How I treat classical Hodgkin lymphoma in patients infected with human immunodeficiency virus

Abstract

HIV-associated classical Hodgkin lymphoma (HIV-cHL) is an important complication of HIV disease in the era of effective combination antiretroviral therapy (cART). Generally, newly diagnosed HIV-cHL should be managed with curative intent. With modern HIV therapeutics, HIV-cHL treatment outcomes are largely comparable to those of the background population with cHL (non-HIV-cHL). To achieve these outcomes, particular attention must be given to managing HIV. This management includes understanding HIV as a comorbid condition with a spectrum of impact that is unique to each patient. Meticulous attention to drug-drug interactions is required to avoid toxicity and pharmacokinetic effects that can undermine cure. Relapsed and refractory HIV-cHL poses additional therapeutic challenges. The standard management in this setting should also be based on that for non-HIV-cHL, and includes the use of salvage chemotherapy followed by autologous stem cell transplant in chemosensitive disease. The role of allogeneic hematopoietic stem cell transplant is less clear but may be useful in select cases. Newer agents with activity in cHL are being tested as part of primary and salvage therapy and are also highly relevant for HIV-cHL.

Figure 1

Histopathology and immunohistochemistry of HIV-cHL. (A) Hematoxylin and eosin staining shows cHL, MC subtype. Immunostaining for (B) CD15, (C) CD30, and (D) EBV latent membrane protein 1 demonstrates Hodgkin Reed-Sternberg cells. (E) CD68 staining showing many (>5%) macrophages. (F) Hematoxylin and eosin staining at time of relapse shows cHL, MC subtype. Original magnification ×40.

Figure 2

¹⁸FDG-PET in HIV-cHL. (A) Baseline ¹⁸FDG-PET. Volumetric image shows bulky intensely hypermetabolic cervical, mediastinal, and axillary lymph nodes and multiple focal bone lesions (representative vertebral lesion, red arrow). (B) Interim ¹⁸FDG-PET. At the end of cycle 2, coronal image focuses on a small suspicious lesion in left axilla (red arrow); diffuse bone uptake attributable to pegfilgrastim is also noted. After cycle 6, a biopsy sample of residual abnormalities in the left axilla showed reactive changes and no evidence of cHL. (C) End-of-therapy ¹⁸FDG-PET. Volumetric image shows resolution of ¹⁸FDG avid nodes. (D) Relapse ¹⁸FDG-PET. Volumetric image shows left axillary avid lymph node (red arrow) and other small nodes above the diaphragm.