AIDS-related Diffuse Large B-cell Lymphoma Research Articles

A Prognostic Nomogram Survival Model for Newly Diagnosed Patients with AIDS-Related Diffuse Large B-Cell Lymphoma: A Multicenter Cohort Study in China

BACKGROUND The prognosis of patients with AIDS-related diffuse large B-cell lymphoma(AR-DLBCL) becomes very poor when the lymphoma relapses or is refractory to first line immunochemotherapy. We aimed to develop a novel ARDPI nomogram prognostic model for risk stratification so as to guide individualized treatment to achieve sustained remission and improve the overall prognosis for newly-diagnosed AR-DLBCL patients. METHODS We interrogated data from 306 patients with newly-diagnosed AR-DLBCL. We filtered variables using LASSO regression and Cox regression to identify prognostic co-variates and develop a survival model, we termed AR-DLBCL Prognostic Index (ARDPI). We evaluated model discrimination, calibration and clinical benefit by Area Under the Receiver-Operator Characteristic (AUROC), calibration plots and decision curve analysis (DCA). Next, we compared the ARDPI model discrimination, calibration and clinical benefit with the IPI and NCCN-IPI models using the same methods. Lastly, we stratified patients into three survival risk cohorts based on ARDPI model by X-tile selecting cutoff point. RESULTS 7 co-variates were independently correlated with survival and were used to develop the ARDPI model including age, lymphocyte monocyte ratio (LMR), CD5 expression on lymphoma cells, blood EBV-DNA copy number, CD4/CD8 ratio, central nervous system (CNS) involvement and anti-HIV therapy (ART). AUROCs of ARDPI model for 1-, 3-, and 5-year were 0.80 (95% Confidence Interval [CI], 0.72, 0.88), 0.78 (0.69, 0.87) and 0.77 (0.63, 0.91). Predicted and calibrated values were concordant. The DCA curve had higher net benefit using the ARDPI model. Prediction accuracy of the ARDPI model was better compared with the IPI and NCCN-IPI models. For example, 3-year survival AUROC in the ARDPI model was 0.78 (0.69, 0.87) compared with the IPI (0.53 [0.43, 0.63] P< 0.001) and the NCCN-IPI (0.52 [0.42, 0.62] P< 0.001). Using the ARDPI model, we identified 3 survival risk cohorts with 3-year survivals of 0.80 , 0.38 and 0.09 ( P<0.001). CONCLUSION The ARDPI has good survival prediction accuracy in newly-diagnosed persons with AIDS-related DLBCL and using it has clinical benefit.Accuracy is better than the IPI and NCCN-IPI models. Validation of our conclusions is needed.

Frequency, Histologic, and Prognostic Significance of CD30 Expression in AIDS-associated Diffuse Large B-Cell Lymphoma

Introduction: AIDS-related Diffuse large B-cell lymphoma (DLBCL) is a heterogeneous disease, with a variable response to chemotherapy depending on, and not limited to, cell of origin, double/triple hit, or MYC/BCL-2 co-expression status. Similar to DLBCL, AIDS-related DLBCL (ARL) with non-germinal center histology or MYC expression reports poorer response to treatment. In the immunocompetent population CD30+ DLBCL defines a histology with improved survival, however, the characteristics and outcomes of ARL expressing CD30 are not well studied.Methods: We assessed 3 cohorts of ARL. The first cohort, consisted of of an immunohistochemistry tissue microarray (TMA) of 30 ARL patients, followed by two validation cohorts. The first validation was a TMA of 80 ARL, from the AIDS Cancer Specimen Resource. Both TMAs were stained for CD10, BCL6, MUM1, CD20, Ki67, EBER, MYC (by IHC) cut off at 40%, BCL2 (by IHC) cut off 50%, and CD30 (considered positive if any CD30 was expressed on the malignant cells). The third validation cohort was from the County Hospital AIDS Malignancy Project (CHAMP), a prospective database of patients with hematological malignancies and HIV. Of the 100 cases with ARL, only 25 cases were found to have CD30 staining performed, thus only those cases were included. In total, 135 patients diagnosed with ARL were assessed. Cell of origin and germinal (GCB) vs. non-germinal center (NGC) was determined by the Hans algorithm. Statistical differences between groups were analyzed by the fisher exact test. Survival data, when available, was estimated using the Kaplan-Meier method and compared using the log-rank test.Results: Of the 135 ARL, 30% (n=41) were CD30+. Ninety-one% of the cohort was male. EBER was 23% positive in the entire cohort (n=29/126). EBER was positive in the CD30+ vs. CD30- population, 59% (N=17) vs 26% (p<0.01). Despite 59% of the CD30+ population being EBER positive, 92% of the population had a NGC phenotype, 2% was germinal, and 5% had a null phenotype (p<0.01). Of the 86 patients that were CD30-, 88% were GC vs. 12% NGC (P<0.01). The CD4+ T-cell count at presentation was higher in the CD30- cohort with a mean CD4+ T-cell count of 234 vs.164 cells/ul (p<0.05), similar to historical studies demonstrating a similar effect in germinal vs. non-germinal center ARL. Ki67 > 80% was also higher in the CD30- vs the CD30+ cohort 75 vs.60%, (p=0.052). Myc, BCL2, and double expressor lymphomas were identified 59 vs. 57%, 59 vs. 57%, and 31 vs. 28%, respectively, in the CD30+ ARL vs. the CD30- population, none were statistically significant. Survival data was only obtained for 56 of the patients. In the patients treated in the combined anti-retroviral era (ART), there was no difference in survival in the CD30+ vs. CD30- population, 74% (n=18) vs. 84% (n=12) at 5 years (p=0.8). In the 15 patients treated in the early ART era, the OS at 5 years was 48% for the CD30+ vs. 52% (p=0.4), the rest were treated in the pre-ART era.Conclusion: CD30+ ARL in this cohort represents 30% of all ARL evaluated, and presents almost exclusively as a non-germinal center phenotype and has a strong correlation with EBV. While no differences in survival were identified in this study, possible due to the small numbers of patients assessed with survival data, historically, NGC ARL have been shown to have poorer outcomes, by 20-30% in studies with da-EPOCH. As such, the need for better therapies, potentially to overcome these poor prognostic factors, should be studied further. [Display omitted] DisclosuresReid: ADC Therapeutics: Other: Serves as Principle Investigator, Research Funding; Aptose Biosciences: Other: Serves as Principle Investigator, Research Funding; Millennium Pharmaceuticals: Other: Serves as Principle Investigator, Research Funding; Xencor: Other: Serves as Principle Investigator.

