Real-World Multicenter Study of PD-1 Blockade in HIV-Associated Classical Hodgkin Lymphoma Across the United States

BACKGROUND

Despite a higher risk of classical Hodgkin lymphoma (cHL) in people with HIV and the demonstrated safety and efficacy of PD-1 blockade in cHL, there are limited data on the use of these agents in HIV-associated cHL (HIV-cHL).

PATIENTS/METHODS

We retrospectively identified patients with HIV-cHL from the "Cancer Therapy using Checkpoint inhibitors in People with HIV-International (CATCH-IT)" database who received nivolumab or pembrolizumab, alone or in combination with other agents, and reviewed records for demographics, disease characteristics, immune-mediated adverse events (imAEs), and treatment outcomes. Changes in CD4+ T-cell counts with treatment were measured via Wilcoxon signed-rank tests. Overall response rate (ORR) was defined as the proportion of patients with partial or complete response (PR/CR) per 2014 Lugano classification.

RESULTS

We identified 23 patients with HIV-cHL who received a median of 6 cycles of PD-1 blockade: 1 as 1st-line, 6 as 2nd-line, and 16 as ≥3rd-line therapy. Seventeen (74%) patients received monotherapy, 5 (22%) received nivolumab plus brentuximab vedotin, and 1 received nivolumab plus ifosfamide, carboplatin, and etoposide. The median baseline CD4+ T-cell count was 155 cells/µL, which increased to 310 cells/µL at end-of-treatment (P = .009). Three patients had grade 3 imAEs; none required treatment discontinuation. The ORR was 83% with median duration of response of 19.7 months. The median progression-free survival was 21.2 months and did not differ between patients with <200 versus ≥200 CD4+ cells/µL (P = .95).

CONCLUSION

Our findings support the use of PD-1 blockade in HIV-cHL for the same indications as the general population with cHL.

Assessment of the safety of nivolumab in people living with HIV with advanced cancer on antiretroviral therapy: the AIDS Malignancy Consortium 095 Study

BACKGROUND

Although immunotherapy has emerged as a therapeutic strategy for many cancers, there are limited studies establishing the safety and efficacy in people living with HIV (PLWH) and cancer.

METHODS

PLWH and solid tumors or Kaposi sarcoma (KS) receiving antiretroviral therapy and a suppressed HIV viral load received nivolumab at 3 mg/kg every 2 weeks, in two dose deescalation cohorts stratified by CD4 count (stratum 1: CD4 count > 200/µL and stratum 2: CD4 count 100-199/µL). An expansion cohort of 24 participants with a CD4 count > 200/µL was then enrolled.

RESULTS

A total of 36 PLWH received nivolumab, including 15 with KS and 21 with a variety of other solid tumors. None of the first 12 participants had dose-limiting toxicity in both CD4 strata, and five patients (14%) overall had grade 3 or higher immune related adverse events. Objective partial response occurred in nine PLWH and cancer (25%), including in six of 15 with KS (40%; 95% CI, 16.3-64.7). The median duration of response was 9.0 months overall and 12.5 months in KS. Responses were observed regardless of PDL1 expression. There were no significant changes in CD4 count or HIV viral load.

CONCLUSIONS

Nivolumab has a safety profile in PLWH similar to HIV-negative subjects with cancer, and also efficacy in KS. Plasma HIV remained suppressed and CD4 counts remained stable during treatment and antiretroviral therapy, indicating no adverse impact on immune function.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02408861.

Wilms' tumor 1 (WT1) antigen is overexpressed in Kaposi Sarcoma and is regulated by KSHV vFLIP

In people living with HIV, Kaposi Sarcoma (KS), a vascular neoplasm caused by KS herpesvirus (KSHV/HHV-8), remains one of the most common malignancies worldwide. Individuals living with HIV, receiving otherwise effective antiretroviral therapy, may present with extensive disease requiring chemotherapy. Hence, new therapeutic approaches are needed. The Wilms' tumor 1 (WT1) protein is overexpressed and associated with poor prognosis in several hematologic and solid malignancies and has shown promise as an immunotherapeutic target. We found that WT1 was overexpressed in >90% of a total 333 KS biopsies, as determined by immunohistochemistry and image analysis. Our largest cohort from ACTG, consisting of 294 cases was further analyzed demonstrating higher WT1 expression was associated with more advanced histopathologic subtypes. There was a positive correlation between the proportion of infected cells within KS tissues, assessed by expression of the KSHV-encoded latency-associated nuclear antigen (LANA), and WT1 positivity. Areas with high WT1 expression showed sparse T-cell infiltrates, consistent with an immune evasive tumor microenvironment. We show that major oncogenic isoforms of WT1 are overexpressed in primary KS tissue and observed WT1 upregulation upon de novo infection of endothelial cells with KSHV. KSHV latent viral FLICE-inhibitory protein (vFLIP) upregulated total and major isoforms of WT1, but upregulation was not seen after expression of mutant vFLIP that is unable to bind IKKƴ and induce NFκB. siRNA targeting of WT1 in latent KSHV infection resulted in decreased total cell number and pAKT, BCL2 and LANA protein expression. Finally, we show that ESK-1, a T cell receptor-like monoclonal antibody that recognizes WT1 peptides presented on MHC HLA-A0201, demonstrates increased binding to endothelial cells after KSHV infection or induction of vFLIP expression. We propose that oncogenic isoforms of WT1 are upregulated by KSHV to promote tumorigenesis and immunotherapy directed against WT1 may be an approach for KS treatment.

