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1248 Part IX: Lymphocytes and Plasma Cells Chapter 81: Hematologic Manifestations of Acquired Immunodeficiency Syndrome 1249

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TABLE 81–7. Characteristics of Hodgkin Lymphoma in HIV– patients. This is corroborated by the SEER Study in which the
5-year risk of death from Hodgkin lymphoma was 6.2 percent in the
HIV+ and HIV– Populations
HIV+ patients and 9 percent in the HIV– patients. However, this inter-
HIV+ HIV– pretation is confounded by competing risks of death: the overall risk of
Number of individuals 848 21,507 death was higher in the HIV+ cohort, and the majority of the deaths
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were from HIV. Many but not all studies conclude that the Inter-
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Percent (%) men 86.2 53.7 national Prognostic Score has predictive value for HIV+ patients with
HISTOLOGY Hodgkin lymphoma.
Lymphocyte rich 1.9% 3.2%
Nodular lymphocyte 0.9% 4.4%
predominant Stem Cell Transplant
There is more than a decade of experience in high-dose therapy fol-
Nodular sclerosis 30.7% 59.6% lowed by autologous blood stem cell transplantation showing that this
Mixed cellularity 25.0% 12.2% technique is feasible, safe, and effective in patients with HIV and NHL
Lymphocyte depleted 3.7% 1.3% or Hodgkin lymphoma. 186,187 Adequate numbers of blood stem cells can
Classical Hodgkin 37.9% 19.3% be mobilized in the majority of patients with HIV-associated NHL or
lymphoma NOS Hodgkin lymphoma. A retrospective study of 155 patients with either
ANN ARBOR STAGE NHL or Hodgkin lymphoma in the ART era showed that mobilization
6
of greater than 2 × 10 CD34+ cells/kg was achieved in 73 percent of
I 14.3% 18.4% patients and greater than 5 × 10 CD34+ cells/kg was achieved in 48
6
II 17.6% 39.5% percent. Factors reducing the chance of optimal mobilization included a
III 22.4% 19.1% low platelet count, a low CD4 count, and use of filgrastim alone, rather
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IV 41.5% 17.0% than chemotherapy plus filgrastim, to mobilize blood stem cells.
Studies of autologous blood stem cell transplantation in HIV+
unknown 4.3% 6.0% patients with NHL (mainly diffuse large B-cell lymphoma) or Hodgkin
B SYMPTOMS lymphoma show that outcomes are similar to those reported for patients
Present 57.4% 34.2% without HIV infection. 189,190 The median time to neutrophil and platelet
Absent 28.9% 43.9% engraftment is 11 and 14 days, respectively. The risk for nonrelapse mor-
tality is in the 5 to 8 percent range and the overall survival at 3 to 4 years
Unknown 13.7% 21.9% after transplantation is approximately 50 percent. 191–193 These patients
Adapted with permission from Shiels MS, Koritzinsky EH, Clarke CA, were supported throughout the transplantation with ART, as well as
et al: Prevalence of HIV Infection among U.S. Hodgkin lymphoma with antibacterial, antifungal, and antiviral prophylaxis. The European
cases. Cancer Epidemiol Biomarkers Prev 23(2):274–281, 2014. group for Blood and Marrow Transplant performed a case-control study
that included 53 HIV+ patients with either NHL (two-thirds of patients)
or Hodgkin lymphoma (one-third of patients) that matched patients on
the basis of histology, Ann Arbor stage, International Prognostic Index
ABVD plus 30 Gy of involved field radiation therapy, while patients and disease status. The overall survival, progression-free survival, and
with early stage unfavorable Hodgkin lymphoma received four cycles relapse rates were similar in the HIV+ and the HIV– groups across all
of bleomycin, etoposide, Adriamycin, cyclophosphamide, vincristine, histologies and disease states. Nonrelapse mortality at 1 year was 8 per-
procarbazine, and prednisone (BEACOPP) baseline or four cycles of cent in the HIV+ group and 2 percent in the HIV– group; the differ-
ABVD plus 30 Gy of involved field radiation therapy. More advanced- ence mainly was a result of early bacterial infections. Overall survival
stage Hodgkin lymphoma patients received six to eight cycles of BEA- at 30 months was 59 percent for both HIV+ and HIV– patients with
COPP. Patients with advanced HIV infection (defined as two of the NHL, and the main cause of death in both HIV+ and HIV– patients
following: CD4 count <50 cells/μL, prior AIDS-defining opportunistic was relapse. A single-institution matched case-control study of HIV+
infection, performance status >2) were treated with six to eight cycles of and HIV– NHL patients showed nonrelapse mortality of 11 percent in
ABVD. ART was used with chemotherapy. CD4 count decreased with the HIV+ group, and 4 percent in the HIV– group. Overall survival at 2
chemotherapy, but recovered over the subsequent 6 to 9 months and years was 75 percent for both the HIV+ and HIV– groups. Thus, HIV
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treatment-related mortality was 5.6 percent, mainly from sepsis. Using status did not affect the outcome of autologous transplantation for NHL
this risk-adapted approach, the 2-year overall survival was 90.7 percent, although there were more viral opportunistic infections, particularly
comparable to HIV– patients with Hodgkin lymphoma. cytomegalovirus (CMV), adenovirus, and varicella in the HIV+ pop-
Areas of controversy in treatment of Hodgkin lymphoma in HIV– ulation. The main cause of death was relapse and the major predictor
patients include whether BEACOPP escalated is better than ABVD of outcome in both groups was disease status at time of transplanta-
for advanced Hodgkin lymphoma. 182–184 Until this controversy is set- tion. Together these data suggest that long-term outcomes are similar
tled, most authorities recommend using ABVD for patients with HIV- in the HIV+ and HIV– patients who undergo autologous blood stem
associated Hodgkin lymphoma. Brentuximab vedotin, an antibody– cell transplant in the setting of NHL or Hodgkin lymphoma and the
drug conjugate that targets CD30, has been combined with Adriamycin, reconstitution of neutrophils and platelets are similar in both groups.
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vinblastine, and dacarbazine (AVD) to treat HIV- patients with Hodg- Experience with allogeneic stem cell transplantation HIV+ patients is
kin lymphoma. Whether brentuximab vedotin plus AVD will be effec- less extensive. 195–197 This remains an area of intensive research, in part
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tive for HIV+ patients with Hodgkin lymphoma is being addressed in a because of the report of cure of HIV in a patient who underwent allo-
prospective phase II clinical trial being done by the AMC (AMC 085). geneic transplant to treat acute myeloid leukemia and received a donor
In the ART era, HIV+ patients with Hodgkin lymphoma graft that was homozygous for a deletion mutation eliminating the
have similar excellent outcomes with systemic chemotherapy as do chemokine and HIV coreceptor CCR5. 109

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