Prevalence and outcomes of sepsis in HIV versus non-HIV patients with diffuse large B-cell lymphoma: A nationwide analysis.

e19567 Background: With the advent combined anti-retroviral therapy (ART), the survival of people living with HIV has improved, thereby increasing their prevalence, while concurrently decreasing the incidence AIDS defining malignancies. Despite its decrease, AIDS-related Diffuse Large B-Cell Lymphoma (DLBCL) remains the 3rd most common malignancy in the HIV population and an important cause of cancer related morbidity and a leading cause cancer attributed mortality. Currently the treatment modalities between HIV and non-HIV DLBCL are similar, however a comparison of the infectious complications has never been assessed. We aim to explore the prevalence and outcomes of sepsis in persons living with HIV and DLBCL versus the non-HIV DLBCL patient population. Methods: We identified all adult DLBCL patients admitted between 2016–2018 from The Nationwide Inpatient Sample (NIS) with a primary diagnosis of sepsis. Patients with and without HIV were identified and compared for demographic differences and primary outcomes of inpatient mortality, length of stay (LOS) and hospital charges. Secondary outcomes studied included rates of septic shock, acidosis, Acute Kidney Injury (AKI), Tumor Lysis Syndrome (TLS) pancytopenia, anemia, neutropenia, protein energy malnutrition (PEM) and history of bone-marrow/stem-cell transplant. Statistics were performed using t-Test, chi-square test and multivariable logistic regression. Results: There was a total of 5740 HIV-DLBCL and 158,445 non-HIV-DLBCL inpatient admissions of which 480 (8.4%) and 16085 (10.1%) respectively had sepsis (p &lt; 0.0001). Compared to non-HIV cohort, HIV-DLBCL patients were significantly younger (47.5 versus 67 years, p &lt; 0.001), more likely to be male (66.7% vs 55.3%, p = 0.02), Black (43% vs 7.7%) or Hispanic (18% vs 11%) (p &lt; 0.001), more likely to be on Medicaid (44.9% vs 8.2%, p &lt; 0.001) and lived-in low-income zip-codes (p &lt; 0.0001). Overall adjusted inpatient mortality was not significantly different between HIV and non-HIV groups (14.6% vs 16.9%, p = NS). But HIV-DLBCL patients had significantly high Chalrson co-morbidity index (p &lt; .0001), longer inpatient LOS (8.75 vs 8.65 days, p &lt; 0.0001) and higher total hospital charges (average $5338 higher for each admission, p &lt; 0.0001). HIV-DLBCL cohort also reported significantly higher TLS (7.3% vs 2.6%, p = 0.005) and PEM (42.7% vs 28.9%, p = 0.004). Other secondary outcomes were not significantly different between the groups. Conclusions: Demographic differences between the two cohorts are reflective of known racial &amp; socio-economic disparities associated with HIV. Lower rates of sepsis in HIV cohort were not translated into improved inpatient mortality. Longer LOS and hospitalization charges in HIV patients likely due to high comorbidity burden.

Pretreatment lymphocyte-to-monocyte ratios predict AIDS-related diffuse large B-cell lymphoma overall survival.

The lymphocyte-to-monocyte ratio (LMR) and platelet-to-lymphocyte ratio (PLR) have been reported to be useful for predicting the prognosis of various malignancies, including diffuse large B-cell lymphoma (DLBCL). However, little is known about the role of LMR and PLR in the prognosis of DLBCL patients with human immunodeficiency virus (HIV) infection. We retrospectively evaluated the prognostic value of the LMR and PLR in patients with newly diagnosed AIDS-related diffuse large B-cell lymphoma (AR-DLBCL) who were treated with CHOP-like chemotherapy at a single institution. In 33 AR-DLBCL patients, the median follow-up period was 32 months (range: 7-85 months), with an estimated 2-year overall survival (OS) rate of 79.9%. The univariate analysis confirmed the LMR ≤ 2.74 (p = .015), PLR ≥ 337.7 (p = .019), and moderate anemia (p = .045) were associated with inferior survival. The independent significant association between low LMR and poor OS in the multivariate analysis was identified (HR: 0.033, 95% CI: 0.001-0.853, p = .040). However, PLR (p = .459) and moderate anemia (p = .102) did not retain an independent significance in the multivariate analysis. Moreover, compared with the high-LMR group, patients with low-LMR more frequently had B symptoms (p = .010) and lower CD4+T cell count (p < .001). The pretreatment LMR may be an effective prognostic factor for predicting OS in patients with AR-DLBCL.

