AIDS-Related Lymphomas 

Updated: Sep 09, 2020
Author: Christina Poh, MD; Chief Editor: Emmanuel C Besa, MD 

Overview

Background

Acquired immune deficiency syndrome (AIDS)–related lymphoma is a subset of lymphomas commonly encountered in patients infected with human immunodeficiency virus (HIV). Most are aggressive lymphomas of B-cell origin[1]  and include the following subtypes[2] :

  • Non-Hodgkin lymphoma (NHL)
  • Hodgkin lymphoma (HL)
  • Primary effusion lymphoma
  • Primary central nervous system (CNS) lymphoma

AIDS-related NHLs include the following:

  • Diffuse large B-cell lymphoma (DLBCL), immunoblastic variant
  • Burkitt lymphoma
  • Plasmablastic lymphoma
  • Other lymphomas (eg, indolent B-cell lymphoma, T-cell and natural killer [NK]-cell lymphoma)

Pathophysiology

The pathogenesis of NHL development in the setting of HIV infection is not well elucidated. However, the following factors are thought to play an important role:

  • Chronic B-cell stimulation [3]
  • Cytokine dysregulation
  • Co-infection with oncogenic viruses (Epstein-Barr virus [EBV], human herpesvirus 8 [HHV-8], hepatitis B and C viruses) in the setting of immune dysregulation, resulting in decreased surveillance for tumor antigens [4, 5]
  • Genetic abnormalities (decreased BCL-2 activation and increased BCL-6 and MYC expression) [6, 7]

Different clinicopathologic categories of AIDS-related lymphomas arise from distinct B-cell subtypes, and the factors mentioned above interplay in varying proportions to give rise to different varieties of NHL.

Epidemiology

It is estimated that 25% to 40% of patients with HIV infection will develop a malignancy and approximately 10% will develop NHL.[8]  AIDS-related lymphoma is more common in males than in females.[9] With the advent of anti-retroviral therapy (ART), the incidence rate of AIDS-defining lymphoma has substantially declined; however, it still remains substantially higher compared with the general population.[10]  A meta-analysis of over 400,000 patients showed the observed rate of lymphoma development in the HIV population to be 11.03 times that of the general population.[11]

Up to 85% of AIDS-related lymphomas are highly aggressive and include DLBCL, immunoblastic variant; and Burkitt lymphoma. Incidences and relative risks of AIDS-related lymphomas are shown in Table 1, below.[12, 13, 14, 15, 16]  

Table 1: Incidence and relative risk of AIDS-related lymphoma subtypes (Open Table in a new window)

Lymphoma subtype

Incidence (% of HIV-related lymphomas)

Relative risk (compared with the general population)

DLBCL, immunoblastic variant

64

652

Burkitt lymphoma

21

260

Indolent B-cell lymphoma

< 10

15

T-cell lymphoma

3

15

Hodgkin lymphoma

< 10

15-30

Primary CNS lymphoma

2-6

1000

Plasmablastic lymphoma

3

>1000

Primary effusion lymphoma

< 1

>1000

Risk Factors

Risk factors for developing AIDS-related lymphoma include the following:[17]

  • Low CD4 count - A study of 52,278 patients from the French Hospital Database found CD4 cell count to be the most predictive risk factor of AIDS-related cancer incidence: Hodgkin lymphoma was 5.4 times more likely to develop in patients with CD4 cell count < 50/μL than in those with CD4 count > 500/μL. [18]
  • High HIV viral load
  • EBV co-infection
  • Genetic factors -  CCR5-32 deletion is associated with favorable prognosis, whereas CXCR-4 is associated with increased risk for NHL development [19, 20]  
  • Other undefined risk factors that increase the risk of NHL in the general population

Prognosis

ART can significantly affect the outcomes of AIDS-related lymphoma by reducing viral replication, and its use plays a pivotal role in improving prognosis. In addition, the prognosis of patients with AIDS-related lymphoma have been associated with the following factors:[2]

  • Stage (extent of disease, extranodal or CNS involvement)
  • Age
  • Severity of the underlying immunodeficiency (measured by CD4 cell count)
  • Performance status

An AIDS-related lymphoma International Prognostic Index (IPI) has been developed and employs the age adjusted-IPI in addition to CD4 count, viral load, and prior history of AIDS.[21] This index performed better in predicting risk of death compared to the age-adjusted IPI.

