASIS

Non-Hodgkin lymphoma (NHL) is one of the commonest neoplasms appearing in subjects infected by the human immunodeficiency virus (HIV). The purpose of this work was to analyse the clinical and laboratory characteristics, along with the clinical course, response to therapy and prognosis in a series of 40 patients with NHL and HIV infection treated in a single institution between 1985 and 1993.

METHODS

The following variables at onset were analysed: age, sex, risky behaviour, NHL location, presence of "B" symptoms, haemoglobin value, platelet count, total number of lymphocytes and CD4-positive lymphocyte count, erythrocyte sedimentation rate, LDH levels, serum albumin, beta 2-microglobulin, NHL type and staging. The following variables during follow-up were also examined: treatment administered, achievement of remission and remission duration, date of relapse and death or date of the last control, relapse-free survival (RFS) and overall survival (OS). A multivariate study of the prognostic factors associated to the achievement of remission, RFS and OS were carried out as well.

RESULTS

The frequency of NHL amongst the HIV-positive subjects was 4.4%. Thirty cases had high-grade lymphoma, 20 were stage IV and 33 had extranodal locations. Anaemia was the commonest blood impairment and CD4-positive lymphocyte count was below 0.2 x 10(9)/L in 72% of the cases. Twenty-eight patients with systemic NHL received chemotherapy (CHOP in 25 instances, MACOP-B in 3), and of them 6 were alive, 5 in maintained remission, as for this paper's writing. The median RFS was 7 months and the median OS was 11 months. Increased serum LDH was associated with lesser probability of attaining both remission (p = 0.03) and RFS (p = 0.03). Response to therapy was the main factor in determining survival (p = 0.002); after excluding such factor, increased serum LDH and low serum albumin rates correlated negatively with OS (p = 0.004 and p = 0.007, respectively).

CONCLUSIONS

HIV-positive patients, when affected by NHL, usually have high-grade lymphoma, frequently in advanced stages and with extra-nodal involvement. They show poor response to therapy. Increased serum LDH level is the main prognostic factor.

[Marrow hypoplasia associated with congenital dyskeratosis. Case report]

Congenital dyskeratosis is a rare disease involving ectodermal derived tissues and presenting bone-marrow hypoplasia as a complication in one half of the cases. A 25 year-old male is presented who at age 12 showed retarded development with shortness of the 4th finger of his left hand, anomalous implantation of teeth, hyperpigmented skin and hyperkeratosis on his knees, hands and feet. He had anaemia (Hb 92 g/L) and leucopenia (2.7 x 10(9)/L) with neutropenia (0.34 x 10(9)/L) and his bone-marrow showed hypoplasia, especially affecting granulopoiesis. The cytogenetic studies were normal. No treatment was given, and a haematological re-evaluation performed 13 years later showed no significant quantitative changes. Decreased number of myeloid and megakaryocytic colonies were present in the bone-marrow cultures. The clinical and laboratory characteristics of the bone-marrow aplasia associated to congenital dyskeratosis are commented, stress being laid on its differentiation from other constitutional forms of aplasia, especially Fanconi's anaemia.

Primary vulvar lymphoma presenting as a clitoral tumor

We report a case of malignant large cleaved cell vulvar lymphoma predominantly affecting the clitoris, in a 60 year-old woman. In a review of the literature, female genital tract lymphomas of vulvar location are exceptional. Histologically, these tumors must be differentiated from pseudolymphomatous lesions. In the present case (Stage IE), response to chemotherapy was good and the patient remains asymptomatic after three years of follow-up.