Why is it important to have specific practical guidelines on
HIV lymphomas? Yeah, as I say, the incidence is
decreasing, but the incidence is 4/24 higher than in general
lymphoma population. And what is also important that
the most frequent type of cancer in people living with HIV.
The the lymphomas and lymphomas contribute to a significant
morbidity and mortality to for this patient and the mortality
rate for for lymphomas is higher than for opportunistic,
opportunistic infections. And so there's a good reason to
take care of these patients. Welcome to EHA Unplugged, the
official podcast channel of the European Hematology Association.
EHA. I am your host Isabella Rivera.
We're here today with Professor Kai Hubel.
Can you please introduce yourself?
Yeah, my name is Kai Hubel. I'm a hematologist and
oncologist from the University Hospital of Cologne in Germany.
I'm practicing now since more than 30 years, my scientific
interests focusing on lymphoid neoplasia, including HIV
associated lymphomas. And I'm also sharing the
European Network for HIV Associate Associated Lymphomas,
which was founded last year. It is part of the EHA Lymphoma
working Party. And we are now, we have now
around 25 members, which is really great.
We're here to discuss the EHA ESMO clinical practice
guidelines on HIV associated lymphomas.
So can you explain first what's your involvement on these
guidelines was I'd? Let me say it was a great
experience to develop such a guideline.
I never thought that it needs more than two or 2 1/2 years
from the very beginning and to getting on the guideline
published. The first challenge was to to
gather a group of very experienced investigators from
different European countries. And the second challenge was to
find a contents on the guide because I really learned that
HIV lymphomas are treated differently in different
European countries and we have to find a consent.
But finally we got it published, I think it was since the summer
last year, so. Why is it important to have
specific practical guidelines on HIV lymphomas?
Yeah, if you see the incidence of HIV associated lymphomas, the
incidence is decreasing since the beginning of the century,
mainly because of the introduction of the modern or
combined antiretroviral therapy C ART.
So this is a good question. Why do we need a guideline?
But there are several reasons. First, the outcome of HIV
associated lymphomas is different or it's worse than for
non HIV associated lymphomas. For example, if you have a blood
lymphoma, you can treat patients with a very intensive protocol.
But if the patient has has Ava bloody lymphoma, then there's a
high rate of fatalities of around 10%.
So we need different treatment approaches.
Another reason is that the con cumin therapies are different
between HIV and non HIV associated lymphomas.
Another reason is that there are rare lymphomas more or less
exclusively developing in people living with HIV.
For example, it's a primary funeral lymphomas and we need
guidelines recommendations for these patients.
And finally, we have a lot of modern treatment approaches like
the T set directed therapies and of course we need a
recommendation. Can we use these therapies in
HIV infected patients? You touched a bit on this, but
how prevalent are HIV associated lymphomas?
Yeah, as I said before, the incidence is decreasing, but the
incidence is 4/24 higher than in general lymphoma population.
And what is also important that the most frequent type of cancer
in people living with HIV is the RV lymphomas and lymphomas
contribute to a significant morbidity and mortality to for
this patient. And the mortality rate for for
lymphomas is higher than for opportunistic, opportunistic
infections. And so there's a good reason to
take care of these patients. Which are the most common
histological types of HIV associated lymphomas?
The most frequent HIV HIV associated lymphomas are other
diffuse large B cell lymphomas that accounts for about 20, 36
or 37%, followed by the Hodgkins lymphomas with with a rate of
26% and the Burger lymphomas with a rate of 20%.
Is the prevalence the same as informers that are not
associated to HIV? It's nearly the same for the
diffuse slash B cell lymphoma but it but it's not the same for
the burger lymphoma is more frequent and what we've rarely
seen in HIV affected patients is the Internet lymphomas and we
only see rare CNS lymphomas mainly because of the CRT.
What are the main challenges in diagnosing HIV associated
lymphomas? How do you combine the
procedures for the diagnosis of lymphomas with the procedures to
assess HIV? Let me say in general we can use
the same diagnostic procedures as the use in non HIV associated
lymphomas. But for example, there's an
ongoing discussion about the PET CT scan, because if you use a
PET CT in patients with HIV infections, then you may have a
high rate of false positive results, mainly due to
overlapping infections or due to immune disregulations, which
should lead to an hyperplasia of the lymph nodes.
So be careful if you use a CT scan, a PET CT scan.
And we often use a situation that the diagnosis of the HIV
infection is a diagnosis of the lymphomas.