Prognosis of AIDS-related lymphoma varies depending on histologic subtype. A large body of evidence indicates that HIV-infected patients whose HIV disease is well controlled with ART, and are treated with standard chemotherapies for DLBCL, Burkitt lymphoma, and Hodgkin lymphoma have outcomes similar to those of their uninfected counterparts.[22]  However, a diagnosis of primary effusion lymphoma or plasmablastic lymphoma generally confers a poor prognosis.[23]

 

Presentation

History and Physical

Presenting symptoms and signs of AIDS-related lymphomas depend on the site of involvement, which can be variable. Common clinical manifestations include lymphadenopathy, organomegaly, and/or constitutional B symptoms. Patients can also present with unexplained cytopenias.

Of note, manifestations of primary central nervous system (CNS) lymphoma can include altered mental status, headache, blurred vision, and cranial neuropathies although these symptoms can also occur with CNS involvement from systemic lymphoma.[24]  Patients with primary effusion lymphoma can present with pleural or pericardial effusions.

Patients with AIDS-related lymphoma are more likely to present with the following, compared with HIV-negative lymphoma patients:[25]

  • Advanced-stage disease
  • Constitutional B symptoms (fever, night sweats, weight loss > 10% over 6 months)
  • Extranodal involvement (GI tract, liver, lung, pleura, CNS, bone marrow)
  • Disease involving uncommon locations (body cavity, soft tissue)

Because AIDS-related lymphoma is generally associated with aggressive lymphoma histologies, advanced-stage disease, and extranodal involvement, patients may experience oncologic emergencies such as tumor lysis syndrome (hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia), and acute organ dysfunction (cardiac tamponade or GI, biliary, or ureteral obstruction).

Although lymphomas may appear at any time during the course of HIV infection, certain emergence patterns have been noted, depending on histologic subtype. Diffuse large B-cell lymphoma (DLBCL) and primary CNS lymphoma tend to occur during CD4 count nadir. In contrast, Burkitt lymphoma generally occurs when CD4 counts are better preserved. Hodgkin lymphoma occurrence has been seen during the first few months of antiretroviral therapy, when CD4 counts are improving.[26]

 

DDx

Diagnostic Considerations

Diagnosis requires histological confirmation of lymphoma in the presence of HIV infection. Like other lymphomas, the Ann Arbor Staging System is utilized in the staging of AIDS-related lymphomas. Of note, staging is not usually valuable for primary CNS and primary effusion lymphomas and thus is not indicated as these malignancies generally remains confined within the CNS/originating body cavity.[27]

Some common AIDS-related lymphoma subtypes are described below.

DLBCL

As the name indicates, the common morphologic features of DLBCL are a relatively large cell size and a diffuse pattern of growth. The cells are about 4 to 5 times larger than a small lymphocyte and usually have a round, vesicular nucleus. The nucleoli are variable in number and position and the cytoplasm is pale or basophilic. The tumor cells typically express CD19, CD20 and have immunophenotypes that resemble DLBCL in the general population.

Diffuse large B cell lymphoma under low magnificat Diffuse large B cell lymphoma under low magnification showing diffuse proliferation of large atypical lymphoid cells in this lymph node specimen.
Diffuse large B cell lymphoma under high power sho Diffuse large B cell lymphoma under high power showing cells that have moderate to abundant cytoplasm, round to irregular nuclear contour, vesicular nuclear chromatin and one to multiple nucleoli. Scattered small mature lymphocytes are seen. Green arrows = atypical lymphocytes; yellow arrows = small lymphocytes.

Burkitt Lymphoma

Burkitt lymphoma has medium-sized tumor cells with a monotonous appearance. The nuclei are round and contain multiple, centrally located nucleoli. The cytoplasm is usually mildly basophilic. The tumor has a high cell turnover, with a proliferation index close to 100 %. Benign macrophages with debris ingested from dead cells may be found within the microscopic field, giving rise to a "starry sky" pattern. Tumor cells are positive for CD20, CD10 and BCL6 but negative for BCL2.

Burkitt lymphoma under low magnification showing s Burkitt lymphoma under low magnification showing sheets of atypical mononuclear cells. Scattered macrophages can be seen (as demonstrated by the green arrows) giving rise to classical "starry-sky" pattern.
Burkitt lymphoma under high magnification showing Burkitt lymphoma under high magnification showing sheets of atypical mononuclear cells. The cells are intermediate to large in size with scant cytoplasm, round to irregular nuclear contour, smudged chromatin and some with nucleoli. Mitosis and apoptosis are frequent with scattered macrophages giving focal "starry-sky" pattern. Green arrows = macrophages; yellow arrows = mitosis.

Plasmablastic lymphoma

Plasmablastic lymphoma forms cohesive masses and has large neoplastic cells. The malignant cells have a "squared off" appearance. The nucleus may be centrally or eccentrically placed. Tumor cells are usually positive for CD38, CD79a, CD138, MUM1, and PRDM1 and negative for CD19,20 and PAX5.