The comparison of clinical and imaging characteristics between AIDS-related diffuse large B-cell lymphoma and Burkitt's lymphoma

ObjectiveThis study evaluated the clinical and imaging differences between the two pathological types. MethodsThis study was a multi-center retrospective study comparing clinical and CT imaging information in 92 patients with AR-DLBCL and 41 with AR-BL. The imaging characteristics, involved sites, the progression or death time and prognosis were compared in both groups of patients. ResultsHomogeneous texture was more common seen in AR-DLBCL both in plain scans (P = .004) and contrast enhancement scans (P = .027). The moderate enhancement was more common seen in AR-DLBCL than that in AR-BL (P = .011). Lesions with irregular shape, fusion tendency and extracapsular infiltration were relatively more common detected in AR-BL. Liver, pancreas, spleen and lung were more prone to be involved in AR-BL. There were no significant differences in clinical parameters and progression or death time between the two groups. ConclusionHomogeneous texture and moderate enhancement support AR-DLBCL as heterogeneous and poor enhancement support AR-BL.

MTOR activity in AIDS-related diffuse large B-cell lymphoma.

BackgroundPatients infected with HIV have a significantly increased risk of developing non–Hodgkin lymphomas despite the widespread use of HAART.To investigate mTOR pathway activity in acquired immunodeficiency syndrome (AIDS) related diffuse large B-cell lymphoma AR-DLBCL, we used immunohistochemistry to examine the presence of the phosphorylated 70 ribosomal S6 protein-kinase (p70S6K), an extensively studied effector of mTOR Complex 1 (mTORC1) and the phosphorylated phosphatase and tensin homolog (pPTEN), a negative regulator of mTORC1 pathway.Materials and methodsWe evaluated tissue samples from 126 patients with AR-DLBCL. Among them, 98 samples were from tissue microarrays (TMAs) supplied by the Aids and Cancer Specimen Resource (ACSR), the remaining 28 samples were from cases diagnosed and treated at the University of California, San Diego (UCSD). The presence of p70S6K was evaluated with two antibodies directed against the combined epitopes Ser235/236 and Ser240/244, respectively; and additional monoclonal anti-bodies were used to identify pPTEN and phosphorylated proline-rich Akt substrate of 40kDa (pPRAS40). The degree of intensity and percentage of cells positive for p70S6K and pPTEN were assessed in all the samples. In addition, a subgroup of 28 patients from UCSD was studied to assess the presence of pPRAS40, an insulin-regulated activator of the mTORC1. The expression of each of these markers was correlated with clinical and histopathologic features.ResultsThe majority of the patients evaluated were males (88%); only two cases (1.6%) were older than 65 years of age. We found high levels of both p70S6K-paired epitopes studied, 48% positivity against Ser235/236 (44% in ACSR and 64% in UCSD group), and 86% positivity against Ser240/244 (82% in ACSR and 100% in UCSD group). We observed more positive cells and stronger intensity with epitope Ser240/244 in comparison to Ser235/236 (p<0.0001). The degree of intensity and percentage of cells positive for pPTEN was positively correlated with p70S6K levels (p = 0.016 for 235/236 and p = 0.007 for 240/244). High levels of pPRAS40 were observed in the majority of the cases evaluated (64.3%), but no correlation was found with either pPTEN (p = 0.9) or p70S6K (p = 0.9) levels.ConclusionAR-DLBCL frequently contain p70S6K, a main downstream effector of the mTOR pathway. The presence of p70S6K is positively correlated with pPTEN, an inactive form of PTEN, which makes mTORC1 activated. The presence of p70S6K was independent of HIV viral load or CD4 (+) counts. These results suggest that the mTOR pathway is active in the majority of AR-DLBCL, and p70S6K, particularly the Ser240/244 epitope immunohistochemistry is an excellent surrogate biomarker, which could be used to identify cases expected to be responsive to mTOR inhibitors.

AIDS-Related Vs. Non-AIDS-Related Diffuse Large B-Cell Lymphoma. Analysis of the County Hospital AIDS Malignancy Project (CHAMP)

