CHOP Chemotherapy for Aggressive Non-Hodgkin Lymphoma with and without HIV in the Antiretroviral Therapy Era in Malawi

• DOI: 10.1371/journal.pone.0150445
• Publication Date: 2016-03-02T18:40:22Z
• Authors: Satish Gopal; Yuri Fedoriw; Bongani Kaimila; Nathan D. Montgomery; Edwards Kasonkanji; Agnes Moses; Richard Nyasosela; Suzgo Mzumara; Carlos Varela; Maria Chikasema; Victor Makwakwa; Salama Itimu; Tamiwe Tomoka; Steve Kamiza; Bal M. Dhungel; Fred Chimzimu; Coxcilly Kampani; Robert Krysiak; Kristy L. Richards; Thomas C. Shea; N. George Liomba
• Keywords: Adult; Male; Malawi; Neutropenia; Lymphoma; Science; HIV Infections; Pathology and Forensic Medicine; 03 medical and health sciences; 0302 clinical medicine; Antineoplastic Combined Chemotherapy Protocols; Health Sciences; Humans; Chemotherapy; Post-Transplant Lymphoproliferative Disease; Lymphoid Neoplasms; Internal medicine; Cyclophosphamide; Lymphoma, Non-Hodgkin; Q; R; Gastroenterology; Non-Hodgkin's lymphoma; Diffuse large B-cell lymphoma; Middle Aged; Survival Analysis; International Prognostic Index; 3. Good health; Diagnosis and Treatment of Primary Central Nervous System Lymphoma; Oncology; Neurology; Doxorubicin; Vincristine; Antirheumatic Agents; Aggressive lymphoma; Prednisone; Medicine; Female; Viral-Related Cancers in Immunocompromised Patients; Rituximab; CHOP; Research Article

There are no prospective studies of aggressive non-Hodgkin lymphoma (NHL) treated with CHOP in sub-Saharan Africa. We enrolled adults with aggressive NHL in Malawi between June 2013 and May 2015. Chemotherapy and supportive care were standardized, and HIV+ patients received antiretroviral therapy (ART). Thirty-seven of 58 patients (64%) were HIV+. Median age was 47 years (IQR 39–56), and 35 (60%) were male. Thirty-five patients (60%) had stage III/IV, 43 (74%) B symptoms, and 28 (48%) performance status ≥2. B-cell NHL predominated among HIV+ patients, and all T-cell NHL occurred among HIV- individuals. Thirty-one HIV+ patients (84%) were on ART for a median 9.9 months (IQR 1.1–31.7) before NHL diagnosis, median CD4 was 121 cells/μL (IQR 61–244), and 43% had suppressed HIV RNA. HIV+ patients received a similar number of CHOP cycles compared to HIV- patients, but more frequently developed grade 3/4 neutropenia (84% vs 31%, p = 0.001), resulting in modestly lower cyclophosphamide and doxorubicin doses with longer intervals between cycles. Twelve-month overall survival (OS) was 45% (95% CI 31–57%). T-cell NHL (HR 3.90, p = 0.017), hemoglobin (HR 0.82 per g/dL, p = 0.017), albumin (HR 0.57 per g/dL, p = 0.019), and IPI (HR 2.02 per unit, p<0.001) were associated with mortality. HIV was not associated with mortality, and findings were similar among patients with diffuse large B-cell lymphoma. Twenty-three deaths were from NHL (12 HIV+, 11 HIV-), and 12 from CHOP (9 HIV+, 3 HIV-). CHOP can be safe, effective, and feasible for aggressive NHL in Malawi with and without HIV.