High-grade B-cell lymphoma, not otherwise specified: a multi-institutional retrospective study

In this multi-institutional retrospective study, we examined the characteristics and outcomes of 160 patients with high-grade B-cell lymphoma, not otherwise specified (HGBL-NOS)-a rare category defined by high-grade morphologic features and lack of MYC rearrangements with BCL2 and/or BCL6 rearrangements ("double hit"). Our results show that HGBL-NOS tumors are heterogeneous: 83% of patients had a germinal center B-cell immunophenotype, 37% a dual-expressor immunophenotype (MYC and BCL2 expression), 28% MYC rearrangement, 13% BCL2 rearrangement, and 11% BCL6 rearrangement. Most patients presented with stage IV disease, a high serum lactate dehydrogenase, and other high-risk clinical factors. Most frequent first-line regimens included dose-adjusted cyclophosphamide, doxorubicin, vincristine, and etoposide, with rituximab and prednisone (DA-EPOCH-R; 43%); rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP; 33%); or other intensive chemotherapy programs. We found no significant differences in the rates of complete response (CR), progression-free survival (PFS), or overall survival (OS) between these chemotherapy regimens. CR was attained by 69% of patients. PFS at 2 years was 55.2% and OS was 68.1%. In a multivariable model, the main prognostic factors for PFS and OS were poor performance status, lactate dehydrogenase >3 × upper limit of normal, and a dual-expressor immunophenotype. Age >60 years or presence of MYC rearrangement were not prognostic, but patients with TP53 alterations had a dismal PFS. Presence of MYC rearrangement was not predictive of better PFS in patients treated with DA-EPOCH-R vs R-CHOP. Improvements in the diagnostic criteria and therapeutic approaches beyond dose-intense chemotherapy are needed to overcome the unfavorable prognosis of patients with HGBL-NOS.

Brentuximab vedotin with AVD for stage II-IV HIV-related Hodgkin lymphoma (AMC 085): phase 2 results from an open-label, single arm, multicentre phase 1/2 trial

BACKGROUND

Brentuximab vedotin in combination with doxorubicin, vinblastine, and dacarbazine (AVD) is approved in the upfront setting for advanced stage classical Hodgkin lymphoma (cHL). People living with HIV have been excluded from these studies. We aimed to understand the activity and safety of brentuximab vedotin-AVD in people living with HIV diagnosed with Hodgkin lymphoma, while focusing on HIV disease parameters and antiretroviral therapy (ART) interactions.

METHODS

We present the phase 2 portion of a multicentre phase 1/2 study. Eligible patients were 18 years or older, had untreated stage II-IV HIV-associated cHL (HIV-cHL), a Karnofsky performance status of more than 30%, a CD4+ T-cell count of 50 cells per μL or more, were required to take ART, and were not on strong CYP3A4 or P-glycoprotein inhibitors. Patients were treated intravenously with 1·2 mg/kg of brentuximab vedotin (recommended phase 2 dose) with standard doses of AVD for six cycles on days 1 and 15 of a 28-day cycle. The primary endpoint of the phase 2 portion was 2-year progression-free survival (PFS), assessed in all eligible participants who began treatment. Accrual has been completed. This trial is registered at ClinicalTrials.gov, NCT01771107.

FINDINGS

Between March 8, 2013, and March 7, 2019, 41 patients received study therapy with a median follow up of 29 months (IQR 16-38). 34 (83%) of 41 patients presented with stage III-IV and seven (17%) with stage II unfavourable HIV-cHL. 37 (90%) of 41 patients completed therapy, all 37 of whom achieved complete response. The 2-year PFS was 87% (95% CI 71-94) and the overall survival was 92% (78-97). The most common grade 3 or worse adverse events were peripheral sensory neuropathy (four [10%] of 41 patients), neutropenia (18 [44%]), and febrile neutropenia (five [12%]). One treatment-related death was reported, due to infection.

INTERPRETATION

Brentuximab vedotin-AVD was highly active and had a tolerable adverse event rate in HIV-cHL and is an important therapeutic option for people with HIV-cHL. The complete reponse rate is encouraging and is possibly related to a unique aspect of HIV-cHL biology. Upcoming 5-year data will evaluate the sustainability of the outcomes obtained.

FUNDING

National Institutes of Health and National Cancer Institute.

Safety and Activity of Immune Checkpoint Inhibitors in People Living With HIV and Cancer: A Real-World Report From the Cancer Therapy Using Checkpoint Inhibitors in People Living With HIV-International (CATCH-IT) Consortium

PURPOSE

Compared with people living without HIV (PWOH), people living with HIV (PWH) and cancer have traditionally been excluded from immune checkpoint inhibitor (ICI) trials. Furthermore, there is a paucity of real-world data on the use of ICIs in PWH and cancer.

METHODS

This retrospective study included PWH treated with anti-PD-1- or anti-PD-L1-based therapies for advanced cancers. Kaplan-Meier method was used to estimate overall survival (OS) and progression-free survival (PFS). Objective response rates (ORRs) were measured per RECIST 1.1 or other tumor-specific criteria, whenever feasible. Restricted mean survival time (RMST) was used to compare OS and PFS between matched PWH and PWOH with metastatic NSCLC (mNSCLC).