Introduction: Stroger Hospital of Cook County (CCH) and the Ruth M. Rothstein CORE Center (CC) are the largest health providers for HIV+ patients (pts) in Chicago and among the largest in the United States. Together, CCH and CC treat over 5,500 HIV+ individuals per year and 60 newly diagnosed HIV-associated cancers yearly. In addition, CCH is the largest safety net hospital in Illinois; in the calendar year 2010, it had over 32,000 outpatient hematology/oncology clinic visits. The County Hospital AIDS malignancy project (CHAMP) is a prospective database of all HIV-associated hematological malignancies from 1995 to present. Here we analyzed the demographic, histological, germinal center status, outcome data, and HIV characteristics of pts with AIDS-related diffuse large B-cell lymphoma (AR-DLBCL). As a control, we compared these data to DLBCL pts not infected with HIV, intra-institutionally instead of national historical controls to better understand the AR-DLBCL population of the inner-city, a mostly minority, and one of the largest growing HIV populations.Methods: We screened the CCH cancer registry from 2001 to 2014, and 240 non-HIV pts were identified to have DLBCL. We searched the CHAMP database for cases of DLBCL from the same period. From 196 lymphomas, 51 were identified. Only pts who had a confirmed pathology report as DLBCL were included in this study. We subsequently identified the HIV characteristics, overall survival (OS), and patient demographics for all pts. In addition to OS data in both cohorts, we compared outcomes based on chemotherapy, stage, germinal center (defined by the HANS algorithm), and IPI status.Statistics: Non-parametric Fisher's exact test was used to examine the difference in proportion of pts in both the HIV and non-HIV arm. Survival data were analyzed using Kaplan-Meier analysis and Cox Proportional Hazards model.Results: The M:F ratio was 7.5:1 in AR-DLBCL and 1.9:1 in the non-HIV cohort (P<0.001). The median CD4+ count for the HIV population was 107 cells/mm3. Patients with germinal center DLBCL had a median CD4+ count of 196 cells/mm3 vs. non-germinal of 87 cells/mm3. The racial composition of the 2 cohorts showed a significantly higher percentage of African-Americans (AA) in the HIV cohort, 51% vs. 35% in the non-HIV, (p<0.04) and no difference in Caucasian or Hispanic populations. The AR-DLBCL population was younger. Only 4% of the HIV pts were 60 years and older compared to 32% in the non-HIV cohort. The HIV positive pts tended to present with more advanced disease. Seventy two % vs. 53% in the non-HIV cohort presented with stage III/IV disease (p <0.01). Only 18% vs. 38% in the non-HIV cohort presented with stage I/II disease (p <0.006). Of pts tested, there were no differences in GC (68 (n=15) vs. 66% (n=77) or NGC (32 (n=7) vs. 34% (n=39)) between HIV and non-HIV cohorts. The OS of the AR-DLBCL at 5 years was 54% vs. 77% in the non-HIV cohort (p<0.003). However, since 2009, pts with AR-DLBCL have been treated with daEPOCHR (Sparano et al, Blood 2010) at CCH, and since then no difference in OS compared to the non-HIV cohort has been identified. At 5 year follow up, the OS of AR-DLBCL was 81% treated with daEPOCHR (n=11) vs. 77% (n=108) in the non-HIV population (p 0.081). Comparing survival between each cohort by stage there was a trend to poorer outcomes in the AR-DLBCL for stage III/IV disease, 58% vs. 75% 5-year survival (p 0.064). Similarly, there was little difference in comparing each cohort by IPI score due to the small number of pts in each IPI category in the HIV cohort.Conclusions: In assessing the cases of AR-DLBCL, it appears to be a disease of AA (51% vs. 35%) men (88% vs. 53%) compared to the non-HIV population at the same institution. But when compared to the general population of Chicago, where AA constitute only 33% of the population, the disparity is more pronounced. Patients are also younger, 4% vs. 32% over 60 years of age. In addition, the AR-DLBCL pts present with more advanced disease (72% vs. 53%). As a whole, the AR-DLBCL cohort had a poorer OS survival than the non-HIV population, at 5 years, 54% vs. 77%. Importantly, pts with AR-DLBCL had the same OS as the non-HIV cohort, 81% vs. 77%, with a 5 year follow up when treated with daEPOCHR despite HIV pts presenting with a higher stage. Thus, education and screening in the AA community is needed, as this is an AA male disease in the inner city. It is also clear that treatment with daEPOCHR should be the therapy of choice when treating AR-DLBCL. DisclosuresNo relevant conflicts of interest to declare.

Changes in the influence of lymphoma- and HIV-specific factors on outcomes in AIDS-related non-Hodgkin lymphoma

We undertook the present analysis to examine the shifting influence of prognostic factors in HIV-positive patients diagnosed with aggressive non-Hodgkin lymphoma (NHL) over the last two decades. We carried out a pooled analysis from an existing database of patients with AIDS-related lymphoma. Individual patient data had been obtained prior from prospective phase II or III clinical trials carried out between 1990 until 2010 in North America and Europe that studied chemo(immuno)therapy in HIV-positive patients diagnosed with AIDS-related lymphomas. Studies had been identified by a systematic review. We analyzed patient-level data for 1546 patients with AIDS-related lymphomas using logistic regression and Cox proportional hazard models to identify the association of patient-, lymphoma-, and HIV-specific variables with the outcomes complete response (CR), progression-free survival, and overall survival (OS) in different eras: pre-cART (1989-1995), early cART (1996-2000), recent cART (2001-2004), and contemporary cART era (2005-2010). Outcomes for patients with AIDS-related diffuse large B-cell lymphoma and Burkitt lymphoma improved significantly over time, irrespective of baseline CD4 count or age-adjusted International Prognostic Index (IPI) risk category. Two-year OS was best in the contemporary era: 67% and 75% compared with 24% and 37% in the pre-cART era (P < 0.001). While the age-adjusted IPI was a significant predictor of outcome in all time periods, the influence of other factors waxed and waned. Individual HIV-related factors such as low CD4 counts (<50/mm(3)) and prior history of AIDS were no longer associated with poor outcomes in the contemporary era. Our results demonstrate a significant improvement of CR rate and survival for all patients with AIDS-related lymphomas. Effective HIV-directed therapies reduce the impact of HIV-related prognostic factors on outcomes and allow curative antilymphoma therapy for the majority of patients with aggressive NHL.

The Role of the Tumor Microenvironment in HIV-Associated Lymphomas

There has been considerable interest in the role of the lymphoma microenvironment. Despite the use of highly active antiretroviral therapy (HAART), AIDS-related diffuse large-B-cell lymphoma remains common and HIV-relatedHIV-associated classical Hodgkin's lymphoma is increasing in incidence. Less is known about the impact HIV and HAART have on the lymphoma microenvironment. AIDS-related diffuse large B-cell lymphoma is highly angiogenic, demonstrates increased lymphoblastic histology, proliferation, increased activated cytotoxic T cells, reduced CD4(+) and FOXP3(+) T cells, but no differences in tumor-associated macrophages. Early initiation of HAART improves immunosurveillance, but cases without viral antigens appear able to avoid immunologic reaction. Increased T cell infiltrates seen with HAART treatment in HIV-related classical Hodgkin's lymphoma may contribute to malignant cell growth.

