A Prognostic Index for Systemic AIDS-Related Non-Hodgkin Lymphoma Treated in the Era of Highly Active Antiretroviral Therapy

  1. Mark Bower, MA, PhD;
  2. Brian Gazzard, MD;
  3. Sundhiya Mandalia, PhD;
  4. Tom Newsom-Davis, MB BS;
  5. Christina Thirlwell, MB BS;
  6. Tony Dhillon, MB BS;
  7. Anne Marie Young, MB BS;
  8. Tom Powles, MD;
  9. Andrew Gaya, MB BS;
  10. Mark Nelson, MD; and
  11. Justin Stebbing, MA, PhD
  1. From The Chelsea and Westminster Hospital, London, United Kingdom.

    Abstract

    Background: The established International Prognostic Index for lymphomas has not included patients with systemic AIDS-related non-Hodgkin lymphoma.

    Objective: To establish the most appropriate prognostic index for use in patients with systemic AIDS-related non-Hodgkin lymphoma.

    Design: A prospective study involving univariate and multivariable analyses of patients with AIDS-related non-Hodgkin lymphoma whose data were used to examine standard and new criteria for survival after diagnosis.

    Setting: The Chelsea and Westminster cohort of HIV-1–infected persons.

    Patients: 9621 HIV-positive patients, 111 in whom AIDS-related non-Hodgkin lymphoma was treated after 1996, in the era of highly active antiretroviral therapy (HAART).

    Intervention: Cox proportional hazards regression analysis to determine the prognostic significance of multiple clinicopathologic variables.

    Results: Survival of patients with AIDS-related non-Hodgkin lymphoma has increased in the HAART era (log-rank chi-square, 9.23; P = 0.002). Univariate analyses using the established International Prognostic Index factors of age, tumor stage, lactate dehydrogenase level, Eastern Cooperative Oncology Group performance status, and number of extranodal sites were confirmed to be significant variables. Regression modeling for patients in whom disease was diagnosed after 1996 revealed only 2 independent predictors of death: International Prognostic Index risk group and CD4 cell count. These predictors yielded 4 internally validated risk strata with predicted 1-year survival rates of 82%, 47%, 20%, and 15% (P < 0.001). Prognostic risk scores in the highest quartile yielded a likelihood ratio for death of 7.90 (hazard ratio, 1.0), whereas a prognostic score less than 1.0 yielded a likelihood ratio of 0.23 (hazard ratio, 0.15 [95% CI, 0.06 to 0.33]).

    Limitations: The sample was small, and different HAART regimens were used.

    Conclusions: For patients with AIDS-related non-Hodgkin lymphoma that was diagnosed in the era of HAART, application of the International Prognostic Index remains useful. The addition of CD4 cell count provides further independent prognostic information. Patients who present with AIDS-related non-Hodgkin lymphoma and a low CD4 cell count have a poor prognosis; this information can be used to guide therapeutic options.

    Article and Author Information

    • Potential Financial Conflicts of Interest: None disclosed.

    • Requests for Single Reprints: Mark Bower, MA, PhD, or Justin Stebbing, MA, PhD, The Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, United Kingdom; e-mail, m.bower{at}imperial.ac.uk or j.stebbing{at}imperial.ac.uk.

    • Current Author Addresses: Drs. Bower, Gazzard, Mandalia, and Nelson: The Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, United Kingdom.

    • Drs. Newsom-Davis, Dhillon, Young, and Powles: Charing Cross and Hammersmith Hospitals NHS Trust, London W6 8RF, United Kingdom.

    • Dr. Thirlwell: Cancer Research UK, Lincoln's Inn Fields, London WC2A 3PX, United Kingdom.

    • Dr. Gaya: Northwick Park Hospital, Watford Road, London HA1 3UJ, United Kingdom.

    • Dr. Stebbing: St. Bartholomew's Hospital, Bodley Scott Chemotherapy Unit, East Wing, West Smithfield, London EC1A 7BE, United Kingdom.

    • Author Contributions: Conception and design: M. Bower, B. Gazzard, S. Mandalia, M. Nelson, J. Stebbing.

    • Analysis and interpretation of the data: M. Bower, B. Gazzard, T. Newsom-Davis, C. Thirwell, T. Dhillon, J. Stebbing.

    • Drafting of the article: M. Bower, A. Gaya, J. Stebbing.

    • Critical revision of the article for important intellectual content: M. Bower, A.M. Young, T. Powles, A. Gaya, J. Stebbing.

    • Final approval of the article: M. Bower, B. Gazzard, C. Thirwell, T. Dhillon, A.M. Young, A. Gaya, J. Stebbing.

    • Provision of study materials or patients: M. Bower, A.M. Young, J. Stebbing.

    • Statistical expertise: M. Bower, S. Mandalia, J. Stebbing.

    • Obtaining of funding: M. Bower, B. Gazzard, J. Stebbing.

    • Administrative, technical, or logistic support: M. Bower, B. Gazzard, A.M. Young, J. Stebbing.

    • Collection and assembly of data: M. Bower, B. Gazzard, T. Dhillon, A.M. Young, J. Stebbing.

    Responses to this article

    • In response
      • Justin Stebbing and
      • Mark Bower PhD FRCP Brian Gazzard MD FRCP
      Ann Intern Med published online October 26, 2009
    • Prognostic modeling in AIDS-related lymphoma
      • Ewout W Steyerberg and
      • and Frank E. Harrell Jr, PhD
      Ann Intern Med published online October 26, 2009
    • A Prognostic Index for Systemic AIDS-Related Non-Hodgkin’s Lymphoma Treated in the Era of HAART
      • Regis A Vilchez
      Ann Intern Med published online October 26, 2009
    • To the Editor
      • Eiji Kusumi and
      • Naoko Murashige, Masahiro Kami
      Ann Intern Med published online October 26, 2009

    Summary for Patients

    • Summaries for Patients:Estimating Outcome in Patients with HIV-Related Lymphoma Ann Intern Med August 16, 2005 143:I-28
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