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In Reply:

Department of Medical Oncology, National Cancer Center of Singapore, Singapore

Roksana Karim

Department of Biostatistics and Epidemiology, University of Southern California, Los Angeles, CA

Bharat N. Nathwani

Department of Pathology and Epidemiology, University of Southern California, Los Angeles, CA

Anil Tulpule, Alexandra M. Levine

Division of Hematology, University of Southern California, Los Angeles, CA

We thank Dr Spina et al for their comments on our article published in the July 1, 2005, issue of the Journal of Clinical Oncology,¹ in which we first reported on our findings that HIV-associated Burkitt's lymphoma (HIV-BL) was an independent poor prognostic factor after treatment with standard combination chemotherapy in the HAART (highly active antiretroviral therapy), but not pre-HAART, era. In their current report involving 253 patients with HIV-associated lymphomas treated in both the pre-HAART and HAART eras, Spina et al confirmed our observation.

Recently, the same authors also reported the results of a multi-institutional phase 2 trial of infusional cyclophosphamide, doxorubicn, and etoposide (CDE) with rituximab (R-CDE) in 74 patients with HIV-associated lymphoma treated in the HAART era, which also included 28 patients with HIV-BL.² Although 57% of the patients had intermediate to high risk or high-risk disease by the age-adjusted international prognostic index, the complete remission rate and estimated 2-year survival rate with infusional R-CDE were 70% and 64%, respectively. These results were encouraging and appeared superior to those reported with methotrexate, bleomycin, doxorubicin, cyclophosphamide, vincristine and dexamethasone and cyclophosphamide, doxorubicin, vincristine and prednisolone in both the pre-HAART and HAART eras.^3,4 Nonetheless, despite the impressive results and the use of HAART, outcomes of patients with HIV-BL treated with infusional R-CDE were significantly worse than those of similarly treated patients with HIV-related diffuse large-cell lymphoma, suggesting that HIV-BL is indeed a more aggressive histologic entity.

Thus, data from both Spina et al and our group now suggest that both HIV-BL and HIV-related diffuse large-cell lymphoma in the HAART era should not be treated with the same approach.^1,2 More intensive regimens similar to those employed in HIV-uninfected patients should be prospectively investigated in this group of patients. Currently, the AIDS-Malignancy Consortium is conducting a randomized trial phase III study comparing concurrent administration of rituximab with EPOCH (R-EPOCH) to EPOCH followed sequentially by rituximab weekly for 6 weeks.⁵ Results of this trial, when completed, may help to further clarify the prognostic significance of histology in patients with AIDS-related lymphomas.

Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

REFERENCES

1. Lim ST, Karim R, Nathwani BN, et al: AIDS-related Burkitt's lymphoma versus diffuse large-cell lymphoma in the pre–highly active antiretroviral therapy (HAART) and HAART eras: Significant differences in survival with standard chemotherapy. J Clin Oncol 23:4430-4438, 2005[Abstract/Free Full Text]

2. Spina M, Jaeger U, Sparano JA: Highly effective treatment of acquired immunodeficiency syndrome-related lymphoma with dose-adjusted EPOCH: Impact of antiretroviral therapy suspension and tumor biology. Blood 101:4653-4659, 2003[Abstract/Free Full Text]

3. Kaplan LD, Strauss DJ, Testa MA, et al: Low-dose compared with standard-dose m-BACOD chemotherapy for non-Hodgkin's lymphoma associated with human immunodeficiency virus infection: National Institute of Allergy and Infectious Diseases AIDS Clinical Trials Group. N Engl J Med 336:1641-1648, 1997[Abstract/Free Full Text]

4. Ratner L, Lee J, Tang S, et al: Chemotherapy for human immunodeficiency virus–associated non-Hodgkin's lymphoma in combination with highly active antiretroviral therapy. J Clin Oncol 19:2171-2178, 2001[Abstract/Free Full Text]

5. Dunleavy K, Little R, Gea-Banacloche J, et al: Abbreviated treatment with short-course dose-adjusted epoch and rituximab (da-epoch-r) is highly effective in aids-related lymphoma (ARL). ASH Annual Meeting Abstracts 104:3111, 2004[Abstract/Free Full Text]

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Related Correspondence

• Patients With HIV With Burkitt’s Lymphoma Have a Worse Outcome Than Those With Diffuse Large-Cell Lymphoma Also in the Highly Active Antiretroviral Therapy Era
  Michele Spina, Cecilia Simonelli, Renato Talamini, and Umberto Tirelli
  JCO 2005 23: 8132-8133 [Full Text]

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