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HIV-associated lymphomas

Written2016-05Annunziata Gloghini, Antonino Carbone, Liron Pantanowitz
Department of Diagnostic Pathology and Laboratory Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy. annunziata.gloghini@istitutotumori.mi.it (AG); Department of Pathology Centro di Riferimento Oncologico Aviano (CRO), Istituto Nazionale Tumori, IRCCS, Aviano, Italy. acarbone@cro.it (AC); Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. pantanowitzl@upmc.edu (LP)

Abstract Lymphoma remains the most frequent neoplastic cause of death among HIV-infected individuals.
Lymphomas in patients infected with HIV are heterogeneous, not only pathologically but also in terms of pathogenetic pathways and cellular derivation.
This CARD summarizes the association of the different types of HIV-associated lymphomas with known genetic lesions and/or oncogenic viruses.
In the setting of HIV infection different, but not mutually exclusive, pathogenic pathways might occur.
For a distinct pathway of AIDS-related lymphomagenesis there can be multiple associated genetic lesions in the tumor.
Several of the HIV-associated lymphomas are also related to EBV and/or KSHV (HHV-8) infection.

Keywords AIDS-related lymphoma; HIV-associated lymphoma; HIV; lymphoma, gamma herpesviruses

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Identity

ICD-Topo C420,C421,C424
Atlas_Id 1732
Other namesAIDS-related lymphomas
HIV-related lymphomas;
Lymphomas associated with HIV infection

Clinics and Pathology

Disease The most common lymphomas arising in HIV-infected individuals include Burkitt lymphoma (BL) and diffuse large B-cell lymphoma (DLBCL). Classical Hodgkin lymphoma (cHL) is also common. Other lymphomas include primary effusion lymphoma (PEL) and its solid variants, lymphoma associated with Kaposi sarcoma herpesvirus (KSHV)-related multicentric Castleman Disease (MCD), and plasmablastic lymphoma (PBL) (Table 1) (IARC 2012; Dolcetti et al., 2016;). The latter three types of lymphomas rarely occur in the general population.
Table 1. Categories of HIV-associated lymphomas

Burkitt lymphoma- mostly plasmacytoid

Primary central nervous system lymphoma

Diffuse large B-cell lymphoma, including primary central nervous system lymphoma (immunoblastic, plasmacytoid and centroblastic)

Plasmablastic lymphoma

Primary effusion lymphoma (PEL) and its solid variant (Classic PEL - in the absence of tumor masses; Solid PEL with or without serous effusion)

Multicentric Castleman Disease (MCD)-associated large cell lymphoma

Hodgkin lymphoma

Other histotypes (rare)

 

Marginal zone lymphoma

 

Unclassifiable lymphomas with features intermediate between Burkitt lymphoma and diffuse large B-cell lymphoma

 

Polymorphic B-cell lymphoma (PTLD-like)

Epidemiology Lymphoma is still the most frequent neoplastic cause of death among HIV-infected individuals (Grulich et al., 2015). Young and middle-aged people afflicted with HIV infection are most often affected. The age of lymphoma occurrence is dependent on the patient's age of HIV infection. Although the incidence of HIV-associated non-Hodgkin lymphomas has declined after the introduction of combination antiretroviral therapy (cART), these lymphomas remain the main type of cancer to be detected in HIV-infected people. Curiously, the incidence of cHL has increased since the Highly Active Antiretroviral (HAART) era whereas the incidence of other HIV-associated lymphomas remains stable. This high incidence of lymphomas, despite the immunoreconstitution promoted by cART, strongly suggests that factors other than HIV-related immunosuppression are probably still acting as lymphomagenic factors in the HIV setting (Pantanowitz et al., 2015; Dolcetti et al., 2016;).
Clinics Sex. There is an apparently higher risk of HIV-associated lymphomas in men than women.
Site. Lymphomas that develop in HIV-infected patients are predominantly aggressive B-cell malignancies. These lymphomas display a marked propensity to involve extra-nodal anatomic sites such as the central nervous system, gastrointestinal tract, liver, bone marrow, and perinodal soft tissue. At diagnosis, most patients with HIV-associated HL present with advanced stages of disease with involvement of such extranodal sites.
Pathology Macroscopy.
Most HIV-associated lymphomas present with extra-nodal tumour masses, lymphadenopathy with necrosis, and/or effusion.
Microscopy
Burkitt lymphoma (BL). HIV-associated BL includes cases that exhibit classic BL features, as well as cases that show plasmacytoid differentiation (Gloghini et al., 2013).
Diffuse large B-cell lymphoma (DLBCL). DLBCL can be morphologically heterogeneous. The different morphological variants of DLBCL include the centroblastic variant, immunoblastic variant (which requires there to be at least 90% of immunoblasts with plasmacytoid features), and the anaplastic variant (Carbone et al., 2001; Gloghini et al., 2013). Primary DLBCL of the central nervous system (PCNSL) associated with HIV infection usually belongs to the immunoblastic type.
Primary effusion lymphoma (PEL). Lymphoma cells range from large tumor cells showing anaplastic morphology to cells with immunoblastic or plasmablastic morphology. These lymphomas frequently display a certain degree of plasma cell differentiation (Carbone et al., 2001; Cesarman et al., 1995).
Plasmablastic lymphoma (PBL). These lymphomas can be subdivided into two morphologic subgroups: 1) lymphomas comprised of a monomorphic population of plasmablasts with no/minimal plasmacytic differentiation, and 2) lymphomas with plasmacytic differentiation, composed of plasmablasts and cells showing plasma cell differentiation (Delecluse et al., 1997; Stein et al., 2008).
Classical Hodgkin lymphoma (cHL). cHL is currently the most common type of non-AIDS-defining cancer. Common encountered histological subtypes in HIV-positive patients include mixed cellularity and lymphocyte depleted cHL (Carbone et al., 2014; Uldrick and Little, 2015).
Immunophenotype
BL: CD45+, CD20+, CD10+, BCL6+, BCL2-, MYC+, Ki67+ 100%
DLBCL (CB): CD45+, CD20+, BCL6+, MUM1/IRF4-, CD138-
DLBCL (IB): CD45+, CD20-/+, BCL6-, MUM1/IRF4+, CD138-
DLBCL (IB with plasmacytoid features): CD45+/-, CD20-/+, BCL6-, MUM1/IRF4+, CD138+
PEL: CD45+, CD20-, T/NK markers+/-, CD30+, CD138+, EMA+/-, LNA-1+
PBL. CD45+/-, CD20+/-, CD79a+/-, PAX5-, CD138+, EMA+/-, CD31-/+, LNA-1-
cHL (Reed Sternberg cells): CD45-, CD20-/+, PAX5+, CD30+, CD15+/-, OCT-2+, BOB.1-, LMP1+
 
