PROGNOSIS STUDY OF HIV-RELATED LYMPHOMA

CHUN CHAO, PH.D.,

DEPARTMENT OF RESEARCH AND EVALUATION

KAISER PERMANENTE SOUTHERN CALIFORNIA

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HIV-INFECTION AND NON-HODGKIN LYMPHOMA (NHL)

• HIV-infected persons are at increased risk of developing NHL compared to the general population.AIDS defining cancer.

• Use of highly active antiretroviral therapy (HAART) has signif icantly decreased the occurrence of NHL in HIV+ persons.

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HIV INFECTION AND RISK OF NHL (CONT.)

• However, HIV-infected persons are st i l l at increase r isk of NHL in the HAART era.

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1 crude rate per 100,000 person-years2 Rate ratios from Poisson regression models included terms for HIV status, age, sex, calendar period, and race/ethnicity. Standard multiple imputation methods were used with imputation for missing race/ethnicity.Table source: Silverberg et al. AIDS 2009, 23(17): 2337-2345.

NHL IN HIV-INFECTED PATIENTS

Not only are HIV+ persons at signif icantly elevated r isk of NHL, they also tend to have a more aggressive course of disease.Diagnosed at advanced stageExtranodal involvement CNS lymphoma

B symptoms

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Graph source: http://diseaseminutely.com/diseases/infectious-diseases/hiv-and-aids/

CHANGE IN TREATMENT PARADIGM FOR HIV+ NHL

Before HAART, NHL mortal ity approaches 100%, and most standard treatment is highly toxic.

In the HAART era, CHOP appear to be tolerably by HIV+ patients diagnosed with NHL.

The safety of r i tuximab use in HIV+ patients has been controversial .

Time to evaluate care standard for HIV+ patients with NHL, and to investigate novel treatment approaches.

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SURVIVAL OF HIV+ NHL PATIENTS IN THE PRE- AND POST-HAART ERA

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Graph source: Lim et al, J Clin Oncol 2005;23:8477-8482.

SURVIVAL IN NHL PATIENTS

More than half (59%) of the HIV+ NHL died within 2 years, compared to 29% in HIV-uninfected cases.

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2-year overall mortality 2-year lymphoma-specific mortality

INCREASED MORTALITY IN HIV+ NHL PATIENTS – MULTIVARIABLE ANALYSES

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Table source: Chao et al. AIDS. 2010; 24(11): 1765–1770

PROGNOSTIC FACTORS IN HIV+ NHL PATIENTS

In the pre-HAART era, only CD4 cel l count, but not lymphoma characteristics, appeared to predict survival. In the HAART era, lymphoma characterist ics, such as stage, have been reported to predict survival in HIV+ NHL.

We are interested in identifying tumor markers that explain the aggressiveness and heterogeneity of HIV+ lymphoma.

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BACKGROUND – HIV+ DIFFUSE LARGE B-CELL LYMPHOMA

Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of HIV+ NHL.

HIV-related DLBCL is no longer invariably fatal and is heterogeneous in cl inical outcomes.Despite the availability of potentially effective

regimens for DLBCL treatment, more than 50% of HIV+ patients continue to succumb to the disease.

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Objective: To determine the prognostic significance of novel

viral/molecular markers in HIV-related DLBCL in the HAART era.

Rationale:Clinical prognostic factors, such as International Prognostic

Index (IPI), do not always accurately predict patient survival. A predictive equation combining clinical prognostic markers

and tumor markers may further enhance patient risk stratification.

Our results may help to identify new molecular therapeutic targets for resistant tumors.

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STUDY METHODS

Study Design: Cohort study.

Study population: HIV+ DLBCL cases diagnosed between 1996-2007 at KP Southern

and Northern California.

Data col lection on outcomes and covariates: Kaiser Permanente’s electronic medical records. Medical chart abstraction. Relevant clinical symptoms: e.g., B symptoms. Earliest date of known HIV infection. Clinical disease progression: e.g., relapse, progression.

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ANALYSIS OF TISSUE SPECIMENS

Pathology review: Selection of appropriate tissue specimen. Diagnosis confirmation and DLBCL subtyping. Two study pathologists independent conducted the assessment.

Discrepancy resolved by consensus.

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ANALYSIS OF TISSUE SPECIMENS (CONT.)

Archived FFPE tumor blocks. Tissue microarray and immunohistochemistry. EBV infection was determined by in situ hybridization of EBV-

encoded RNA (EBER). Tumor expression of selected B-cell oncogenic markers in the

following categories: Viral factor: EBV, HHV8. Cell cycle promoters: cyclin D2, cyclin E, cMYC, p27, SKP2. B-cell activators: BCL6, FOXP1, PKC-beta 2 and CD21. Apoptotic regulators: BCL2, p53, survivin, BAX, GAL3, and BLIMP1. Others: CD10, MUM1, Ki-67, CD44, CD30, CD43, LMO2, and

MMP9.

