Treating Hodgkin Lymphoma in HIV Positive Patients: a Comparative Analysis with the HIV Negative Population.

HIV-associated Hodgkin Lymphoma (HIV-HL) has peculiar clinicopathologic features and less favourable outcome compared to HL of the HIV negative (neg) population. After the advent of HAART, HIV positive (pos) people seem to be at increased risk of HL than in first years of the epidemic; however, HIV-HL prognosis is expected to improve due to immunepreservation with HAART.

To evaluate the chance of cure of HIV pos patients (pts) with HL, in comparison with the HIV neg population.

We evaluated the proportion of pts who received treatment with curative intent and analysed the outcome in an intention to treat basis, in our series of consecutive HIV pos and neg pts with HL. Pts were excluded from curative treatment because of poor Performance Status (PS), major infections or severe comorbidities. Since 1997 all HIV pos pts received HAART during chemotherapy and thereafter.

Since 1985 to Dec 1996 (pre-HAART period) we diagnosed 11 HIV-HL and from 1997 to Dec 2008 (HAART period) 29 HIV-HL. Median age was 39.5 ys (23-63). In the pre-HAART period we could treat with curative intent 7/11 pts (64%) with a complete remission (CR) rate of 43% and a median overall survival (OS) and progression free survival (PFS) of treated pts respectively 14 and 9 ms and 5y-OS and 5y-PFS both 28.5%. During the HAART period the proportion of treated pts was similar with 21/29 pts (72%) treated, the CR rate increased to 62% (versus 43% pre-HAART, P=NS) and the median OS and PFS of treated pts to 31 ms both (vs 14 and 9 ms pre-HAART, P=NS), with 5y-OS 35.4% and 5y-PFS 36%. According to the intention to treat, the OS of all pts was 6 ms pre-HAART (5y-OS 18.1%), and 16 ms in the HAART period (5y-OS 25.6%), with a follow-up of 37.5 ms (7-119). Median CD4 count at diagnosis was higher in the HAART period (213/cmm, range 15-648, vs 119/cmm, range 38-245, P=0.05), while no other significant differencies were seen in pts'characteristics between the two periods. During the HAART period 65% of pts were on HAART at lymphoma diagnosis; this proportion increased throughout the HAART era, from 57% between 1997-2002 to 73% between 2003-2008. The clinical features of HIV-HL showed a trend towards less aggressive disease from 1997-2002 to 2003-2008 (extranodal disease 64% and B symptoms 85% between 1997-2002 vs 42% and 53% between 2003-2008) and less drug abusers (71% vs 33%) and pts with previous AIDS-defining conditions (38% vs 22%). However, the proportion of pts we could treat remained low, 79% (1997-2002) and 67% (2003-2008). Between 1997-2002 most pts received Stanford V, while between 2003-2008 all pts received VEBEP. No pts died because of treatment toxicity. CR rate increased from 55% (1997-2002) to 70% (2003-2008) (P=NS) and the 3y-OS and 3y-PFS of treated pts from respectively 36.3% (median 20 ms) and 18.1% (median 7 ms) between 1997-2002 to 63.4% (P=NS) and 68.5% (P=0.05) between 2003-2008. The overall probability for survival, according to the intention to treat, did not significantly increased with 3y-OS 28.5% (median 9 ms) between 1997-2002 versus 42.3% (median 18 ms) between 2003-2008. The HIV-HL outcome, even in the recent years (2003-2008), remains unsatisfactory compared with a concomitant series of HIV neg pts. From Jan 2003 to Dec 2008 we diagnosed 144 HL in HIV neg subjects with less than 66 ys. All pts (100%) received therapy with curative intent, mostly ABVD, compared with 67% of HIV pos pts during the same period of time (P< 0.001). The CR rate was 90%, higher than in the concomitant series of HIV pos pts (70%) (P=0.05), as well as the probability of OS and PFS for pts receiving treatment (3y-OS 96.1% in HIV neg vs 63.5% in HIV pos pts, P<0.001, and 3y-PFS 79.7% in HIV neg vs 68.5% in HIV pos, P=NS). Relapse rate was 12% (15/126 pts) in the HIV neg pts, compared to 23% (3/13 pts) in the HIV pos group (P=NS). According to the intention to treat, the OS for all pts was strongly higher in the HIV neg group, with 3y-OS 96.1% compared to 42.3% in HIV pos pts (P<0.001).

Though the outcome of HIV-HL has improved throughout the HAART era, in our single-Institution experience it remains significantly worse compared to the HIV neg population (lower CR and survival rates). Still a high proportion of pts cannot receive adequate treatment due to poor PS or comorbidities. Better control of HIV infection is advisable and specific treatment programs derived from the experience in the HIV negative setting seem warranted.

No relevant conflicts of interest to declare.