Hodgkin Lymphoma (HL) accounts for approximately 15% of all lymphomas. The incidence of HL is increased in HIV infection. The International Prognostic Score (IPS) is the most commonly used tool to risk-stratify patients with advanced HL but it has not been validated in HIV-associated HL (HIV-HL). We conducted a retrospective study to describe characteristics and evaluate the IPS and other prognostic factors for survival in HIV-HL.
Institutions in the United States (US) and internationally submitted clinical and pathological patient-level data on HIV-positive individuals with a pathological diagnosis of HL who were treated concurrently with doxorubicin, bleomycin, vinblastine and dacarbazine (ABVD) and highly-active antiretroviral therapy (HAART). Continuous and categorical variables are presented using descriptive statistics. Univariate and multivariate analyses were performed for progression-free survival (PFS) and overall survival (OS). P-values <0.05 were considered statistically significant.
Data on 199 patients were obtained from 12 institutions; 148 cases (74%) were from Europe, 28 (14%) from North America (US, Canada), and 23 (12%) from South America. All patients were diagnosed between 1996 and 2010. The most common subtype was mixed cellularity (51%). Median age at diagnosis of HL was 42 years (range: 22–73 years), and 87% (n=184) were men. Median CD4+ count was 245 cells/mm3 (range: 4–1209 cells/mm3), and 51% (n=98) had a CD4+ count <200 cells/mm3. Median duration of HIV infection prior to HL diagnosis was 7 years (range: 0–30 years). In 24 patients (12%) HIV and HL were diagnosed concurrently, and 49% (n=95) had a previous diagnosis of AIDS. At presentation, 86% (n=170) of patients exhibited B symptoms, 56% (n=111) presented with stage IV disease, 79% (n=127) had albumin level <4 g/dl, 43% (n=74) had hemoglobin level <10.5 g/dl, 1% (n=1) had WBC >15,000 cells/mm3, 26% (n=44) had lymphocyte count <600 cells/mm3, and 41% (n=68) of patients had an IPS >3. All patients received concurrent HAART and ABVD chemotherapy, opportunistic infection prophylaxis was used in 89% (n=146), and 71% (n=128) received G-CSF therapy. Complete response (CR) was obtained in 82% (n=159) of patients. After a median follow-up of 5 years, the 5-year PFS and OS were 75% and 78%, respectively. In univariate analyses, adverse prognostic factors for PFS included albumin <4 g/dl (p=0.04) and CD4+ count <200 cells/mm3 (p=0.0002) while diagnosis of AIDS (p=0.03) and CD4+ count <200 cells/mm3 (p=0.002) were adversely prognostic of OS. In multivariate analyses, CD4+ count <200 cells/mm3 was the only independent adverse prognostic factor for PFS and OS (p=0.002 and p=0.004, respectively). Separately, an IPS >3 was significant for a worse PFS (p=0.04) and had a trend towards significance for a worse OS (p=0.06). When compared side-to-side, CD4+ count <200 cells/mm3 was a stronger adverse factor than IPS >3 for PFS and OS.
HIV-HL commonly presents with high-risk features such as advanced stage, B symptoms and hypoalbuminemia. Despite high-risk presentations, we demonstrate an encouraging prognosis when these patients are treated with ABVD and concurrent HAART. Low CD4+ count was the strongest adverse predictor of prognosis in this population.
No relevant conflicts of interest to declare.
Asterisk with author names denotes non-ASH members.