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 Zambia HIV National Guidelines
 


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WHO Staging in Adults and Adolescents  

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 Guide Editors
 Editor In Chief
    Joel E. Gallant, MD, MPH

Pharmacology Editor
    Paul Pham, PharmD, BCPS

Zambia Guideline Team
   Peter Mwaba MMed PhD FRCP
   Alywn Mwinga MMed
   Isaac Zulu MMed MPH
   Velepie Mtonga MMed
   Albert Mwango MBChB
   Jabbin Mulwanda MMed FCS
 

 

 

Diagnosis>Malignancies>
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Lymphoma, Hodgkins

Mark Levis, M.D., Ph.D. and Nina Wagner, M.D.
01-06-2009

  • Little specific information regarding incidence of HIV-related lymphoma in sub-Saharan Africa.
  • From available studies, there appears to be low rate or no association at all with Hodgkin's lymphoma.
  • In comparison, there is strong association between HIV and increased risk for non-Hodgkin's lymphoma.
  • Burkitt's lymphoma due to EBV remains a common childhood tumor in Africa regardless of HIV status.

REFERENCES

Zambia Information Author: Paul Auwaerter, M.D.

PATHOGENS

  • Almost always EBV-associated, unlike in HIV-negative pts.

CLINICAL

  • Risk of developing HL is 8-10 x higher in HIV-infected persons compared with general population. Incidence has unexpectedly increased in HAART era.
  • Associated with higher CD4 counts (~300) vs. NHL.
  • Pts often have diffuse lymphadenopathy but with uninvolved nodes. Lymphadenopathy can make Dx and accurate staging difficult.
  • Tends to present with advanced stage and in unusual locations, especially bone marrow.
  • Frequently presents with "B Sx," e.g., night sweats & weight loss, which are commonly associated with other AIDS-related illnesses.
  • Histologic subtypes in HIV+ population are less favorable mixed cellularity and lymphocyte-depleted variants.
  • Tumor cells show strong expression of EBV latent membrane protein-1 (LMP-1).

DIAGNOSIS

  • Bx of node or affected organ essential. Fine needle aspiration (FNA) is NOT desired mode of Dx, as usually non-diagnostic in Hodgkin's.
  • Immunophenotyping of paraffin block or flow cytometric analysis of cell surface markers (CD3, CD5, CD10, CD15, CD20, CD30, Ki-67) in combination with molecular studies (EBV or HHV-8, cytogenetics, FISH).
  • Staging workup should include chest/abdomen/pelvic CT, bone marrow Bx and aspirate, LP, CBC, LDH and complete chemistries.
  • Role of PET imaging in HIV-associated lymphomas is still unclear, though frequently obtained.

TREATMENT

Prognosis

  • International Prognostic Scores (IPS) useful in predicting outcome. Poor risk features in this index: albumin < 4 g/dL, Hgb < 10.5 g/dL, male sex, age >/= 45, stage IV disease, WBC >15,000, and lymphocytopenia (lymphocyte count < 600 and/or less than 8% of the WBC)
General considerations

  • HAART (either during or immediately following chemotherapy) is essential for any chance at prolonged survival.
  • AZT should be avoided as it can prolong or exacerbate chemotherapy-induced neutropenia.
  • ddI and/or d4T can increase incidence of neuropathy.
  • In post-HAART era, complete remission rates approach 80%, with overall survival greater than 50%.
  • G-CSF routinely used during chemotherapy to shorten duration of neutropenia.
Regimens

  • Standard regimens of ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) and Stanford V have been used.
  • Plans for a collaborative study evaluating Rituxan and ABVD are underway.
  • Case reports exploring autologous stem cell transplant for patients with relapsed/refractory disease demonstrate tolerance and efficacy.

REFERENCES

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