Alexandra M. Levine MD
What’s new in this update?
— Updated data on the impact of HAART on the incidence and outcomes of AIDS-related lymphoma — Additional information on risk factors for AIDS-related lymphoma — New data on potential utility of positron emission tomography in diagnosis — Updated findings of studies of infusional CDE, infusional EPOCH, liposomal daunorubicin, and ESHAP —New subsection on therapy for primary CNS lymphoma — New case history
Lymphoma is a late manifestation of HIV disease, occurring after years of HIV-induced B lymphoid stimulation and proliferation. All risk groups for HIV appear to be at approximately equal risk for the development of lymphoma. The first symptoms of AIDS-related lymphoma may include the development of systemic “B” symptoms: unexplained fever, drenching night sweats, and/or weight loss in excess of 10% of normal body weight. In the presence of such symptoms, careful work-up for an infectious aetiology should be sought, since Mycobacterium avium complex or other opportunistic infections also can present in a similar fashion. Aside from these symptoms, almost any particular symptom may occur, depending upon where the lymphoma is located. Thus, lymphadenopathy is quite common and is usually asymmetric. With involvement of the gastrointestinal tract, abdominal pain, nausea, vomiting, or a change in bowel habits can occur. Involvement of the spleen may be associated with early satiety or abdominal discomfort. Hepatic involvement may cause nausea or abdominal pain or discomfort. The brain can be a tumour site, presenting either as isolated disease in the CNS (primary CNS lymphoma) or as leptomeningeal involvement in the setting of lymphomatous disease elsewhere in the body. Symptoms of leptomeningeal lymphoma include cranial neuropathy or chin numbness. Approximately 20% of patients with known leptomeningeal lymphoma are asymptomatic. The vast majority of patients will be found to have widespread visceral involvement upon staging evaluation.
Factors associated with poor prognosis in AIDS-related lymphoma include criteria related to the HIV, to the host, and to the tumour itself. Poor prognostic indicators of disease are a CD4+ count less than 100 cells/mm3, a history of AIDS prior to the lymphoma, age greater than 35 years, a history of injection drug use, elevated serum lactic dehydrogenase (LDH), and advanced-stage (III or IV vs I or II) disease.
Use of a low-dose regimen of m-BACOD combination chemotherapy has been associated with complete remission rates of 46%, with the majority of patients never experiencing relapse. While standard-dose chemotherapy may be associated with similar rates of complete remission, toxicity has been significantly greater, and median survival time has not increased. Newly described infusional regimens, such as EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin), appear very promising.
Use of antiretroviral agents, coupled with multiagent chemotherapy, has been shown to be safe, with the exception of zidovudine, which is associated with significant marrow compromise. The use of combination chemotherapy (CHOP) with highly active antiretroviral therapy (HAART) results in no major changes in the pharmacokinetic profile of either chemotherapy or the protease inhibitor, and no excessive or unexpected toxicity. Use of HAART with infusional chemotherapy such as the CDE regimen (cyclophosphamide, doxorubicin, etoposide) is associated with significant — and unexpected — mucositis.
Medscape Clinical Management Series, 2000. (c) 2000 Medscape, Inc