Differential Diagnoses

  • Infections

    o Tuberculosis

    o Toxoplasmosis

    o Disseminated fungal infections

    o Infectious mononucleosis

    o Cat scratch disease

    o Lymphadenopathy associated with HIV

  • Inflammatory conditions

    o Sarcoidosis

  • Malignancies associated with HIV

    o Kaposi sarcoma

    o Cervical cancer

    o Immune reconstitution inflammatory syndrome (IRIS)

 

Workup

Approach Considerations

The workup of AIDS-related lymphoma includes laboratory studies, imaging studies, and biopsies. Specific choices in the workup should be guided by the patient's signs and symptoms (see Presentation/History and Physical). In addition, opportunistic infections should be evaluated.

Laboratory Studies

Laboratory studies should include the following:

  • Complete blood count (CBC) with differential
  • Complete metabolic panel (CMP)
  • Lactate dehydrogenase (LDH)
  • Tumor lysis assays (potassium, phosphorus, calcium, uric acid)
  • CD4 count
  • HIV viral load
  • Hepatitis B and C screening

Imaging Studies and Procedures

Position emission tomography (PET) and/or computed tomography (CT) are generally used for staging purposes.[28]  Bone marrow biopsy is recommended for unexplained cytopenias.[29]  In addition, endoscopy or bronchoscopy may be considered if gastrointestinal (GI) tract or pulmonary involvement is suspected.[30, 31]

If central nervous system (CNS) involvement is suspected, neuroimaging with contrast-enhanced MRI or CT and lumbar puncture is recommended.[32]  All patients with HIV-related Burkitt lymphoma and selected patients with diffuse large B-cell lymphoma (DLBCL) who are at high risk for CNS involvement should undergo CNS evaluation.[33]

Cerebrospinal fluid (CSF) analysis should include the following studies:

  • Cell count
  • Protein and glucose level
  • Cytology
  • Flow cytometry
  • Immunoglobulin heavy-chain (IgH) rearrangement studies
  • Polymerase chain reaction (PCR) for Epstein-Barr virus and JC virus

Tissue Evaluation

Histological confirmation is usually obtained with biopsy of involved tissue. Excisional biopsy or multiple core biopsies are preferred, while fine needle aspirations (FNA) are suboptimal.

In primary CNS lymphoma, diagnosis can also be obtained by cerebrospinal fluid evaluation (see Imaging Studies and Procedures). In primary effusion lymphoma, diagnosis can also be obtained from malignant cells with human herpesvirus 8 (HHV-8) in effusion or ascites samples.

 

Treatment

Approach Considerations

The optimal treatment for AIDS-lymphoma has yet to be defined. Treatment regimen is determined by disease histological subtype and stage, along with patient performance status and comorbidities, including CD4 cell count, HIV viral load, and prior history of AIDS-related complications. Generally, treatments for AIDS-related lymphoma are extrapolated from their non–AIDS-related lymphoma counterparts, with the addition of antiretroviral therapy (ART). However, several prospective studies have recently clarified the treatment of these lymphomas.

Although ART and chemotherapy may have overlapping side effects, which can make treatment more challenging, all patients should be initiated on both ART and chemotherapy, as concurrent therapy has been associated with improved outcomes.[34, 35]  ART should be continued throughout the duration of chemotherapy.

Due to HIV-associated immunosuppression, which can be worsened with chemotherapy, all patients—regardless of CD4 cell count—should be started on prophylaxis against Pneumocystis jiroveci pneumonia (PJP) and toxoplasmosis.

Of note, the role of rituximab in AIDS-related lymphoma is not as clearly defined as it is in the HIV-negative population, due to rituximab-induced cellular and humoral immunodeficiency, which is worsened with HIV infection. Therefore, the addition of rituximab is generally recommended for CD20+ disease when CD4 count is above 50/μL.[36]

Medical Care

Diffuse large B-cell lymphoma (DLBCL)

Common chemotherapeutic options used in the initial treatment of AIDS-related DLBCL include the following:

Table 2: Common chemotherapeutic options for initial treatment of AIDS-related DLBCL (Open Table in a new window)

Chemotherapy

Outcomes (complete remission rate %)

Indication

CHOP

63[37]

most patients with advanced stage disease, recommend addition of rituximab for CD20+ disease when CD4 count over 50 /μL

Dose-adjusted EPOCH

74[38]

Patients with a high proliferation index or plasmabatic histology; recommend addition of rituximab for CD20+ disease when CD4 count > 50 /μL

CDE

45[39]

 

