Patients with HIV-related lymphoma should now be considered candidates for stem cell transplantation if need be, and the treatment does not need to be limited to certain centers, according experts commenting on the results of a new study.

Autologous hematopoietic stem cell transplantation (AHCT) has been offered to patients with relapsed or treatment-resistant HIV-related lymphoma since the late 1990s, observed lead study author Joseph Alvarnas, MD, of City of Hope Medical Center, in Monrovia, California.

But transplantation has been limited to centers with HIV-specific expertise, Dr Alvarnas explained to reporters at a press conference here at the American Society of Hematology (ASH) 56th Annual Meeting.

Dr Joseph Alvarnas

In addition, most clinical trials of AHCT have excluded patients with HIV, he added.

In an effort to open up these two closed worlds, a clinical trial of AHCT was undertaken in patients with HIV-related lymphoma that had relapsed or was refractory.

Among 40 patients who participated, the overall 1-year survival rate was 86.6%, and the progression-free survival rate was 82.3%, both of which compared well with 151 matched control patients with lymphoma who did not have HIV.

In fact, there was no statistically significant difference between the HIV-related lymphoma patients and the control patients for rates of survival, treatment failure, disease progression, and treatment-related mortality.

Dr Alvarnas summarized that patients with HIV-related lymphoma that is responsive to antiviral treatment “should be considered candidates for autologous HCT if they meet standard transplant criteria.”

The implication was that these patients can be treated in a much wider range of facilities and not just centers with HIV specialization.

Another expert agreed.

“I think the data you saw today will change the standard of practice,” said Brad Kahl, MD, of the University of Wisconsin Carbone Cancer Center, in Madison. “The impact is large,” he added.

The exclusion of these patients in clinical trials “on the basis of HIV infection alone” is “no longer justified,” added Dr Alvarnas.

And thus another barrier in HIV disease should be dropped, suggested both clinicians.

Prognosis Used to Be Less Than 2 Months

The limited opportunities for patients with HIV-related lymphoma are a legacy of their dismal prognosis before the advent of combination antiviral therapy (cART), suggested Dr Alvarnas.

“When I started in San Francisco at UCSF back in 1985, the median survival for someone [with HIV] diagnosed with one of these lymphomas was less than 2 months,” he told an audience of reporters at a meeting press conference.

Dr Alvarnas explained that the effectiveness of cART for HIV enabled this new study.

He said that the hallmarks of cART ― such as viral suppression, recovery of T-cell immunity, and decreased infections ― allowed oncologists to offer standard antilymphoma therapies to HIV- infected patients.

In the new study, researchers from the National Cancer Institute Bone Marrow Transplant Clinical Trials Network worked in collaboration with the AIDS Malignancy Consortium.

All 40 patients had received fewer than 2 salvage regimens. Prior to transplant, 30 patients (75%) were in complete remission (CR), eight (20%) were in partial remission (PR), and two (5%) had relapsed/progressive disease (RPD).

Patients underwent AHCT using the BEAM regimen (carmustine 300 mg/m2 [day -6], etoposide 100 mg/m2 twice daily [days -5 to -2], cytarabine 100 mg/m2 [days -5 to -2], and melphalan 140 mg/m2 [day -1]).

Patients received AHCT on day 0 and standard supportive care through discharge. Antiviral therapy was withheld during the preparative regimen and until any therapy-related GI toxicity (nausea and vomiting) had resolved.

At 100 days posttransplant, 36 patients (92.3%) had achieved complete response, one (2.6%) had reached partial remission, and two (5.1%) had relapsed.

Within a year after transplant, 17 patients (42.5%) developed a total of 42 unique infections. Nine of 17 patients developed severe infection.
By 1 year posttransplant, five patients had died (three from recurrent/persistent disease, one from cardiac arrest, and one from invasive fungal infection). The cumulative incidence of treatment-related mortality was 5.2%. This was a secondary outcome and was also not statistically significantly different from the outcomes seen in control patients.