RESULTS

Among 390 PWH, median age was 58 years, 85% (n = 331) were males, 36% (n = 138) were Black; 70% (n = 274) received anti-PD-1/anti-PD-L1 monotherapy. Most common cancers were NSCLC (28%, n = 111), hepatocellular carcinoma ([HCC]; 11%, n = 44), and head and neck squamous cell carcinoma (HNSCC; 10%, n = 39). Seventy percent (152/216) had CD4+ T cell counts ≥200 cells/µL, and 94% (179/190) had HIV viral load <400 copies/mL. Twenty percent (79/390) had any grade immune-related adverse events (irAEs) and 7.7% (30/390) had grade ≥3 irAEs. ORRs were 69% (nonmelanoma skin cancer), 31% (NSCLC), 16% (HCC), and 11% (HNSCC). In the matched mNSCLC cohort (61 PWH v 110 PWOH), 20% (12/61) PWH and 22% (24/110) PWOH had irAEs. Adjusted 42-month RMST difference was -0.06 months (95% CI, -5.49 to 5.37; P = .98) for PFS and 2.23 months (95% CI, -4.02 to 8.48; P = .48) for OS.

CONCLUSION

Among PWH, ICIs demonstrated differential activity across cancer types with no excess toxicity. Safety and activity of ICIs were similar between matched cohorts of PWH and PWOH with mNSCLC.

Genetic subgroups inform on pathobiology in adult and pediatric Burkitt lymphoma

Burkitt lymphoma (BL) accounts for most pediatric non-Hodgkin lymphomas, being less common but significantly more lethal when diagnosed in adults. Much of the knowledge of the genetics of BL thus far has originated from the study of pediatric BL (pBL), leaving its relationship to adult BL (aBL) and other adult lymphomas not fully explored. We sought to more thoroughly identify the somatic changes that underlie lymphomagenesis in aBL and any molecular features that associate with clinical disparities within and between pBL and aBL. Through comprehensive whole-genome sequencing of 230 BL and 295 diffuse large B-cell lymphoma (DLBCL) tumors, we identified additional significantly mutated genes, including more genetic features that associate with tumor Epstein-Barr virus status, and unraveled new distinct subgroupings within BL and DLBCL with 3 predominantly comprising BLs: DGG-BL (DDX3X, GNA13, and GNAI2), IC-BL (ID3 and CCND3), and Q53-BL (quiet TP53). Each BL subgroup is characterized by combinations of common driver and noncoding mutations caused by aberrant somatic hypermutation. The largest subgroups of BL cases, IC-BL and DGG-BL, are further characterized by distinct biological and gene expression differences. IC-BL and DGG-BL and their prototypical genetic features (ID3 and TP53) had significant associations with patient outcomes that were different among aBL and pBL cohorts. These findings highlight shared pathogenesis between aBL and pBL, and establish genetic subtypes within BL that serve to delineate tumors with distinct molecular features, providing a new framework for epidemiologic, diagnostic, and therapeutic strategies.

KSHV/HHV8-mediated hematologic diseases

Kaposi sarcoma (KS) herpesvirus (KSHV), also known as human herpesvirus 8, is the causal agent of KS but is also pathogenetically related to several lymphoproliferative disorders, including primary effusion lymphoma (PEL)/extracavitary (EC) PEL, KSHV-associated multicentric Castleman disease (MCD), KSHV+ diffuse large B-cell lymphoma, and germinotropic lymphoproliferative disorder. These different KSHV-associated diseases may co-occur and may have overlapping features. KSHV, similar to Epstein-Barr virus (EBV), is a lymphotropic gammaherpesvirus that is preferentially present in abnormal lymphoid proliferations occurring in immunecompromised individuals. Notably, both KSHV and EBV can infect and transform the same B cell, which is frequently seen in KSHV+ EBV+ PEL/EC-PEL. The mechanisms by which KSHV leads to lymphoproliferative disorders is thought to be related to the expression of a few transforming viral genes that can affect cellular proliferation and survival. There are critical differences between KSHV-MCD and PEL/EC-PEL, the 2 most common KSHV-associated lymphoid proliferations, including viral associations, patterns of viral gene expression, and cellular differentiation stage reflected by the phenotype and genotype of the infected abnormal B cells. Advances in treatment have improved outcomes, but mortality rates remain high. Our deepening understanding of KSHV biology, clinical features of KSHV-associated diseases, and newer clinical interventions should lead to improved and increasingly targeted therapeutic interventions.