CDE = cyclophosphamide, doxorubicin, etoposide; CHOP = cyclophosphamide, doxorubicin, vincristine, prednisone; EPOCH = etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin (hydroxydaunorubicin)

Central nervous system (CNS) prophylaxis is indicated for patients with double-hit lymphoma or lymphomatous involvement of bone marrow, testes, sinuses, or epidural regions.[40]

Burkitt lymphoma

Common chemotherapeutic options in AIDS-related Burkitt lymphoma include the following:

Table 3: Common chemotherapeutic options for initial treatment of AIDS-related Burkitt Lymphoma (Open Table in a new window)

Chemotherapy

Complete remission (%)

Survival

Modified CODOX-M/IVAC

Not reported[41]

1-year PFS: 69%

2-year PFS: 69%

SC-EPOCH-RR

100[42]

73-month OS: 100%

Carmen trial

80[43]

3-year PFS: 70%

3-year OS: 77%

CODOX-M-IVAC = cyclophosphamide, vincristine (Oncovin), doxorubicin, high-dose methotrexate/ifosfamide, etoposide, high-dose cytarabine;

SC-EPOCH-RR = short-course rituximab, etoposide, prednisone, vincristine (Oncovin), cyclophosphamide, doxorubicin (hydroxydaunorubicin), with dose-dense rituximab

 

CNS prophylaxis is recommended in all patients with Burkitt lymphoma.

Plasmablastic lymphoma

For plasmablastic lymphoma, a highly aggressive lymphoma that is predominantly observed in persons with HIV disease, National Comprehensive Cancer Network (NCCN) guidelines recommend initial therapy with a more intensive regimen such as the following[40] :

  • CODOX-M-IVAC
  • HyperCVAD (cyclophosphamide, vincristine, doxorubicin [Adriamycin], dexamethasone, administered on a hyperfractionated schedule)
  • Dose-adjusted EPOCH 

Autologous SCT should be considered in first complete remission in select high-risk patients.​[44]  

Hodgkin lymphoma

Treatment of Hodgkin lymphoma in HIV-positive patients should be stage-adapted, as follows[45] :

  • Early favorable disease - Two cycles of ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) with subsequent 20-Gy involved-field radiotherapy
  • Early unfavorable disease -  Four cycles of ABVD followed by 30-Gy involved-field radiotherapy
  • Advanced-stage disease -  Six cycles of BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisolone) or ABVD 

Primary CNS lymphoma

For patients with primary CNS lymphoma who have adequate renal function, high-dose methotrexate, 3 g/m2 every 2 weeks for 6-8 doses, in conjunction with ART has been shown to be effective.[46, 47]  A retrospective study of 51 patients with HIV-related primary CNS lymphoma treated with high-dose methotrexate in conjunction with ART showed median overall survival of 5.7 years.[48] The addition of rituximab to methotrexate has not been associated with a clear benefit and should not be used, especially in the HIV-positive population.[49]  

For patients who cannot tolerate high-dose methotrexate, there is a paucity of evidence for alternative agents. However, whole-brain radiation or temozolomide can be considered.

Primary effusion lymphoma

Standard treatment approaches, such as CHOP, have yielded disappointing results in patients with primary effusion lymphoma (PEL). Therefore, patients with PEL should be offered clinical trials if possible. Novel treatment approaches include bortezomib,[50]  lenalidomide,[51]  or daratumumab.[52]

Treatment for Relapsed or Refractory Disease

Relapsed/refractory disease is treated similarly to its HIV-negative counterpart, with platinum-based salvage regimens such as ICE (ifosfamide, carboplatin, etoposide), DHAP (dexamethasone, high-dose cytarabine [ARA-C], cisplatin [Platinol]), or GDP (gemcitabine, dexamethasone, cisplatin) followed by autologous stem cell transplantation. Several clinical trials have shown that intensive salvage regimens followed by high-dose chemotherapy and autologous bone marrow and stem-cell transplantation are feasible and effective in chemotherapy-sensitive relapsed or refractory AIDS-related lymphoma.[53, 54, 55]

Chimeric antigen receptor (CAR) T-cell therapy has proved effective in the relapsed/refractory setting for some NHL subtypes and is recommended in patients with stable or progressive disease despite salvage therapy.[56] However, no studies have been done to specifically evaluate CAR T-cell therapy in the HIV-positive population.