Treatment Outcomes in AIDS-Related Diffuse Large B-cell Lymphoma in the Setting Roll Out of Combination Antiretroviral Therapy in South Africa

Long-term survival for patients with AIDS-related diffuse large B-cell lymphoma (DLBCL) is feasible in settings with available combination antiretroviral therapy (cART). However, given limited oncology resources, outcomes for AIDS-associated DLBCL in South Africa are unknown. We performed a retrospective analysis of survival in patients with newly diagnosed AIDS-related DLBCL treated at a tertiary teaching hospital in Cape Town, South Africa, with cyclophosphamide, doxorubicin, vincristine, and oral prednisone (CHOP) or CHOP-like chemotherapy (January 2004 until December 2010). HIV-related and lymphoma-related prognostic factors were evaluated. Thirty-six patients evaluated; median age 37.3 years, 52.8% men, and 61.1% black South Africans. Median CD4 count 184 cells per microliter (in 27.8% this was <100 cells/μL), 80% high risk according to the age-adjusted International Prognostic Index. Concurrent Mycobacterium tuberculosis in 25%. Two-year overall survival (OS) was 40.5% (median OS 10.5 months, 95% confidence interval: 6.5 to 31.8). Eastern Cooperative Oncology Group performance status of 2 or more (25.4% vs 50.0%, P = 0.01) and poor response to cART (18.0% vs 53.9%, P = 0.03) predicted inferior 2-year OS. No difference in 2-year OS was demonstrated in patients coinfected with M. tuberculosis (P = 0.87). Two-year OS for patients with AIDS-related DLBCL treated with CHOP like regimens and cART is comparable to that seen in the United States and Europe. Important factors effecting OS in AIDS-related DLBCL in South Africa include performance status at presentation and response to cART. Patients with comorbid M. tuberculosis or hepatitis B seropositivity seem to tolerate CHOP in our setting. Additional improvements in outcomes are likely possible.

The microenvironment of AIDS-related diffuse large B-cell lymphoma provides insight into the pathophysiology and indicates possible therapeutic strategies

AbstractDespite the use of highly active antiretroviral therapy (HAART), AIDS-related lymphoma remains common. We investigated the tumor, microenvironment, and viral components in 41 AIDS-related diffuse large B-cell lymphomas (AR-DLBCLs) in the pre- and post-HAART era. The outcome has improved and the frequency of the prognostically unfavorable immunoblastic histology has decreased after HAART. Compared with sporadic cases, AR-DLBCL demonstrated increased hyperproliferation (P < .001) and c-Myc rearrangements, reduced CD4+ (P < .001) and FOXP3+ T cells (P < .001), increased activated cytotoxic cells (P < .001), but no difference in tumor-associated macrophages. Our analysis showed that AR-DLBCL is highly angiogenic with higher blood-vessel density than sporadic cases (P < .001) and highlighted the role of Epstein-Barr virus in angiogenesis. We recognized viral profiles and as a second step examined the reactive cytotoxic cell infiltrates. Our observation of markedly higher numbers of cytotoxic cells in AR-DLBCL with LMP1 and/or p24 compared with cases lacking viral antigens (P < .001) has important clinical implications, implicitly linked to the immunosurveillance theory. Whereas early initiation of HAART should improve immunosurveillance and reduce the incidence of LMP1-positive AR-DLBCL, cases without viral antigens appear able to avoid immunologic reaction and likely require additional strategies to improve surveillance.

Role of Molecular Subtype in Predicting Outcome of AIDS-Related Diffuse Large B-Cell Lymphoma

TO THE EDITOR: We read with interest the study by Chadburn et al that examined the prognostic significance of molecular subtype in AIDS-related diffuse large B-cell lymphoma (DLBCL). Herein, the authors obtained DLBCL biopsies from two AIDS Malignancy Consortium studies and examined multiple immunohistochemical (IHC) markers to identify tumors derived from germinal center B cells (GCB) or postgerminal center B cells and correlated these with outcome. In contrast to what has been demonstrated in HIV-negative DLBCL, the authors concluded that molecular subclassification by IHC may not be clinically relevant in HIV-associated DLBCL. The role of molecular subtype in predicting outcome in HIVnegative DLBCL is now well established across many independent studies, both in the preand postrituximab era, and by IHC and gene expression profiling. In this regard, the authors’ findings are surprising and also contrary to our own prospective findings in HIVassociated DLBCL, where IHC analysis of DLBCL subtype predicts both lymphoma-specific and overall survival. Furthermore, we are unaware of a biologic basis to suggest that the tumor histogenesis of HIV-associated DLBCL is fundamentally different from HIVnegative DLBCL. Indeed, studies show that immune deficiency and stimulation as well as Epstein-Barr virus activation are risk factors in both HIV-positive and -negative patients with DLBCL. In our opinion, the negative results of the Chadburn et al study may be related in part to its retrospective analysis of samples from two different studies that have incorporated four different treatments (cyclophosphamide, doxorubicin, vincristine, and prednisone [CHOP]; rituximab [R] plus CHOP; dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin [DA-EPOCH] with sequential rituximab; and DA-EPOCH with concurrent rituximab). The follow-up time is also relatively short and highly variable among the various treatment groups. Understanding the role of tumor biology in HIV-associated lymphoma is a prerequisite for identifying and targeting novel and specific pathways to improve the outcome of these biologically diverse subtypes of DLBCL. In HIV-negative DLBCL, for example, the activated B-cell (ABC) subtype (which constitutes most cases identified as nonGCB by IHC) has been associated with an inferior prognosis. The poor outcome of this subtype may relate to the constitutive activation of the nuclear factorB pathway, which has been ascribed to a signaling cascade involving CARD-11, BCL-10, and MALT-1 leading to activation of I-B-kinase. Inhibition of nuclear factorB and blocking its ability to inhibit apoptosis in ABC cell lines is toxic, and recent clinical evidence suggests that the ABC type of DLBCL can be preferentially targeted (over the GCB type) by strategies that block IB degradation through proteasome inhibition. These studies highlight the pivotal role of tumor biology in the rational design of targeted therapies in DLBCL and the importance of well-designed prospective studies.

