Clinical Presentation, Treatment, and Outcomes Among 65 Patients with HIV-Associated Lymphoma Treated at the University of North Carolina, 2000–2010

Abstract

HIV increases risk of non-Hodgkin lymphoma (NHL) and Hodgkin lymphoma (HL). The effect of HIV on presentation, treatment, and outcomes of NHL and HL in routine care in the combination antiretroviral therapy (cART) merits further characterization. We performed a retrospective analysis of HIV-infected patients with NHL and HL receiving care at the University of North Carolina at Chapel Hill from January 1, 2000 until December 31, 2010. Statistical analyses were conducted using SAS, version 9.2 (SAS Institute Inc). Sixty-five HIV-infected patients with NHL and HL were identified. Patients with non-CNS NHL and HL presented with advanced disease (85% stage III or IV) and adverse prognostic features. Patients completed 87% of planned chemotherapy cycles, and 68% of patients completed stage-appropriate therapy. Dose reduction, interruption, and/or delay occurred during more than 25% of administered cycles in 64% of patients. Infectious complications, febrile neutropenia, and myelosuppression accounted for 78% of deviations from planned cumulative dose and dose intensity. Primary CNS lymphoma (PCNSL) was associated with poor prognosis, but 2-year overall survival was 66% for all non-CNS lymphoma. Among patients surviving at least 2 years, 75% had CD4 count >200 cells/μl and 79% had HIV viral load <400 copies/ml at last follow-up. Despite advanced disease and difficulty tolerating chemotherapy with optimal cumulative dose and dose intensity, most patients with non-CNS HIV-associated lymphoma survived more than 2 years after diagnosis, the majority with suppressed HIV RNA.

HIV-associated lymphoma sub-type distribution, immunophenotypes and survival in an urban clinic population

“…This finding is consistent with other smaller studies that have found similarly high rates of stage III/IV disease: 88% of 26 NHL cases [14], 74% of 34 DLBCL cases [15] and 71% of 97 DLBCL cases [16]. It is unclear why HIV-infected patients tend to have more advanced disease at presentation, but biologic (immunosuppression allowing unchecked tumor growth or more aggressive tumor biology) and sociologic (delayed presentation to care) mechanisms are both possible, whether HIV-associated lymphomas 5…”

“…Although access to death certificates or Maryland state data was not possible in this study, prior studies [14,22,27] have all found the vast majority of deaths in patients dually diagnosed with HIV and cancer are from progression of underlying cancer rather than infections or treatment-related complications and toxicities.…”

Temporal Trends in Presentation and Survival for HIV-Associated Lymphoma in the Antiretroviral Therapy Era

“…Discordant findings may partially reflect differences in the HIV-infected populations and health-care systems in the United States and Europe, respectively. Other reasons for a lack of survival improvement may include continued presentation with advanced stage and poor performance status (25,27,33), difficulty achieving stage-appropriate chemotherapy cumulative dose and dose intensity (25,33), reduced effectiveness or greater toxicity of chemotherapy due to ART interactions (34), discontinuity or suboptimal concentrations of ART due to chemotherapy interactions (33,34), diminished immunologic response against malignant lymphocytes, intrinsically aggressive tumor biology, and mortality from lymphoma-unrelated causes. Treatment incorporating more intensive first-line and salvage chemotherapy, immunotherapy, radiotherapy, and high-dose therapy with autologous stem cell rescue may also be less frequently used in HIV-infected patients (33).…”

Clinical and Therapeutic Implications of Epstein–Barr Virus in HIV-Related Lymphomas

“…PCNSL usually occurs in patients with advanced immunosuppressed status and low CD4+ lymphocyte counts (<50 cells/µL), and frequently with an AIDS-defining illness before lymphoma diagnosis [ 31 , 45 , 64 , 65 , 66 ]. In this regard, low CD4+ lymphocyte counts and high HIV load are associated with a worse outcome in patients with PCNSL [ 31 , 42 ].…”