Allogeneic stem cell transplantation has been performed in selected cases of relapsed HIV-related lymphoma in patients receiving combined antiretroviral therapy. Both reduced-intensity conditioning and myeloablative conditioning proved feasible. However, given the limited amount of experience and the lack of long-term efficacy data, no firm conclusions can be drawn.[57]

Supportive Care

The following is recommended for all patients with AIDS-related lymphoma[40] :

  • Begin growth factor support 24-48 hours after chemotherapy and continue past nadir to recovery of blood counts of each cycle.
  • Continue PJP prophylaxis until CD4 > 200/μL after completion of chemotherapy.
  • Provide antimicrobial prophylaxis with a quinolone during the period of neutropenia.
  • Hold azole antifungals from 24 hours prior through 24 hours post chemotherapy with agents that have CYP3A4 metabolism.
  • Provide  Mycobacterium avium complex (MAC) prophylaxis for patients with CD4 < 100/μL.
  • Strongly consider varicella-zoster virus/herpes simplex virus (VZV/HSV) prophylaxis
  • Encourage consultation with an infectious disease specialist for febrile neutropenia in the context of extensive prophylaxis and for refractory diarrhea.

Long-Term Monitoring

Follow-up visits are usually arranged every 3-4 months initially, depending on the individual patient, but these may be tailored as the condition mandates. These visits are utilized to follow response to treatment and to provide psychosocial support for the patient. During follow-up visits, it is important to ask patients about constitutional symptoms, new lymphadenopathy, or pain; patients should be educated about reporting any of these signs and symptoms to the physician.

The physical examination should focus on the presence of enlarged lymph glands and an enlarged liver or spleen. Laboratory workup should be repeated, including the minimum of a complete blood cell count with differential and a comprehensive metabolic panel. Imaging should be done only if there is suspicion of recurrence.

 

Questions & Answers

Overview

What is AIDS-related lymphoma (ARL)?

What is the US prevalence of AIDS-related lymphoma (ARL)?

What is the global prevalence of AIDS-related lymphoma (ARL)?

What are the racial predilections of AIDS-related lymphoma (ARL)?

What are the sexual predilections of AIDS-related lymphoma (ARL)?

Which age groups have the highest prevalence of AIDS-related lymphoma (ARL)?

What is the prognosis of AIDS-related lymphoma (ARL)?

What is included in patient education about AIDS-related lymphoma (ARL)?

What causes AIDS-related lymphoma (ARL)?

What causes AIDS-related systemic non-Hodgkin lymphoma (NHL)?

What causes AIDS-related primary effusion lymphoma (PEL)?

What causes AIDS-related primary CNS lymphoma (PCNSL)?

Presentation

Which clinical history findings are characteristic of AIDS-related lymphoma (ARL)?

What are the signs and symptoms of AIDS-related primary CNS lymphoma (PCNSL)?

What is the focus of the physical exam to evaluate AIDS-related lymphoma (ARL)?

DDX

Which conditions are included in the differential diagnoses of AIDS-related lymphoma (ARL)?

What are the differential diagnoses for AIDS-Related Lymphomas?

Workup

What is the role of lab tests in the diagnosis of AIDS-related lymphoma (ARL)?

What is the role of lab tests in the treatment of AIDS-related lymphoma (ARL)?

What is the role of radiography in the workup of AIDS-related lymphoma (ARL)?

What is the role of imaging studies in the GI workup of AIDS-related lymphoma (ARL)?

What is the role of MRI and CT scanning in the workup of AIDS-related primary CNS lymphoma (PCNSL)?

What is the role of ultrasonography in the workup of AIDS-related lymphoma (ARL)?

What is the role of imaging in the workup of AIDS-related lymphoma (ARL) of the bone?

What is the role of PET scanning in the workup of AIDS-related lymphoma (ARL)?

What is the role of MUGA scanning and echocardiography in the workup of AIDS-related lymphoma (ARL)?

What is the role of biopsy in the workup of AIDS-related lymphoma (ARL)?

What is the role of bone marrow exam in the workup of AIDS-related lymphoma (ARL)?

What is the role of lumbar puncture in the workup of AIDS-related lymphoma (ARL)?

Which histologic findings are characteristic of AIDS-related lymphoma (ARL)?

How is AIDS-related lymphoma (ARL) staged?

Treatment

How is AIDS-related lymphoma (ARL) treated?

What is the role of chemotherapy in the treatment of AIDS-related lymphoma (ARL)?

How is lymphomatous meningitis treated in patients with AIDS-related lymphoma (ARL)?

How is AIDS-related primary CNS lymphoma (PCNSL) treated?

How is AIDS-related primary effusion lymphoma (PEL) treated?

How is AIDS-related systemic Hodgkin lymphoma (HL) treated?

What are the possible complications of AIDS-related lymphoma (ARL)?

What is included in the long-term monitoring of AIDS-related lymphoma (ARL)?

How is recurrent or refractory AIDS-related lymphoma (ARL) treated?