Management of lymphoma in a centre with high HIV and tuberculosis prevalence
Date
2021-12
Authors
Journal Title
Journal ISSN
Volume Title
Publisher
Stellenbosch : Stellenbosch University
Abstract
Background
The staging and management of patients with lymphoma (PWL) can be challenging
and is particularly so in environments of high HIV and TB prevalence such as South
Africa, for which there is little guidance.
The additional contribution of positron emission tomography/computerised
tomography (PET/CT) for assessing bone marrow involvement (BMI) in this setting is
also uncertain.
Methods
This cross-sectional analytic study evaluated the clinical profiles, therapeutic
interventions, including PET/CT scans, and outcomes of PWL at the Haematology
unit, Tygerberg Hospital.
We evaluated the potential utility of differential uptake of 18F- flouro deoxyglucose
(FDG) on PET/CT in identifying second pathologies such as HIV and TB, in
conjunction with clinical information and the use of additional testing, such a biopsy
of discrepant uptake. The relative frequencies and causes of discrepancies of
intensity of visual uptake of FDG, which the study termed the two-tone sign (2TS),
was evaluated in both HIV- positive and HIV-negative patients.
Results
Two hundred and eighty patients, 101 HIV-positive and 178 HIV-negative, were
recruited from a pool of 516 PWL, referred to the unit from March 2015 to March
2020. The median age of the patients was 42 years, with HIV-positive patients
significantly younger than the HIV-negative cohort (p= 0.02). Significantly more HIV-
positive patients had a history of TB or were on therapy for TB at presentation
(p=<0.01). However, HIV-negative patients had significantly more other co-
morbidities (p=<0.01). The 2 main subtypes of lymphoma were diffuse large B-cell lymphoma (DLBCL) and
Hodgkin lymphoma (HL), with DLBCL being commoner in HIV-positive and HL in
HIV- negative patients. Seventy-six percent of patients presented with advanced
disease, similar in HIV-positive and HIV-negative patients (75.2 vs.76.4%).
Complete remission rate was significantly better in HIV-negative patients with
DLBCL while, with HL, there was no significant difference in outcomes between HIV-
positive and HIV-negative patients.
The 2TS was found with a higher frequency in the HIV-positive group than HIV-
negative group (39.5% vs 25.3%), with a trend towards statistical significance
(p=0.056). Causes of a 2TS were HIV, TB, lymphoma, synchronous malignancies or
reactive uptake. In most patients, the cause of the discrepancy was identifiable and
disease burden and response to therapy could be assessed.
With respect to bone marrow involvement with lymphoma, congruence was
demonstrated between the bone marrow biopsy (BMB) and PET/CT in 63.2% of
patients with no significant difference between HIV positive and negative patients.
The overall sensitivity of PET/CT was 87% (CI: 77.4-93.6%) and specificity 75.2%
(CI: 66.7-82.5%). There was no impact of HIV on the BMB patterns on PET/CT,
despite there being HIV-associated changes on the BMB in some patients. None of
the patients evaluated, had TB on the BMB. Incongruence between BMB and
PET/CT was found in 17 HIV negative patients with HL, with diffuse bone marrow
uptake on PET/CT and a negative BMB.
Conclusions
This study demonstrated the complexities of patients with lymphoma managed at the
unit, both HIV-positive and HIV-negative. Despite the aggressive rollout of
antiretroviral therapy, many HIV-positive patients were not virologically controlled
and presented with advanced, aggressive subtypes of lymphoma. The study found
that it is possible to stage HIV-positive patients and those with TB using PET/CT,
provided this is done with all available clinical information. We propose that in
patients with HL and in most patients with DLBCL in our setting, both HIV-positive
and HIV-negative, BMB is not required for assessment of BMI.
AFRIKAANSE OPSOMMING: Geen opsomming beskikbaar
AFRIKAANSE OPSOMMING: Geen opsomming beskikbaar
Description
Thesis (PhD)--Stellenbosch University, 2021.
Keywords
Tuberculosis, UCTD, Lymphoma -- Patients -- Management, HIV-positive persons