Metagenomic analysis to identify novel infectious agents in systemic anaplastic large cell lymphoma

Systemic anaplastic large cell lymphoma (ALCL) is a rare CD30-expressing T-cell non-Hodgkin lymphoma. Risk of systemic ALCL is highly increased among immunosuppressed individuals. Because risk of cancers associated with viruses is increased with immunosuppression, we conducted a metagenomic analysis of systemic ALCL to determine whether a known or novel pathogen is associated with this malignancy. Total RNA was extracted and sequenced from formalin-fixed paraffin-embedded tumor specimens from 19 systemic ALCL cases (including one case from an immunosuppressed individual with human immunodeficiency virus infection), 3 Epstein-Barr virus positive diffuse large B-cell lymphomas (DLBCLs) occurring in solid organ transplant recipients (positive controls), and 3 breast cancers (negative controls). We used a pipeline based on the Genome Analysis Toolkit (GATK)-PathSeq algorithm to subtract out human RNA reads and map the remaining RNA reads to microbes. No microbial association with ALCL was identified, but we found Epstein-Barr virus in the DLBCL positive controls and determined the breast cancers to be negative. In conclusion, we did not find a pathogen associated with systemic ALCL, but because we analyzed only one ALCL tumor from an immunosuppressed person, we cannot exclude the possibility that a pathogen is associated with some cases that arise in the setting of immunosuppression.

Prevalence and outcomes of sepsis in HIV versus non-HIV patients with diffuse large B-cell lymphoma: A nationwide analysis

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Background: With the advent combined anti-retroviral therapy (ART), the survival of people living with HIV has improved, thereby increasing their prevalence, while concurrently decreasing the incidence AIDS defining malignancies. Despite its decrease, AIDS-related Diffuse Large B-Cell Lymphoma (DLBCL) remains the 3rd most common malignancy in the HIV population and an important cause of cancer related morbidity and a leading cause cancer attributed mortality. Currently the treatment modalities between HIV and non-HIV DLBCL are similar, however a comparison of the infectious complications has never been assessed. We aim to explore the prevalence and outcomes of sepsis in persons living with HIV and DLBCL versus the non-HIV DLBCL patient population. Methods: We identified all adult DLBCL patients admitted between 2016–2018 from The Nationwide Inpatient Sample (NIS) with a primary diagnosis of sepsis. Patients with and without HIV were identified and compared for demographic differences and primary outcomes of inpatient mortality, length of stay (LOS) and hospital charges. Secondary outcomes studied included rates of septic shock, acidosis, Acute Kidney Injury (AKI), Tumor Lysis Syndrome (TLS) pancytopenia, anemia, neutropenia, protein energy malnutrition (PEM) and history of bone-marrow/stem-cell transplant. Statistics were performed using t-Test, chi-square test and multivariable logistic regression. Results: There was a total of 5740 HIV-DLBCL and 158,445 non-HIV-DLBCL inpatient admissions of which 480 (8.4%) and 16085 (10.1%) respectively had sepsis (p < 0.0001). Compared to non-HIV cohort, HIV-DLBCL patients were significantly younger (47.5 versus 67 years, p < 0.001), more likely to be male (66.7% vs 55.3%, p = 0.02), Black (43% vs 7.7%) or Hispanic (18% vs 11%) (p < 0.001), more likely to be on Medicaid (44.9% vs 8.2%, p < 0.001) and lived-in low-income zip-codes (p < 0.0001). Overall adjusted inpatient mortality was not significantly different between HIV and non-HIV groups (14.6% vs 16.9%, p = NS). But HIV-DLBCL patients had significantly high Chalrson co-morbidity index (p < .0001), longer inpatient LOS (8.75 vs 8.65 days, p < 0.0001) and higher total hospital charges (average $5338 higher for each admission, p < 0.0001). HIV-DLBCL cohort also reported significantly higher TLS (7.3% vs 2.6%, p = 0.005) and PEM (42.7% vs 28.9%, p = 0.004). Other secondary outcomes were not significantly different between the groups. Conclusions: Demographic differences between the two cohorts are reflective of known racial & socio-economic disparities associated with HIV. Lower rates of sepsis in HIV cohort were not translated into improved inpatient mortality. Longer LOS and hospitalization charges in HIV patients likely due to high comorbidity burden.

Impact of Myc in HIV-associated non-Hodgkin lymphomas treated with EPOCH and outcomes with vorinostat (AMC-075 trial)

EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) is a preferred regimen for HIV-non-Hodgkin lymphomas (HIV-NHLs), which are frequently Epstein-Barr virus (EBV) positive or human herpesvirus type-8 (HHV-8) positive. The histone deacetylase (HDAC) inhibitor vorinostat disrupts EBV/HHV-8 latency, enhances chemotherapy-induced cell death, and may clear HIV reservoirs. We performed a randomized phase 2 study in 90 patients (45 per study arm) with aggressive HIV-NHLs, using dose-adjusted EPOCH (plus rituximab if CD20+), alone or with 300 mg vorinostat, administered on days 1 to 5 of each cycle. Up to 1 prior cycle of systemic chemotherapy was allowed. The primary end point was complete response (CR). In 86 evaluable patients with diffuse large B-cell lymphoma (DLBCL; n = 61), plasmablastic lymphoma (n = 15), primary effusion lymphoma (n = 7), unclassifiable B-cell NHL (n = 2), and Burkitt lymphoma (n = 1), CR rates were 74% vs 68% for EPOCH vs EPOCH-vorinostat (P = .72). Patients with a CD4+ count <200 cells/mm3 had a lower CR rate. EPOCH-vorinostat did not eliminate HIV reservoirs, resulted in more frequent grade 4 neutropenia and thrombocytopenia, and did not affect survival. Overall, patients with Myc+ DLBCL had a significantly lower EFS. A low diagnosis-to-treatment interval (DTI) was also associated with inferior outcomes, whereas preprotocol therapy had no negative impact. In summary, EPOCH had broad efficacy against highly aggressive HIV-NHLs, whereas vorinostat had no benefit; patients with Myc-driven DLBCL, low CD4, and low DTI had less favorable outcomes. Permitting preprotocol therapy facilitated accruals without compromising outcomes. This trial was registered at www.clinicaltrials.gov as #NCT0119384.

