Treatment

All treatment for HIV-related lymphoma should be considered experimental, although treatment for NHL among people who do not have HIV is well established.

The British HIV Association's HIV-associated malignancy guidelines recommend that first-line treatment for NHL should be doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD), the current standard of care for HIV-negative patients.

More intensive regimens have been investigated in non-randomised studies, and BEACOPP is being investigated in a large trial at present. BHIVA does not recommend these intensive regimens at present due to the high rates of serious toxicity seen in the small studies so far reported. In one study of Stanford V, another intensive regimen, despite administration of GSCF during half of all chemotherapy cycles, three-quarters of patients developed grade 3-4 neutropenia and six developed serious infections as a result.1

People with CD4 cell counts above 200 cells/mm3 are best able to tolerate aggressive treatment. Reduced dose regimens may be better for people with CD4 cell counts below 100 cells/mm3. Chemotherapy is usually given periodically, such as once every two weeks for six months, and anti-anxiety and anti-nausea medicines should also be offered.

The usual treatment for NHL which is concentrated in the brain (primary CNS lymphoma) is radiotherapy of the whole brain. This is usually accompanied by a short-term course of steroids such as dexamethasone (Decadron) to shrink oedema (swelling due to the accumulation of fluid) and the tumour. Whole-brain radiotherapy seems to result in improvement in symptoms in about three-quarters of recipients. There is no evidence that more aggressive treatments such as chemotherapy are more effective.

If first-line treatment fails BHIVA recommends salvage chemotherapy with GMCSF to protect bone marrow production of white blood cells. There is very limited evidence regarding the use of salvage chemotherapy in HIV-positive people, but case series reported so far suggest that if an individual still has antiretroviral options to control HIV, high-dose chemotherapy can achieve remission.

Rituximab is a treatment which kills both normal and cancerous B-cells. The body can replace normal B-cells after several months. Rituximab is an approved treatment in the United Kingdom and the United States for NHL which is resistant to other chemotherapies. The addition of rituximab to a CDE regimen in 41 HIV-infected people who were also taking HAART produced an 76% complete remission rate.2 Rituximab has also been added to CHOP, with 40 of 50 patients having complete remission at the end of six cycles of treatment. However, over 18 months of follow-up, 17 patients died of lymphoma-related causes.3

References

  1. Ratner L et al. Chemotherapy for human immunodeficiency virus-associated non-Hodgkin's lymphoma in combination with highly active antiretroviral therapy. J Clin Oncol 19: 2171–2178, 2001
  2. Tirelli U et al. Rituximab and infusional cyclophosphamide, doxorubicin, and etoposide: A safe and highly active regimen in HIV-related non-Hodgkin's lymphomas. Tenth Conference on Retroviruses and Opportunistic Infections, Boston, abstract 804, 2003
  3. Boue F et al. CHOP chemotherapy plus rituximab in HIV patients with high-grade lymphoma-results of an ANRS trial. Tenth Conference on Retroviruses and Opportunistic Infections, Boston, abstract 805P, 2003
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