Human immunodeficiency and Hodgkin lymphoma

Abstract

Presentation of Hodgkin lymphoma (HL) is distinctive in the infected individual being more advanced, accompanied by B symptoms and the presence of extranodal disease particularly lymphadenopathy of the head and neck. Bone marrow involvement may be found in over 50% of cases. Virtually all co express gamma-herpesvirus. Phenotypically there is prominence of the mixed-cellularity and lymphocyte depleted histopathologic subtypes that define an aggressive clinical course in comparison to other variants. Prior to the induction of cART, median survival was only 1-2 years. Notably the first chemotherapy trial using ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) in 21 patients, without treating the viral infection, resulted in a 43% complete remission rate accompanied by severe haematological toxicities but did not extend median survival with this being 1.5 years matching the negative cases.Significant change accompanied concomitant anti-retroviral therapy that could be given safely even with dose intensive regimens exemplified by BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone) in 12 patients or the Stanford V regimen (doxorubicin, vinblastine, mechlorethamine, etoposide, vincristine, bleomycin, prednisone) coupled with involved-field radiation for bulky disease studied in 59 patients. BEACOPP extended overall survival (OS) to 83% at 2 years. A similar trend was seen 1 when using the Stanford V regimen with an OS rate of 51% at 3 years, disease-free survival (DFS) of 68% and freedom from progression (FFP) in 60%. Additional benefits accrued from supportive care with stimulatory peptides such as G-CSF and when combined with bacterial prophylaxis results approached that found in the uninfected reference group. Current consensus holds this particular lymphoma as still among the non-AIDS defining cancers being lung, stomach, liver or anal despite these having recently gained more attention as several of these neoplasms may be occurring more commonly in the era of cART.While the relative risk of developing a non-AIDS-defining neoplasm in HIV-infected persons on the average is 2-3 times, the risk for developing HL in HIV-infected cases impressively ranges between 5 and 25 times when compared to the general population. Based on the precedent in which Kaposi sarcoma and the non-Hodgkin lymphomas distinctively alter the course of this retroviral infection in a way indistinguishable from concurrent Hodgkin lymphoma we propose that this entity be similarly regarded and the hypothesis tested in large randomised prospective study.

Benign and Malignant Lymphoproliferative Disorders in HIV/AIDS

“…In this series, only 3 of 21 patients in this study were diagnosed with Hodgkin's lymphoma (Ioachim, et al, 1985). Since these first cases were diagnosed, many more cases of Hodgkin's lymphoma in HIV/AIDS patients have been identified and modern epidemiologic data suggests that HIVpositive patients have at least a 2-10-fold increased risk of developing Hodgkin's lymphoma relative to the HIV-negative population (Carbone, et al, 2009;Sissolak, et al, 2010). Despite this increase, Hodgkin's lymphoma is infrequent relative to diffuse large B-cell lymphoma and Burkitt's lymphoma (the latter two accounting for at least 60% of HIV-associated lymphomas) .…”

“…It is thought that the Reed-Sternberg cell of Hodgkin's lymphoma relies upon intact immunomodulatory signals from T-cells. With T-cell numbers sufficiently stabilized in HIV-infection treated with antiretrovirals-but in an immunologically active environment caused by chronic HIV infection with upregulated inflammatory cytokine production-Reed-Sternberg cells may be inadvertently stimulated and Hodgkin's lymphoma may develop (Sissolak, et al, 2010). Despite the relatively low risk of Hodgkin's lymphoma in HIV-infection, therefore, it is incumbent that HIV patients on anti-retroviral therapy be carefully surveilled for the development of potential Hodgkin's lymphoma.…”

“…As noted previously, HIV/AIDS patients are at extremely high risk for lymphadenopathy; when these patients present with symptoms of fever, chills, night sweats and weight loss, furthermore, a long differential must be considered-with lymphomas high on the list. Most HIV-associated Hodgkin's cases will present with lymphadenopathy, typically in a cervical www.intechopen.com distribution (Sissolak, et al, 2010). Perhaps due to the unique pathobiology of HIVassociated Hodgkin's lymphomas, many HIV-associated Hodgkin patients present at a relatively young age (in addition to possibly presenting earlier on in the course of infection).…”

“…Perhaps due to the unique pathobiology of HIVassociated Hodgkin's lymphomas, many HIV-associated Hodgkin patients present at a relatively young age (in addition to possibly presenting earlier on in the course of infection). Many of these patients will also present with advanced stage disease relative to the HIVnegative population (Sissolak, et al, 2010). High clinical suspicion warrants lymph node biopsy, which is required for accurate diagnosis.…”

“…High clinical suspicion warrants lymph node biopsy, which is required for accurate diagnosis. Most authorities also recommend an initial staging bone marrow biopsy given that 40-60% of cases present with bone marrow involvement (Sissolak, et al, 2010). While a complete discussion of the possible histological subtypes of Hodgkin's lymphoma is beyond the scope of this chapter, it is warranted to discuss the histopathologic features of the most common form, namely the mixed cellularity subtype of classical Hodgkin's lymphoma.…”