Immunophenotypic Analysis of AIDS-Related Diffuse Large B-Cell Lymphoma and Clinical Implications in Patients From AIDS Malignancies Consortium Clinical Trials 010 and 034

Diffuse large B-cell lymphoma (DLBCL) represents a clinically heterogeneous disease. Models based on immunohistochemistry predict clinical outcome. These include subdivision into germinal center (GC) versus non-GC subtypes; proliferation index (measured by expression of Ki-67), and expression of BCL-2, FOXP1, or B-lymphocyte-induced maturation protein (Blimp-1)/PRDM1. We sought to determine whether immunohistochemical analyses of biopsies from patients with DLBCL having HIV infection are similarly relevant for prognosis. We examined 81 DLBCLs from patients with AIDS in AMC010 (cyclophosphamide, doxorubicin, vincristine, and prednisone [CHOP] v CHOP-rituximab) and AMC034 (etoposide, doxorubicin, vincristine, prednisone, and dose-adjusted cyclophosphamide plus rituximab concurrent v sequential) clinical trials and compared the immunophenotype with survival data, Epstein-Barr virus (EBV) positivity, and CD4 counts. The GC and non-GC subtypes of DLBCL did not differ significantly with respect to overall survival or CD4 count at cancer presentation. EBV could be found in both subtypes of DLBCL, although less frequently in the GC subtype, and did not affect survival. Expression of FOXP1, Blimp-1/PRDM1, or BCL-2 was not correlated with the outcome in patients with AIDS-related DLBCL. These data indicate that with current treatment strategies for lymphoma and control of HIV infection, commonly used immunohistochemical markers may not be clinically relevant in HIV-infected patients with DLBCL. The only predictive immunohistochemical marker was found to be Ki-67, where a higher proliferation index was associated with better survival, suggesting a better response to therapy in patients whose tumors had higher proliferation rates.

A prognostic score for AIDS-related diffuse large B-cell lymphoma in Brazil

The aim of this study was to evaluate a prognostic score for aids-related lymphoma (ARL). A retrospective study of 104 patients with ARL treated between January 1999 and December 2007 was conducted. Diffuse large B-cell lymphoma (DLBC) was the most observed histological type (79.8%). The median CD4 lymphocyte count at lymphoma diagnosis was 125 cells per microliter. Treatment response could be evaluated in 83 (79.8%) patients, and 38 (45.8%) reached complete remission (CR); overall response rate was 51.8% (95 CI = 38.5-65.1%). After a median follow-up of 48 months, the 4-year overall survival (OS) rate among all patients was 35.8%, with a median survival time of 9.7 months (95% CI = 5.5-13.9 months). The survival risk factors observed in multivariate analysis (previous AIDS and high-intermediate/high international prognostic index (IPI)) were combined to construct a risk score, which divided the whole patient population in three distinct groups as low, intermediate, and high risk. When this score was applied to DLBC patients, a clear distinction in response rates and in OS could be demonstrated. Median disease-free survival (DFS) for patients that achieved CR was not reached, and DFS in 4 years was 83.0%. Our results show that the reduced OS observed could be explained by poor immune status with advanced stage of disease seen in our population of HIV-positive patients. Further studies will be needed to clarify the role of different treatment approaches for ARL in the setting of marked immunosuppression and to identify a group of patients to whom intensive therapy could be performed with a curative intent.

Immunophenotypic analysis of AIDS-related diffuse large B-cell lymphoma and clinical implications in patients from AIDS malignancies consortium clinical trials 010 and 034

Purpose Diffuse large B-cell lymphoma (DLBCL) represents a clinically heterogeneous disease. Models based on immunohistochemistry predict clinical outcome. These include subdivision into germinal center (GC) versus non-GC subtypes; proliferation index (measured by expression of Ki-67), and expression of BCL-2, FOXP1, or B-lymphocyte-induced maturation protein (Blimp-1)/PRDM1. We sought to determine whether immunohistochemical analyses of biopsies from patients with DLBCL having HIV infection are similarly relevant for prognosis. Patients and Methods We examined 81 DLBCLs from patients with AIDS in AMC010 (cyclophosphamide, doxorubicin, vincristine, and prednisone [CHOP] v CHOP-rituximab) and AMC034 (etoposide, doxorubicin, vincristine, prednisone, and dose-adjusted cyclophosphamide plus rituximab concurrent v sequential) clinical trials and compared the immunophenotype with survival data, Epstein-Barr virus (EBV) positivity, and CD4 counts. Results The GC and non-GC subtypes of DLBCL did not differ significantly with respect to overall survival or CD4 count at cancer presentation. EBV could be found in both subtypes of DLBCL, although less frequently in the GC subtype, and did not affect survival. Expression of FOXP1, Blimp-1/ PRDM1, or BCL-2 was not correlated with the outcome in patients with AIDS-related DLBCL. Conclusion These data indicate that with current treatment strategies for lymphoma and control of HIV infection, commonly used immunohistochemical markers may not be clinically relevant in HIV-infected patients with DLBCL. The only predictive immunohistochemical marker was found to be Ki-67, where a higher proliferation index was associated with better survival, suggesting a better response to therapy in patients whose tumors had higher proliferation rates.