HIV associated hepatocellular cancer (HCC) in an inner-city minority population

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Background: The Highly Active Anti-Retroviral Therapy (HAART) era has seen a rise in the incidence of non-AIDs defining cancers. This study was undertaken to study the characteristics associated with HIV+ HCC in an inner-city minority population. Methods: Patients with diagnosis of HCC since January 2011 until December 2018 were identified from our hospital’s electronic medical database using ICD-9/ICD-10 codes. Charts were retrospectively screened to confirm diagnosis of HCC and identify HIV+ patients. HIV+ HCC were compared to HIV- cohort from 2011 to 2016. Statistical analysis was done using the chi-square and t-test. Results: A total of 14 HIV+ HCCs were identified and compared to 239 HIV- HCC (Table 1). All HIV+ HCC were men (100%) with 86% African Americans (AA) (p < 0.05). HIV+ HCC were more likely to be HCV+, HBV+ and less likely to have history of alcoholism. Seventy-nine percent HIV+ HCC were Child-Pugh A at diagnosis compared to 35% in HIV- HCC. The median years between diagnosis of HIV and HCC was 18. All 14 HIV+ HCC (100%) were on HAART at the time of HCC diagnosis with viral load (available for 12) undetectable in 10 (83%) and < 100 copies/mL in 2 (17%). The average CD4 count at HCC diagnosis was 258 cells/µL with 10 (71%) having CD4 counts > 200 cells/µL. HCC was multifocal in 71% HIV+ compared to 49% of HIV- patients. AFP levels were < 20 ng/mL for 50% of the HIV+ HCC patients. There were 43% BCLC B and no BCLC D patients in HIV+ HCC compared to 17% and 24% in HIV- (p < 0.05 for both). 67% HIV+ BCLC Stage C patients died within 20 weeks of HCC diagnosis. Conclusions: HIV+ HCC is predominantly AA, exclusively male disease in our inner-city population. Compared to other studies showing HIV+ HCC to be younger than the HIV- patients, our HIV+ patients were similar in age to the HIV- cohort. HIV+ HCC is more multifocal with early mortality despite early BCLC stage.. Studies are needed to investigate if frequent HCC screening may be needed in HIV+ patients with HCV/HBV co-infection.[Table: see text]

HIV associated head and neck cancers in an inner-city minority population

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Background: Head and Neck Cancer (HNC) is a common non-AIDS defining malignancy and its risk increases by 1.7 to 4-fold with HIV infection. Little is known about the epidemiology and outcomes in this subset of patients. This study was undertaken to evaluate the characteristics of HIV+ HNC in an inner city minority population. Methods: All patients with a diagnosis of HNC from January 2008 to December 2017 were identified from the Tumor Registry Database of Cook County Health. We screened patients for HIV+ status at the time of HNC diagnosis. Retrospective chart review of those with Squamous cell carcinoma (SCC) was performed and compared to the largest reported HIV+ HNC cohort (SPORE consortium – J Acquir Immune Defic Syndr. 2015; 65(5):603-10). Other histologies were not included. Results: A total of 1379 charts were screened and 38 unique HIV+ patients with SCC were identified. The most common tumor sites were oral cavity (34%), larynx (26%) and oropharynx (26%), similar to SPORE. However, our cohort had a higher number of African Americans (AA) and a greater proportion of female patients. The median age of diagnosis was 52 years, which is similar in both studies but much lower than the non-HIV population (SEER database - median age 65). Over 63% had an undetectable viral load (VL) compared to 1.4% in SPORE, but the median CD4 count did not differ (298 vs 300 cells/µL). Survival information was available for 27 patients, with a median of 21 months (mo) versus 49 mo in SPORE. Overall survival (OS) was higher in non-smokers (34.5 mo vs 21 mo) and those with CD4>500 when compared to CD4<100 (42mo vs 15mo) Table summarizes the comparison of data. Conclusions: HIV+ HNC was predominantly seen in AA males. When compared to the SPORE cohort, OS was much poorer in the inner city minority, despite similar median age and CD4 counts. In addition, smokers and those with CD4 <100 cells/µL at diagnosis seem to have worse outcomes. [Table: see text]

Tolerability of paclitaxel/carboplatin (PCb) in solid tumor patients (pts) infected with HIV