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IMAGE OF TMA CORES

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STUDY METHODS (CONT.)

Outcome of interest: Overall survival and progression-free survival.

Follow-up: Up to 5 years after DLBCL diagnosis (minimum 3 yrs).

Statist ical analysis: Multivariable Cox model. Propensity score used for adjusting for potential confounding.

Bootstrapping for validation.

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STUDY POPULATION

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STUDY POPULATION FOR TUMOR MARKER ANALYSIS

Of 194 HIV+ DLBCL cases identif ied; 80 had suff icient t issue for study inclusion.

We compared the demographic, HIV disease factors, DLBCL characterist ics, and co-morbidity history among those who did vs. did not have an adequate tumor specimen. No important difference was found between those who

were included vs. those who were not.

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BASELINE CHARACTERISTICS

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KP Northern

California

(N=131)

KP Southern California

(N=63)

Total (N=194)

  Mean (SD)/Percent

Age, yr 47 (10) 48 (10) 47 (10)

Male gender 97% 90% 95%

White Race 66% 49% 60%

Stage      

    I (Localized) 26% 19% 24%

    II (Regional) 17% 16% 16%

    III (Distant) 54% 49% 53%

Extranodal involvement      

    Stage I: 10, 11, 12 27% 22% 25%

    Stage II: 20, 21, 22, 23 16% 14% 15%

    Stage III: 30, 31, 32, 33 15% 16% 15%

Stage IV: 88 Disseminated

40% 44% 42%

B symptoms      

    No B symptoms 47% 46% 47%

    Any B symptoms 32% 43% 36%

    Unknown 21% 10% 17%

HIV risk group      

    Heterosexual 11% 22% 15%

    IDU 8% 0% 5%

    MSM 61% 30% 51%

    OTH/UNK 20% 48% 29%

Prior AIDS diagnosis 42% 63% 49%

Prior use of HAART 59% 71% 63%

CD4 cell count at DLBCL dx204.3 (181.08) 187.4 (159.82) 198.5 (173.84)

    Mean (SD), cells/mm3

FINDINGS OF TUMOR MARKER EXPRESSION

We found that Ki-67, PKC-beta 2, CD44, and survivin were expressed ( i .e. , 2+) in the majority of these HIV-related DLBCL cases.

On the other hand, expression of HHV8, CD21, cyclin D2, SKP2, and BLMIP1 was uncommon.

31% of cases were posit ive for EBV; 4% posit ive for HHV8.

We did not f ind universal CD20 expression in these cases, suggesting that CD20 might be lost in some HIV+ DLBCL.

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CLUSTER EXAMINATION OF TUMOR MARKERS

We examined the pair-wise Pearson’s correlation coefficient between the expressions of all markers.

The correlation coefficient was generally low (i.e., <0.25).

Notably, EBV and HHV8 infection status was associated with the expression of several markers.

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MARKER EXPRESSION & HAZARD RATIO (HR) OF MARKER POSITIVITY ON 2-YEAR MORTALITY

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Adjusted HR adjusted for stage, presence of B symptom, Germinal Center phenotype, prior AIDS and CD4 cell count.

HIV+ DLBCL PROGNOSTIC TUMOR MARKERS

Red : cMYC+, Blue: cMYC - Red : EBV+, Blue: EBV -

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In the crude analysis, cMYC, EBV and BLIMP1 positivity was associated with greater 2-yr overall mortality.

2-YEAR OVERALL SURVIVAL BY CD4 AND MARKER LEVELS

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Red: high CD4/low marker; Blue: high CD4/high markerGreen: low CD4/low marker; Black: low CD4/high marker

SUMMARY OF IMMUNODECIFENCY AND PROGNOSTIC TUMOR MARKER ANALYSIS

Cases with low CD4 and high levels of EBV or cMYC had worse survival.

Risk stratif ication may consider both CD4 and tumor marker expression, although confirmation is needed in larger studies.

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FUTURE STEPS

Future analysis wil l incorporate Progression-free survival. Validation using bootstrapping. Examination of trend in treatment pattern for HIV+ DLBCL. Effects of antiretroviral medication discontinuation on

lymphoma outcome. Tumor marker expression comparison by HIV infection

status.

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ACKNOWLEDGEMENTS

HIV-related DLBCL study investigator team:

Kaiser Permanente Southern California: Drs. Chun Chao (PI), Reina Haque, and Daniel H Zha.

Kaiser Permanente Northern California: Drs. Michael Si lverberg (site PI) and Laurel Habel.

University of California, Los Angeles: Drs. Jonathan Said (Site PI) and Otoniel Martínez-Maza.

University of California, San Francisco: Dr. Donald Abrams (Site PI).

Funding: R01CA134234-01 from the NCI (Chao), K01AI071725 from the NIAID (Silverberg).

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THANK YOU FOR YOUR ATTENTION

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Questions?