People with HIV treated for aggressive forms of non-Hodgkin lymphoma or Burkitt lymphoma appear no more likely to suffer a relapse after treatment than HIV-negative people treated for the same conditions, according to findings of an analysis of the German HIV Lymphoma Cohort.
Non-Hodgkin lymphoma and Burkitt lymphoma are Aids-defining cancers that occur much more frequently in people with HIV than in the general population. Non-Hodgkin lymphoma is a cancer of lymphocytes (white blood cells) that develops in lymph nodes. The most aggressive form is Diffuse Large B-Cell Lymphoma. Burkitt lymphoma is a form of non-Hodgkin lymphoma that develops in B-lymphocytes and is very aggressive.
Both cancers are treatable with chemotherapy and complete remission is possible in the majority of people treated. Relapse after treatment occurs in about one in ten cases in the general population but German researchers wanted to know if people with HIV suffered higher rates of relapse and whether dose reductions or chemotherapy cycle reductions had any impact on the risk of relapse.
The study looked at people with HIV in Germany treated for Diffuse Large B-Cell Lymphoma (DLBCL), Burkitt lymphoma, plasmablastic lymphoma (PBL) or non-classifiable B-cell lymphoma since 2005. The treatment cohort consisted of 387 people, of which 254 achieved remission after the first course of treatment, 21 after further chemotherapy, 22 achieved partial remission (reduction in lymphoma mass of at least 50% and no further spread) and 15 were still receiving chemotherapy at the time of analysis. Of the non-responders, 23 died during treatment, 45 had progressive disease and 7 had received no treatment.
A total of 254 achieved complete remission after the first course of treatment (127 with DLBCL, 91 with Burkitt lymphoma, 29 with PBL and seven with other non-classifiable B-cell lymphomas). This group represented just under two-thirds (63%) of those treated. Complete remission from lymphoma was achieved if there was no visible evidence of lymphoma for at least three months after the completion of treatment. Relapse was defined as 50% growth in a previously abnormal lymph node after complete remission.
The primary outcomes evaluated in the study were relapse and 5-year relapse-free survival.
People were followed for a median of 4.6 years after complete remission. During the follow-up period, 11.4% experienced relapse. In comparison, recent studies in HIV-negative people report relapse rates of 6-10% for DLBCL and 12% for Burkitt lymphoma using similar treatment regimens to those employed in this study population.
Five-year relapse-free survival was 88.4% for Diffuse Large B-Cell Lymphoma, 88.9% for Burkitt lymphoma and 88.6% for plasmablastic lymphoma. Survival was much lower for unclassified Aids lymphoma (57.1%) and the investigators say that these hard-to-classify lymphomas may include especially aggressive atypical lymphomas.
The following factors were associated with relapse: higher Ann Arbor score, representing more disseminated disease (stages III/IV) (hazard ratio 4.85, 95% CI 1.44-16.34); no antiretroviral therapy during chemotherapy (HR 4.28, 95% CI 1.19-15.39)
R-CHOP chemotherapy (HR 7.59, 95% CI 1.87-30.81); and non-classifiable lymphoma (HR 5.08, 95% CI 1.13-22.08).
The treatment regimens used – R-CHOP or GMALL – last up to four months. GMALL is more intensive and may require in-patient care. Reductions in doses or the number of cycles of chemotherapy may be necessary or advisable depending on the lymphoma stage and general health.
Looking at the treatment course, investigators found that only 37% of patients had a full treatment course, without delay, after diagnosis. There was no difference in outcome in those who received shorter courses of treatment or lower doses for either the R-CHOP or GMALL regimens.
The investigators concluded that “treatment outcomes compare favourably with those patients with NHL (non-Hodgkin lymphoma) and no HIV infection.”
Outcome of HIV-infected patients with AIDS-related lymphomas has improved during recent years. However, data on incidence, risk factors, and outcome of relapses in AIDS-related lymphomas after achieving complete remission are still limited. This prospective observational multicenter study includes HIV-infected patients with biopsy- or cytology proven malignant lymphomas since 2005. Data on HIV infection and lymphoma characteristics, treatment and outcome were recorded. For this analysis, AIDS-related lymphomas patients in complete remission were analyzed in terms of their relapse-free survival and potential risk factors for relapses. In total, 254 of 399 (63.7%) patients with AIDS-related lymphomas reached a complete remission with their first-line chemotherapy. After a median follow up of 4.6 years, five-year overall survival of the 254 patients was 87.8% (standard error 3.1%). A relapse had occurred in 29 patients (11.4%). Several factors were independently associated with a higher relapse rate, including an unclassifiable histology, a stage III or IV according to the Ann Arbor Staging System, no concomitant combined antiretroviral therapy during chemotherapy and R-CHOP-based compared to more intensive chemotherapy regimens in Burkitt lymphomas. In conclusion, complete remission and relapse rates observed in our study are similar to those reported in HIV-negative non-Hodgkin lymphomas. This data provides further evidence for the use of concomitant combined antiretroviral therapy during chemotherapy and a benefit from more intensive chemotherapy regimens in Burkitt lymphomas. The impact of chemotherapy regimen modifications on relapse rate appears to be limited.
Philipp Schommers, Daniel Gillor, Marcus Hentrich, Christoph Wyen, Timo Wolf, Mark Oette, Alexander Zoufaly, Jan-Christian Wasmuth, Johannes R. Bogner, Marcus Müller, Stefan Esser, Alisa Schleicher, Bjöern Jensen, Albrecht Stoehr, Georg Behrens, Alexander Schultze, Jan Siehl, Jan Thoden, Ninon Taylor, Christian Hoffmann