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Background: Although cancer has long been a recognized hallmark of the HIV epidemic, the preservation of immunologic health with modern antiretroviral therapy (ART) and aging has resulted in a population increasingly susceptible to cancers not traditionally associated with advancing immunosuppression. Several of these cancers (including lung, anal and head & neck) are seen in excess compared to the background population. Defining tolerability of standard treatments and analyzing potential interactions between ART and chemotherapy provides evidence necessary to mitigate treatment disparities. Methods: We conducted a study to evaluate the tolerability of PCb in HIV+ cancer pts. AMC-078 (NCT01249443), originally designed as a phase I of vorinostat in combination with fixed doses of P (at 175mg/m2) and Cb (AUC 6) every 3 weeks, was amended to study pts treated with PCb alone after phase III testing in the background population was negative for the combination in lung cancer. Eligibility criteria: PS ≤ 2, advanced solid tumor and normal organ function, including CD4 count > 100 cells/mcL on stable ART. Up to 6 cycles of PCb were permitted. Clinically significant adverse events (AE) in prior cycles were managed by dose reductions. Results: 17 pts (10M/7F; median CD4, 389/mcL) were accrued, including lung (9) and anal (3) cancers; 8 pts had ritonavir (potent CYP inhibitor)-containing ART. 65 PCb cycles were administered to 16 evaluable pts, for a mean of 4+ cycles/pt; only 2 pts were treated with vorinostat. AE of special interest included ≥G3 (febrile) neutropenia and ≥ G2 neuropathy, below. 4 pts had partial responses (3 confirmed). Pharmacokinetic analyses (7 pts) are pending. Conclusions: PCb has similar toxicity profile in fit pts with HIV infection. No signal for worse myelosuppression or neuropathy was observed by ART regimen. Routine use of GCSF or empiric dose reduction for presumed risk is unjustified. Results support standard cancer treatment for this underserved population. Clinical trial information: NCT01249443. [Table: see text]

Long-term survival in AIDS-related primary central nervous system lymphoma

BACKGROUND

The optimal therapeutic approach for patients with AIDS-related primary central nervous system lymphoma (AR-PCNSL) remains undefined. While its incidence declined substantially with combination antiretroviral therapy (cART), AR-PCNSL remains a highly aggressive neoplasm for which whole brain radiotherapy (WBRT) is considered a standard first-line intervention.

METHODS

To identify therapy-related factors associated with favorable survival, we first retrospectively analyzed outcomes of AR-PCNSL patients treated at San Francisco General Hospital, a public hospital with a long history of dedicated care for patients with HIV and AIDS-related malignancies. Results were validated in a retrospective, multicenter analysis that evaluated all newly diagnosed patients with AR-PCNSL treated with cART plus high-dose methotrexate (HD-MTX).

RESULTS

We provide evidence that CD4+ reconstitution with cART administered during HD-MTX correlates with long-term survival among patients with CD4 <100. This was confirmed in a multicenter analysis which demonstrated that integration of cART regimens with HD-MTX was generally well tolerated and resulted in longer progression-free survival than other treatments. No profound differences in immunophenotype were identified in an analysis of AR-PCNSL tumors that arose in the pre- versus post-cART eras. However, we detected evidence for a demographic shift, as the proportion of minority patients with AR-PCNSL increased since advent of cART.

CONCLUSION

Long-term disease-free survival can be achieved in AR-PCNSL, even among those with histories of opportunistic infections, limited access to health care, and medical non-adherence. Given this, as well as the long-term toxicities of WBRT, we recommend that integration of cART plus first-line HD-MTX be considered for all patients with AR-PCNSL.

Initial Experience with the Use of Thrombopoetin Receptor Agonists in Patients with Refractory HIV-Associated Immune Thrombocytopenic Purpura: A Case Series

HIV-associated immune thrombocytopenic purpura (ITP) has decreased in incidence 10-fold since the advent of highly active antiretroviral therapy (HAART). For patients with detectable HIV viral loads, first-line treatment approaches involve optimizing HAART followed by standard ITP options used to treat those without HIV infection. In the general population, the thrombopoetin receptor agonists (TRAs), eltrombopag and romiplostim, are effective when used as salvage ITP therapy. In addition, eltrombopag has been used effectively in patients with thrombocytopenia secondary to hepatitis C--a virus seen commonly in HIV-infected patients, especially in those who also have a history of intravenous drug use. There are, however, few reports or studies of TRAs use in those with HIV infection. Herein, we describe 5 cases of refractory HIV-associated ITP managed with TRAs. Although platelet counts improved for all patients, 2 patients succumbed to thromboembolic complications. Our initial experience, as well as our findings from a Medline review, supports the potential utility of TRA as salvage therapy in the treatment of HIV-related ITP; however, we recommend caution in the use of these agents in those who are at highest risk of thrombosis. Additional studies are needed to determine the efficacy and, more importantly, the safety of TRAs in treatment of HIV-associated ITP.

Adverse events in non-AIDS-defining cancer patients receiving chemotherapy and combined antiretroviral therapy

