Treatment Strategies for Lymphoma in Patients With HIV

Other less common types of NHL, such as plasmablastic lymphoma, primary CNS lymphoma, and primary effusion lymphoma, are now rarely seen in patients receiving ART. Due to their rarity, most data regarding optimal treatment strategies come from retrospective studies. However, results from these studies suggest that in patients with HIV who have good CD4 count and low or undetectable viral load, these lymphomas can be treated with strategies similar to those administered to HIV-negative patients with lymphoma.

Treating Hodgkin Lymphoma

Risk for Hodgkin lymphoma (HL) is significantly increased among patients with HIV. In addition, the presentation of HIV-associated HL is different compared with the presentation of HL in patients who are HIV-negative and involves noncontiguous spread and less mediastinal involvement, and EBV infection is very common in HIV-associated HL.

Outcomes with HIV-associated HL are comparable to outcomes in HIV-negative patients with HL, with one study finding 2-year progression-free survival and OS rates of 94% and 89%, respectively, in HIV-positive patients. In addition, there is a correlation between response to ART and HL outcome in HIV-positive patients who have not undergone ART. New treatment strategies include the use of brentuximab vedotin, which was recently approved by the US Food and Drug Administration for HIV-associated HL.

Treating Comorbidites in Patients With HIV-Associated Lymphoma

Myeloablative autologous transplants have been performed safely in patients with NHL and HL who did not response to first-line treatment, and transplant outcomes are similar compared with those reported among HIV-negative patients receiving transplant. One study reported 1-year transplant-related mortality of 5.2% and 2-year OS of 87% in HIV-positive patients.

Nonmyeloablative allogeneic transplantation has also been used safely in some patients with refractory disease, with one study reporting that some patients achieved short-term remission with little toxicity. Conversely, autologous chimeric antigen receptor T-cell therapy has not been assessed in patients with HIV; Dr Noy noted that “future studies could explore what level of immunity is necessary to support this approach.”

For prophylactic treatment of infection, administration of hematopoietic growth factor is recommended for all patients with HIV-associated lymphoma as it can help prevent neutropenia and secondary infection. Pneumocystis jirovecii prophylaxis is also recommend for all patients with HIV, while patients receiving intensive chemotherapy should also receive prophylaxis for herpes simplex and varicella.

In most cases, ART can be safely continued during chemotherapy. However, some ART regimens, especially those using therapeutic agents from older generations, may interact with chemotherapeutic agents such as doxorubicin and vinca alkaloids, and combination of these treatments should be avoided.

Expert Opinion

“In the early days of the HIV epidemic, the risk of developing lymphoma was extremely high,” Dr Noy told Hematology Advisor. “However, patients often did not get treated aggressively as the prognosis for their underlying AIDS-related problems was so poor. The risk [for lymphoma] is lower than [it was] in the pre-ART era, but it has not been eliminated, and patients remain at [increased] risk compared with the general population.”

She continued, “While some lymphoma subtypes are no longer common in patients on ART, others are still a significant burden, [such as] Hodgkin lymphoma and systemic diffuse large B-cell lymphoma. Many trials have now shown excellent results for these lymphomas, as long as patients are also treated with ART.” She noted that these study results suggest treatment regimens currently regarded as standard of care are safe to use in patients with HIV, and that autologous and allogeneic transplantation can be used in certain settings as well.

“The care of patients [with HIV] has progressed sufficiently, [and] the American Society of Clinical Oncology advocates inclusion of HIV-positive patients alongside HIV-negative patients in clinical trials [for cancer] when appropriate,” Dr Noy explained.

In her paper, Dr Noy concluded that many HIV-positive patients on ART ought to be managed using similar treatment strategies compared with the general population. Research suggests the combination of intensive curative lymphoma therapies and pedant infection may achieve optimal outcomes in this patient population. Dr Noy noted that future studies should explore the utilization of unique biological features of HIV-related lymphoma to develop therapeutic strategies.

Reference

1.     Noy A. Optimizing treatment of HIV-associated lymphoma [published online October 24, 2019]. Blood. doi:10.1182/blood-2018-01-781400

This article originally appeared on Hematology Advisor