HIV-related Lymphoma

Table 1.  Prognostic index for HIV-related non-Hodgkin's lymphoma.

Index	Risk group	Weighted score
IPI score
0 or 1	Low risk	0
2	Low–intermediate risk	1.0
3	High–intermediate risk	1.84
4 or 5	High risk	2.9
CD4 count
<100 cells/µl		1.34
>100 cells/µl		0

Score 1 for each factor present: age >60 years; serum LDH >normal; performance status >1; stage III/IV; extranodal sites >1.
IPI: International Prognsotic Index; LDH: Lactate dehydrogenase.

Data taken from [24].

Table 3.  Summary of published Phase II/III trials in the post-HAART era.

Chemotherapy regimen (author, year)	Patients (n)	Receiving HAART	CR rate	Median survival	Overall survival	Ref.
BEMOP-CA (Bower et al., 2000)	30	50%	60%		2-year: 46% (95% CI: 27–65)	[56]
CHOP (Ratner et al., 2001)	25	100%	48%			[31]
mCHOP (Ratner et al., 2001)	40	100%	30%			[31]
CHOP (Navarro et al., 2001)	17	100%	75%		2-year: 0.59 (95% CI: 0.31–0.87) Median OS not reached	[33]
da-EPOCH (Little et al., 2003)	39	0%	74%		60% (at median follow-up of 53 months)	[46]
CDE (Sparano et al., 2004)	55	100%	44%	13.7 months (95% CI: 11 – not reached)	1-year: 57% (95% CI: 43–70) 2-year: 45% (95% CI: 20–58)	[27]
CDE (Bower et al., 2004)	46	100%	50%	26 months	2-year: 61% (95% CI: 47–70)	[28]
CDE + rituximab (Spina et al., 2005)	74	76%	70%		2-year: 64% (estimated) (95% CI: 52–76)	[39]
CHOP (Weiss et al., 2006)	72	100%	79% (standard-risk group); 29% (high-risk group)	Not reached after 47 months (standard-risk group); 7.2 months (high-risk group)	3-year: 60% 5-year: 33%	[29]
CHOP + rituximab (Boue et al., 2006)	52	100%	77%		2-year: 75%	[38]
EPOCH + concomitant rituximab (Sparano et al., 2010)	48	77%	73%	30 months	2-year: 70% (95% CI: 57–83)	[40]
EPOCH + sequential rituximab (Sparano et al., 2010)	53	77%	55%	30 months	2-year: 67% (95% CI: 54–80)	[40]
da-EPOCH + rituximab (Dunleavy et al., 2007)	19	31%	100%		100% (at 29-month follow-up)	[47]
Stanford V (Spina et al., 2002)	59	100%	81%	>17 months	3-year: 51%	[54]

BEMOP: Bleomycin, etoposide, vincristine, methotrexate and prednisolone; CA: Cyclophosphamide and doxorubicin; CDE: Cyclophosphamide, doxorubicin and etoposide; CHOP: Cyclophosphamide, doxorubicin, vincristine and prednisolone; CR: Complete response; da: Dose-adjusted; EPOCH: Etoposide, prednisolone, vincristine, cyclophosphamide and doxorubicin; mCHOP: Modified cyclophosphamide, doxorubicin, vincristine and prednisolone; OS: Overall survival.

Authors and Disclosures

Belinda Lee¹, Mark Bower¹, Thomas Newsom-Davis¹ & Mark Nelson<sup>†

1</sup>Department of Oncology Chelsea & Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK

^†Author for correspondence
HIV Medicine, Chelsea & Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK m.nelson@chelwest.nhs.uk

Sidebar

Executive Summary

Non-Hodgkin's lymphoma

• The incidence of HIV-related non-Hodgkin's lymphoma (NHL) has fallen since the introduction of HAART.

• There is a clear correlation between declining CD4 count and the risk of developing NHL.

• Prognostic factors in HIV-related lymphoma are similar to the general population, and can be scored according to the international prognostic index.

• The concomitant use of HAART and combination chemotherapy in HIV-related lymphoma is recommended, especially in patients whose CD4 cell count is less than 100/µl.

• The use of rituximab with combination chemotherapy is effective and well-tolerated in HIV-related lymphoma.

Burkitt's lymphoma

• HIV-related Burkitt's lymphoma (BL) should be managed with intensive therapy such as cyclophosphamide, doxorubicin, vincristine, high-dose methotrexate, ifosphamide, etoposide and high-dose cytarabine (CODOX-M/IVAC) or cyclophosphamide, vincristine, doxorubicin, dexamethasone, methotrexate and cytarabine (hyperCVAD).

• Prophylactic intrathecal chemotherapy should be offered to all HIV-related BL, and high-risk HIV-related NHL patients to reduce the risk of CNS relapse.

Hodgkin's lymphoma

• The incidence of Hodgkin's lymphoma (HL) has increased in the post-HAART era and is associated with better outcomes.

• HIV-related HL tends to present with advanced-stage disease, extranodal involvement and 'B' symptoms.

• Intense chemotherapy with regimens such as mustine, vincristine, procarbazine and prednisolone (MOPP)/doxorubicin, bleomycin, vinblastine and dacarbazine (ABVD) with concomitant HAART and G-CSF has been successful employed in HIV-related HL.

• Autologous stem cell transplant is feasible and effective in HIV-related relapsed lymphoma.

Conclusion

• Aggressive chemotherapy treatment in those with a good performance status and good organ function should be pursued in HIV-related lymphoma cases on the grounds that their treatment is of curative intent.