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Background: From 1991 to 2005, the number of cases of non-AIDS defining cancers (NADC) rose from 3,192 to 10,059 in the USA. Studies have shown an improvement in survival for many HIV-associated malignancies in the post HAART era. Drug-drug interactions between HIV therapy and chemotherapy (CTX) are not well understood. HIV medications can inhibit or induce the cytochrome p450 system, modulating CTX clearance. To understand CTX-HIV medication interactions, we performed a retrospective analysis of all patients (pts) diagnosed with a solid NADC who took CTX with combined antiretroviral therapy (cART). Methods: 157 pts with solid NADC were identified via a computer search at County Hospital. Adverse events (AE) during CTX in pts taking cART were assessed by chart review and graded per the NCI Common Terminology Criteria. Statistics: A Fisher's exact test was used to examine the differences in AE incidence. Results: Patients who did not take cART in conjunction with, or did not require CTX, were excluded. The number of pts analyzed for anal cancer (n=25), lung carcinoma (n=9), breast (n=7), and head and neck carcinoma (HNSCC) (n=4) represents 94% of pts taking cART with CTX in our cohort. Interestingly, Forty-two pts (50%) never received cART during therapy. All pts with anal carcinoma were treated with mitomycin/5FU/radiotherapy. 46 % of the patients taking ritonavir-based cART (6 pts of 13) developed a G4 neutropenia versus 8% (1 pt of 12) taking non-ritonavir cART (p<0.07). Anemia all grades with ritonavir, 54%, versus non-ritonavir cART 16% (p<0.09). All grades neutropenia for lung carcinoma while taking ritonavir was 83% versus 33% while taking non-ritonavir cART. No other correlations were identified. In this cohort, 17 pts received platinum (37%), taxanes (n=5) (11%), anthracyclines (n=5) 11%, gemcitabine (n=2) (4%), and pemetrexed (n=1). No difference in AE was noted between any CTX class, AE, and cART. Conclusions: Ritonavirinduced a 38% increase in G4 neutropenia and anemia during treatment of anal carcinoma with mitomycin/5FU. More trials including HIV-associated cancer pts are needed to assess the role of cART when given in conjunction with CTX.

Thalidomide-associated thrombosis in the treatment of HIV-associated severe aphthous disease: a case report and review of the literature

Venous thrombosis is a well-described complication of thalidomide therapy in patients with multiple myeloma (MM). However, an association between thalidomide use and thrombosis in HIV-positive patients has not been previously described. We present the case of a 48-year-old HIV-positive man who developed a deep venous thrombosis while on thalidomide for the treatment of severe aphthous ulcers. We review the management of severe aphthous disease and the potential adverse effects of thalidomide therapy. We examine the association between thalidomide and thrombosis in patients with MM and discuss how the same relationship may or may not exist in HIV-positive patients. Although the strength of the association between thalidomide use and thrombosis in HIV-positive patients being treated for aphthous disease remains unclear, HIV providers should be aware of the potential risk of thrombosis in all patients receiving thalidomide.

Concurrent chemoradiotherapy with 5-fluorouracil and mitomycin-C for invasive anal carcinoma in HIV-positive patients receiving highly active anti-retroviral therapy versus non-HIV patients

e14590

Background: In the non-HIV population, radiotherapy (RT), fluorouracil (5FU) with mitomycin (MMC) has become the standard in the non-metastatic setting for anal carcinomas (AC). To date, most studies with AC in HIV patients (pts) are small case series where multiple chemoradiation (CRT) regimens were used and analyzed as one cohort. In addition, little data exists on the inner city HIV population. Cook County Hospital (CCH) is the largest health provider for HIV pts in Chicago and together with its outpatient clinic, the Ruth M. Rothstein CORE Center (CC) 5,500 HIV+ pts are treated per year. The County Hospital (CCH) AIDS Malignancy Project (CHAMP Study) is a retrospective study of all HIV cancer pts treated for the past 14 years. Methods: We identified all HIV+ pts with invasive AC in CHAMP cohort. We analyzed HIV characteristics, overall survival (OS), PFS and pt demographics and compared it to a HIV- cohort from the same institution. All AC treated without MMC/5FU/RT were excluded. Statistics: Time to local recurrence (TLR), time to distant metastasis (TDM), and OS data was analyzed using Kaplan-Meier analysis and a Cox Proportional Hazards model. Results: 35 HIV + and 52 HIV - pts were included. Of the HIV+ vs. HIV- pts, 89 vs. 52% were male, 82 vs. 48% were AA and the average age in HIV+ vs. HIV- was 44 vs. 52 yrs. 45 % of the HIV pts presented with stage IIIA or IIIB disease vs. 46% in HIV- pts. 15 % HIV- pts had stage IV vs. 0% HIV +. The median survival in the HIV+ vs. HIV- was 34 vs. 39 mo (p>0.5). In the HIV- population, 22% survived 120 months, while no HIV pt survived over 90 months. TLR was 20 months shorter in the HIV+ arm (p<0.5). OS based on CD4 count did not differ. Conclusions: HIV associated AC is an AA male disease compared to HIV- pts in the inner city. More stage IV disease was reported in the HIV- cohort, but the median survival was equal with no long-term survivors in the HIV+ arm, possibly due to TLR, which was 20 months shorter, implying more aggressive disease. Both inner city groups present late but tolerate chemotherapy equally well. Education is needed in both HIV+ and HIV- pts to diagnose the cancers early so the OS can match the national average.