Figure 1. HIV-associated Burkitt lymphoma involving the colon (H&E stain, 40x magnification).
 
Figure 2. HIV-associated pericardial primary effusion lymphoma (cell block preparation, H&E stain, 40x magnification).
 
Figure 3. HIV-associated classical Hodgkin lymphoma of mixed cellularity subtype (H&E stain, 40x magnification).
Treatment The combination of cART and chemotherapy treatment has resulted in a remarkable prolongation of survival among HIV-infected patients with lymphoma. Safety and efficacy of combined treatment including rituximab plus chemotherapy (R-CT) has been documented (Dunleavy and Wilson, 2012; Carbone et al., 2014). HIV-associated Hodgkin lymphoma shows unusually aggressive clinical behaviour, which mandates the use of specific therapeutic strategies. The combination of cART with better supportive therapy has made standard ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) and intensive chemotherapy regimens feasible in patients with HIV-associated Hodgkin lymphoma (Carbone et al., 2014; Uldrick and Little, 2015).
Prognosis The outcome of HIV-associated lymphomas including Non-Hodgkin and Hodgkin lymphomas has dramatically improved since the introduction of cART with intensive chemotherapy regimens (Carbone et al., 2014;Uldrick and Little, 2015).

Genetics

Immunodeficiency states usually increase susceptibility to cancer as a result of reduced immune surveillance and enhanced chances for viral-driven oncogenesis. The viral contribution to the development of HIV-associated malignancies has been extensively studied (IARC 2012); but only two oncogenic viruses -i.e., Epstein Barr virus (EBV) and Kaposi sarcoma-associated herpesvirus (KSHV)/Human Herpresvirus-8 (HHV8) - have been pathogenically associated with specific lymphomas occurring in the HIV setting (Carbone et al., 2009). Table 2 lists those lymphoid proliferations occurring in HIV-infected patients that are known to be associated with infection by EBV and/or KSHV. Importantly, these co-infected lymphomas are frequently associated with single or multiple genetic lesions, as shown in Table 2 (Carbone et al., 2001; Chadburn et al., 2013). The HIV virus itself is thought to contribute to lymphomagenesis through induction of chronic B-cell activation, due to HIV-mediated immune dysfunction. In summary, the pathogenesis of HIV-associated lymphomas is the result of different factors including impaired immune surveillance, genetic alterations, viral infection and chronic B-cell activation.
Table 2. Co-infected lymphomas in people with HIV/AIDS
Histotype

BL

DLBCL-CB

DLBCL-IB

PBL

PEL

Viral Infection

 

 

 

 

 

           EBV

+/-

-/+

+

+/-

+/-

           KSHV

-

-

-

-

+

Genetic abnormalities

 

 

 

 

 

           BCL2

-

-

30%

20%

-

           BCL6

100%

>75%

-

<10%

-

           TP53

50-60%

Rare

-

-

-

           MYC

100%

0-50%

-

40%

-


Abbreviations. BL, Burkitt lymphoma; CB, centroblastic; DLBCL, diffuse large B-cell lymphoma; EBV, Epstein Barr virus; HIV, human immunodeficiency virus; IB, immunoblastic; KSHV, Kaposi sarcoma-associated herpesvirus; PEL, primary effusion lymphoma; PBL, plasmablastic lymphoma;
+, positive in 100% of cases; -, negative in 100% of cases; -/+, positive in less than 50% of cases; +/-, positive in more than 50% of cases

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Citation

This paper should be referenced as such :
Gloghini A, Carbone A, Pantanowitz L
HIV-associated lymphomas;
Atlas Genet Cytogenet Oncol Haematol. in press
On line version : http://AtlasGeneticsOncology.org/Anomalies/LymphomAssocHIVID1732.html


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