Good outcome of AIDS-related Burkitt lymphoma (BL) and diffuse large B-cell lymphoma (DLBCL) with abbreviated cycles of EPOCH-rituximab

The addition of rituximab to CHOP chemotherapy may augment tumor response but in patients with low CD4 counts, one study suggested that this benefit may be offset by increased infectious deaths (Kaplan. Blood 2005; 106:1538). We hypothesized that the addition of rituximab to EPOCH chemotherapy could improve tumor kill, allowing fewer cycles of treatment and therefore reducing toxicity. Patients received EPOCH-R (in mg/m2/d – etoposide 50, vincristine 0.4 and doxorubicin 10 all CIV d 1–5; cyclophosphamide 750 mg IV d 5; prednisone 60 po days 1–5 and rituximab 375 IV d 1,5 and G-CSF sc d 6–15) every 21 days. Prophlactic IT methotrexate was administered and HAART was suspended during therapy. Cyclophosphamide was adjusted based on absolute neutrophil count (ANC) nadir. Response was assessed by CT and FDG-PET scan and patients received one cycle beyond CR for a minimum of three cycles. Characteristics of 40 enrolled patients are: median (range) age 42 (9–60) years; IPI 3 (0–4); ECOG PS 1 (1–4), CD4 count 222 (0–835) cells/mm3; HIV viral load 34,766 (0–6,080000) RNA copies/mL; male sex 35 (88%); LDH > N 27 (68%); stage IV 27 (68%) and histology DLBCL 32 (80%) and BL 8 (20%). Of 38 evaluable patients (2NE), median (range) number of cycles given is three (3–5) with CR/CRu in 35 (92%) and PR in one (3%) patients. All eight patients with Burkitt lymphoma are in continuous remission. At four years median potential follow-up, PFS and OS are 86 percent and 70 percent. For patients with CD4 > and 100/mm3 have an extremely favorable outcome with and survival following EPOCH-R. The addition of rituximab did not appear to contribute to infection related complications or deaths. EPOCH-R showed excellent efficacy in eight patients with BL with an OS and PFS of 100 percent. PET scanning has a high negative but low positive predictive value for subsequent relapse. Accrual continues.

High resolution profiling of DNA copy number and gene expression changes in AIDS-related lymphoma

The incidence of B cell non-Hodgkin lymphoma (NHL) is increased substantially in the HIV-1-infected immunosuppressed population. Clinically, AIDS-related lymphoma (ARL) is more aggressive and has a worse prognosis than in non-immunocompromised patients, though there has been significant improvement in the post-HAART era. While HIV-induced immunosuppression, chronic antigenic stimulation, and cytokine overproduction may contribute to differences in disease progression and outcome, distinct genetic changes in ARL may also mediate these effects. Chromosomal DNA copy number alterations are known to play a major role in lymphomagenesis and have been studied in non immunocompromised patients for some NHLs. To determine whether ARL has distinct molecular features and pathogenetic mechanisms, we assessed genome-wide copy number changes and gene expression profiles using 24 HIV+ cases with B cell NHL obtained from the AIDS and Cancer Specimen Resource (ACSR). High resolution aCGH was performed using the 250 K NspI SNP platform (Affymetrix). Selecting for frequent aberrations present in >20 percent of the cases, 43 chromosomal gains and 30 chromosomal losses were identified. Many of these regions replicated copy number changes previously reported for high-grade B cell NHL, including: gains of X, 12, 11q, 8q, 2p16.1, 9p11.2, 17q21, and 3p; and losses of 1p36, 4q23, 9p21.3, 13q34, and 17q23. The aberrant regions ranged in size from 12 kb to 6.5 Mb, providing concise boundaries for these intervals, which harbor a relatively small number of genes. Several novel recurrent regions were also identified, including a loss of 7q21.2–q22.1, and gains of 4p16.1, 15q11.2, and 19p13.2. To identify coordinate changes in gene expression associated with the chromosomal aberrations, gene expression profiles were generated using the Human Genome U133 Plus 2.0 Array (Affymetrix). This approach identified specific candidate genes for these intervals that may contribute to ARL pathogenesis. Gene expression profiles were also used to cluster the ARL cases. Gene signatures that reliably distinguish activated B-cell (ABC) like Diffuse Large B Cell Lymphoma (DLBCL), germinal center B-cell (GCB) like DLBCL and Burkitt lymphoma (BL), were applied to the ARL gene expression profiles. The ARL samples showed no correlation with the BL gene signature. In contrast, the ABC and GCB gene signatures divided the ARL samples into two distinct groups with either a predominantly ABC- or GCB-type expression. Assigning ABC and GCB phenotypes to these groups of samples, Goeman's global test found a highly significant association (p = 0.00012) of the ABC and GCB phenotypes with the DLBCL ABC and GCB predictor gene set. The classification of AIDS-related DLBCLs into distinct ABC and GCB groups has significant implications given the differences in pathogenesis, biology, and survival for these two subtypes of DLBCL.