Prevention of adverse events during treatment of HIV-associated Hodgkin lymphoma with ritonavir and zidovudine

8085

Background: In response to very high rates of neurologic and hematologic adverse events (AE) when ABVD was used in combination with ritonavir (RTV) or zidovudine (AZT) in HIV-associated Hodgkin (HL) we instituted a policy to use alternative antiretroviral agents during HL therapy in our HIV patients. In this study, we examined all AE in HIV-HL since the exclusion of RTV and AZT over 2 years ago. We also evaluated the AEs when HAART and chemotherapy for NHL were taken together in an expanded cohort of 52 pts. Methods: A screen of pharmacy and hospital databases between 1998-2012 identified all HIV-associated HL and NHL patients. Adverse events during chemotherapy were assessed by chart review and graded per the NCI Common Terminology Criteria for Adverse Events. Statistics: Fisher's exact test was used to examine the differences in AE incidence associated with use of specific antiretrovirals. Results: HAART use during chemotherapy was identified in 35/36 (96%) pts with HL and 52/108 (48%) of pts with NHL. Before RTV and AZT were prohibited, G3/4 neuropathy, neutropenia, and anemia developed in 31, 68, and 57% of 23 pts with HIV-HL respectively. Since then, 12 patients were treated with non-RTV and AZT based HAART. 0% neuropathy and only 20% G3/4 neutropenia and 10% anemia was observed, each statistically significant (p<0.01). Of the 54 patients with NHL, 64% received CHOPR like, HYPERCVADR (18%), and daEPOCHR (11%). All AEs for each NHL regimen were similar to historical controls and no anti HIV medication was found to correlate with any AE, despite 28% of the HAART regimens containing RTV. Conclusions: No relationship between any AE and anti HIV medications was identified during treatment for NHL. But, excluding RTV or AZT-based HIV therapy during HL treatment, decreased neuropathy, neutropenia, and anemia by 100%, 38%, and 28% respectively. We suggest that exclusion of ritonavir and zidovudine from HAART regimens used with ABVD become the standard.

A retrospective analysis of all non-AIDS defining cancers (NADC): A subset analysis of the County Hospital AIDS Malignancy Project (CHAMP)

1611

Background: County Hospital (CCH) with its HIV clinic, the CORE Center (CC) is the largest provider for HIV patients (pts) in Chicago, treating over 5,500 HIV pts yearly. There is paucity of data on characteristics of HIV+ cancers (ca) in the inner city. The CHAMP cohort is a retrospective study of all HIV associated cancers at CC and CCH over past 14 years (yrs). We analyzed all of the NADC from this cohort. Methods: All HIV pts with NADC were identified from the CHAMP cohort and retrospectively reviewed for HIV and cancer characteristics, overall survival (OS), and pt demographics. Statistics: Survival data was analyzed using Kaplan-Meier analysis and Cox Proportional Hazards model. Results: Of 438 pts identified, 157 were NADC representing 21 ca. The average (ave) age was 48 yrs (range 44-57), with prostate ca having highest age presentation. Over the past 10 yrs, the number of NADC has risen from 10 to over 20 each yr. Unlike historical controls (HC) where lung ca is most common, anal ca (21%) was most frequent followed by lung ca (17%). Prostate, head and neck (HNSCC), liver, and colorectal ca were seen in 9, 9, 8, and 7% respectively. 65% of pts were African Americans (AA) and 18% Caucasians. 78% of all NADC were men. 45% of anal ca present with stage IIIa/b disease, moderately to poorly differentiated ca in 48%, with a median OS of 34 mo. CD4 count did not alter OS but stage predicted better outcomes. 86% lung ca presented as stage III/IV disease with ave CD4 count 204. Histologically, 36% were SCC, 28% adenosquamous and 20% adenocarcinoma. OS was 5.5 mo and did not change by histology, CD4, or age. 68% HNSCC present with stage IVa/b but no IVc. Ave age was 48 yrs with an OS of 18mo. 50% were oropharyngeal compared to 22% in HC. Conclusions: Based on data by Sheilds et. al, CCH treats just over 1% of the country’s NADC population. We demonstrate a higher incidence of NADC over time, dominated by a younger, AA and male population. Each ca presents with advanced stage 45-86% and poorly differentiated tumors ranging from 15-30%. The OS of each cancer is consistent with HC with exception of HNSCC. As HIV pts age becoming prone to cancers of elderly, education and screening of inner city HIV pts will help improve cancer rates.

Mechanism of action of des-His1-[Glu9]glucagon amide, a peptide antagonist of the glucagon receptor system

We have investigated the mechanisms through which des-His1-[Glu9]glucagon amide functions as a peptide antagonist of the glucagon receptor/adenylyl cyclase system. Studies with radiolabeled peptides identified that (i) the antagonist bound to intact hepatocytes according to a single first-order process, whereas the rate of association of glucagon with the same preparation could be described only by the sum of two first-order processes; (ii) the interaction of the antagonist with saponin-permeabilized hepatocytes was not affected by the addition of GTP to the incubation medium or by the elimination of Mg2+, whereas the interaction of glucagon with the same cell preparation was modified significantly by the presence of the nucleotide or by the absence of the divalent metal ion; (iii) the dissociation of antagonist from intact hepatocytes incubated in buffer was complete, whereas that of agonist was not; and (iv) the antagonist bound to intact hepatocytes at steady state according to a single binding isotherm (as did both agonist and antagonist in permeabilized hepatocytes), whereas glucagon bound to the intact cell system with two clearly defined apparent dissociation constants. A model is presented for the mechanism of action of the glucagon antagonist in which the analog binds to glucagon receptors in a Mg(2+)- and GTP-independent fashion and in which resulting ligand-receptor complexes fail to undergo sequential adjustments necessary for the stimulation of adenylyl cyclase.