Rituximab as single agent reversed paediatric Non-Hodgkins Lymphoma (NHL)
Simon Collins, HIV i-Base
Several adult studies have suggested that use of the monoclonal antibody rituximab, in addition to chemotherapy, may provide additional benefit in treatment of CD20+ Non-Hodgkins Lymphoma (NHL), although this is also associated with increased toxicity. [1, 2]
A research letter to the 26 September issue of AIDS reported a case of remission of HIV-associated paediatric NHL following treatment with rituximab alone. 
The 14-year-old congenitally infected girl was highly treatment-experienced having initiated monotherapy shortly after birth and HAART in 1996, with 16 treatment changes due to virological and clinical failure and extensive resistance. Despite combined prophylaxis the patient had HIV-related complications including systemic CMV, cryptosporidiosis, pneumocystosis and candidiasis. CD4 count was 77 cells/mm3 and viral load was 390 copies/mL.
Ultrasonography and CET scan disclosed massive involvement of multiple site visceral nodes with maximum size of 22-30mm and a highly malignant follicular NHL already at stage III-2 was diagnosed by biopsy. A cycle of chemotherapy with MACOP-B regimen only produced a very limited response.
A salvage treatment of four administrations of 375mg/m2/week of rituximab plus antihistaminic premedication was prescribed. A significant reduction in neoplastic bulk was noted after the first four-dose cycle. PET scans four months later showed suspected residual mediastinal disease and prompted a second month’s course of rituximab and lead to a negative PET scan at 10-months post diagnosis with complete disappearance of pathological superficial and visceral lymph nodes.
A further change in HAART (to ddI, d4T, LPV/r) led to a significant increase in CD4 count to 380 cells/mm3 and reduction in viral load to 9,800 copies/mL. The authors report that the patient has since been able to completely resume daily activities including returning to school.
Rituximab is now used in a pediatric population, if a tumor is CD20 positive. The normal dose is 375 mg/m2 once weekly x four weeks), and combined with CHOP, seems to work well and is well tolerated.
This practice has come from copying adult treatment. The child should be reported with IVIG every other week for at least six months, since the mature B cells will get eliminated with this therapy.
HIV-associated NHL in children is rare it has not disappeared completely even with the introduction of HAART.
- Boue F, Gabarre J, Costagliola D et al. CHOP Chemotherapy plus rituximab in HIV patients with high-grade lymphoma-results of an ANRS trial. 10th Conference of Retrovirus and Opportunistic Infections, Feb 2003. Abstract 805.
- Tirelli U, Spina M, Bernardi D et al. Rituximab and infusional cyclophosphamide, doxorubicin, and etoposide: a safe and highly active regimen in HIV-related Non-Hodgkin’s Lymphoma. 10th Conference of Retrovirus and Opportunistic Infections, Feb 2003. Abstract 804.
- Manfredi R, Tadolini M, Fortunato L et al. Rituximab alone proves effective in the treatment of refractory, severe stage III AIDS-related non-Hodgkin’s paediatric lymphoma. AIDS 2003; 17(14):2146-2148