It's the same time. And in this situation, you have
to follow for the HIV infections recommendation for newly
diagnosed HIV infections. How do you combine the
antiretroviral treatment for HIV with the lymphoma treatments?
This is a very important question and there was content
in the guideline that is no reason to stop the CRC entero
retroviral therapy during the lymphoma treatment.
Sometimes investigators are a little bit uncertain to continue
the CR during lymphoma treatment because of maybe interactions,
but there's no reason to stop it.
Also if you use a high dose chemotherapy or not only
transmutation or a Carkeesa therapy, does this mean that
there is no interaction? No, there could be an
interaction between the retroviral therapy and
cellophoma treatment. So if you are not you are
unfamiliar with this, you have to ask a HIV specialist or you
can visit websites who may have you.
But again, no reason to stop the anti retroviral therapy.
It's dangerous to stop. It it's a very important part of
the lymphoma therapy. We know that since we have the
modern angioedral viral therapy available, it's a prognosis.
It's much better for the patients.
How do you manage the increased risk of infections on HIV
lymphoma patients? Well, if the patient has a good
immune system that let me say in 64 cell count of more than 200,
you can for the same recommendation As for the HIV
negative patients. However, if the cell count is
less than 200, we recommend a general PCP prophylaxis and we
also recommend an antiviral prophylaxis, especially if the
patient has a history of a viral infection.
And if the patient has the CD 4's hair count less than 100, we
recommend the CMB monitoring and also we'll cause it and
candidias as prophylaxis. So this is a little bit
different from the HIV negative lymphomas.
It depends a little bit on the CD 4's hair counts.
This is about. So what are the key differences
for you in treating an HIV positive versus an HIV negative
lymphoma? So let me say in most situations
we can use the same therapies for the HIV positive and HIV
negative lymphomas, but there are some differences.
I will give you some examples. First, the use of rituximab.
Rituximab significantly improves the overall outcome of patients
with B cell lymphomas and this was also shown for the HIV
associated lymphomas. However, we know from randomized
trials that if the patient has ACD 4 cell count less than 50
and you use rituximab and you have a higher rate of fatal
infections. So there's a general
recommendation to be careful with the use of rituximab if the
CD 4 cell count is less than 50. Another point, CAR T cells, I
know in different European countries CAR T cells are not
allowed in HIV lymphomas if it data are rare, but we know from
several case reports and we know from one clinical trial
including nearly 30 patients, CAR T cells are visible in HIV
lymphomas. So we gave the recommendation if
the patient has ACT 4 cell count of more than 200, then you can
use the CAR T cells if it's in label.
And I will briefly focus on the Burger lymphoma.
I said at the very beginning that we have a higher fatality
rate if you use an intensive regimen in HIV burger lymphoma.
So if the patient is in a good condition, you may use of course
an intensive protocol like the German female protocol or the M
Codex IVAC protocol. However, if the patient has
comorbidities, then you should not use these intensive
protocols. We recommend to use something
like those adjusted epoch R. The results are great for HIV
burger lymphomas, but, and this is also important only if the
patient has no CNS involvement and has no POMERA involvement.
And you also give, as I said this, as I said at the
beginning, give recommendations for rare lymphomas like the
plasmoblastic lymphomas or the primary fusion lymphomas.
So we would like to highlight that in this HA guidelines,
there are specific and detailed recommendations for DLBCL, for
Birkett's lymphoma, for plasma plastic lymphoma, for primary
fusion lymphoma, for CNS lymphoma, primary and
secondaries, for Hodgkin's lymphoma and more.
We cannot summarize everything in this podcast, of course, so
please check the full details in the paper in hemisphere.
The the full link will be in the description.
Is there anything else that we haven't touched on that you
would like to add for the audience about these guidelines?
I would like to to close this interview with a call because
it's so important that we get more data on HIV lymphoma.
So it is very important to open clinical trials for HIV, for
patients with HIV lymphomas. It's general.
In general, it's an exclusive criterion to have an IGV
infection. So I don't know understand why
please open clinical trials for HIV lymphomas.
And 2nd, to get more data, it is necessary to have a registry and
we have a European registry which is chaired by my colleague
Marco Sandrich Munich. And so if you treat patients
with HIV, inform us, please send us an e-mail or call us, and we
will try to include your patients in the registry.
Thank you very much, Professor Huwen, for being with us today
It. Was my pleasure.
And thank you to the audience for listening.
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