HIV-1 Tat mimetic of VEGF correlates with increased microvessels density in AIDS-related diffuse large B-cell and Burkitt lymphomas

Angiogenic switch marks the beginning of tumor’s strategy to acquire independent blood supply. In some subtypes of non-Hodgkin’s lymphomas, higher local vascular endothelial growth factor (VEGF) expression correlates with increased microvessel density. However, this local VEGF expression is higher only in tumors with elevated expression of the receptors of the growth factor, suggesting an autocrine growth-promoting feedback loop. Several studies have indicated that VEGF receptors are also targeted by Tat protein from the HIV-1-infected cells. Given the similarity of the basic region of Tat to the angiogenic factors (basic fibroblast growth factor, VEGF), Tat mimics these proteins and binds to their receptors. We evaluated the role of HIV-1 Tat in regulating the level of VEGF expression and microvessel density in the AIDS-related diffuse large B-cell (DLBCL) and Burkitt lymphomas (BL). By luciferase assay, we showed that VEGF promoter activity was downregulated in vitro in cells transfected with Tat. Reduced VEGF protein expression in primary HIV-1 positive BL and DLBCL, compared to the negative cases, supported the findings of promoter downregulation from the cell lines. Microvascular density assessed by CD34 expression was, however, higher in HIV-1 positive than in HIV-1 negative tumors. These results suggest that Tat has a wider angiogenic role, besides the regulation of VEGF expression. Thus, targeting Tat protein itself and stabilizing transient silencing of VEGF expression or use of monoclonal antibodies against their receptors in the AIDS-associated tumors will open a window for future explorable pathways in the management of angiogenic phenotypes in the AIDS-associated non-Hodgkin’s lymphomas.

EBV MicroRNAs in Primary Lymphomas and Targeting of CXCL-11 by ebv-mir-BHRF1-3

EBV-encoded microRNAs (miRNAs) have been identified and their functions are being studied. The expression pattern of these miRNAs in clinical samples of EBV-associated non-Hodgkin's lymphomas is unknown. We analyzed five primary "endemic" pediatric Burkitt's lymphomas (BL), two acquired immunodeficiency syndrome (AIDS)-related type I latency BL lines, a type III latency line, three EBV(+) primary effusion lymphomas (PEL), and three AIDS-related diffuse large B-cell lymphomas (DLBCL) for expression of EBV-encoded miRNAs. A markedly elevated expression of miRNA BHRF1-3 in type III relative to its parental type I BL line was found. Primary unmanipulated type I BLs and EBV(+) PELs expressed high levels of BART2 miRNA, whereas DLBCLs expressed both BART2 and BHRF1-3 species. BHRF1-3 miRNA expression inversely correlated with levels of a putative cellular target, the IFN-inducible T-cell attracting chemokine CXCL-11/I-TAC, and suppression of this factor was reversed by transfection of an antisense oligo to the EBV miRNA BHRF1-3. EBV-encoded miRNAs are expressed in primary lymphomas classically linked to the virus and are associated with the viral latency status. Targeted suppression of CXCL-11/I-TAC by a viral-encoded miRNA may serve as an immunomodulatory mechanism in these tumors.

Physician Perceptions and Preferences in the Treatment of Acquired Immunodeficiency Syndrome (AIDS)-Related Lymphoma (ARL).

The treatment of ARL is complicated by the numerous immuno-chemotherapy, antiretroviral, and prophylactic options available to lymphoma specialists. The optimal management in the era of combination antiretroviral therapy (cART) is unclear. We administered a survey instrument to determine physician preferences and perceptions in the management of ARL and to assess the variability in treatment in Canada. The survey was developed with items grouped into key domains of ARL management (physician demographics, attitudes, and treatment preferences) and piloted for content validity and clarity. The final questionnaire was administered to lymphoma physicians with valid contact information in the provinces of Ontario (ON; n=155) and British Columbia (BC; n=48). The Dillman Tailored Design Method was followed for multi-modality (internet and standard mail) survey administration. Of 196 physicians, 131 either responded by completing the questionnaire (n=117; 60% response rate) or declining to participate (n=14; 7%). Most responders were male (63%), white (70%), practicing in an academic setting (63%), and belonged to a median age group range of 41–50 years. The majority (98%) had a positive attitude towards the treatment of ARL, as measured by a previously validated 2-item attitude scale. However, barriers to adequate care were still identified; 84% of physicians agreed that uncontrolled human immunodeficiency virus infection represented a major barrier to ARL care and 54% agreed that a patient's concurrent intravenous drug abuse impaired care. Most physicians recommended the concomitant use of cART in the care of their patients with ARL (n=72 of 109 responses; 66%). Similarly, a majority of respondents recommended CHOP-like regimens (cyclophosphamide, doxorubicin, vincristine, and prednisone; n=92 of 108 responses; 85%) to form the backbone of chemotherapy. The addition of the rituximab was preferred by 41% physicians but not by 40% others, with remaining respondents unsure of the agent's role. In logistic regression analysis, use of rituximab was predicted only by location of practice (province), after adjusting for other potential predictors including physician age, race, gender, practice environment (academic vs. community), years of experience, ARL patient volume, and modality of survey response. Physicians from BC were much more likely to administer rituximab than ON practitioners (OR 44.5; 95% CI: 7.76–255.0, p<0.0001). We explored the reasons that physicians did not recommend rituximab; most cited a concern for additional toxicity with rituximab in ARL. Eight physicians in ON highlighted the lack of formulary funding for rituximab in the province as the primary reason they did not treat patients with this agent. In the current cART era, Canadian physicians have a positive attitude towards ARL treatment. The majority prefer to use cART in combination with CHOP for AIDS-related diffuse large B-cell lymphoma. The use and perceived benefit of rituximab may be influenced by inter-provincial formulary differences and by regional variation in policy and guideline recommendations.