Acute Leukemias - Republican Scientific Medical Library

a 15.7 ·L 3ALL in Adults Positive for the Human Immunodeficiency Virus (HIV) 199
none of the patients who relapsed could be durably salvaged
[17–19]. Those patients generally had failure, only
PR, or had rapid relapse after salvage treatment, and
rarely achieved sufficient tumor reduction to envisage
subsequent intensification by allogeneic or autologous
SCT.
Outcome of adult L3ALL patients who had PR or relapsed
after first-line, more optimal intensive protocols
(SFOP, BFM or German ALL trials) also appeared dismal.
In the French experience [35], four of the six adult
L 3ALL patients refractory or who relapsed after first line
treatment were refractory to salvage treatment. The remaining
two patients, who had sufficient tumor response
with salvage chemotherapy, could be intensified
by allo (one case) or auto (one case) SCT. However, they
also rapidly died from relapse. Only two patients in the
report of Soussain et al. [35] on adult BL and L 3ALL
could be salvaged after a relapse, but they initially
had stage I and stage II E BL. Outcome of relapses was
not detailed in Hoelzer’s et al. study [9], but none of
the patients who relapsed appeared to have obtained
subsequent disease cure.
The EBMT recently assessed the benefit of allogeneic
bone marrow transplant when compared to high-dose
therapy and autologous stem cell reinjection in lymphomas
including Burkitt lymphomas [45]. No benefit was
observed with allogeneic bone marrow transplant when
compared to autologous bone marrow transplant in this
series including 71 patients who received an allograft
compared to 416 patients who received an autograft.
Most of the patients were intensified when their disease
remained chemosensitive, but results with allogeneic or
autologous bone marrow transplant were disappointing.
Allogeneic bone marrow transplant gave similar results
to autologous bone marrow transplant, with a median
survival of 4.7 months from the date of transplant and
a progression-free survival of 2.5 months [37].
15.7 L3ALL in Adults Positive for the Human
Immunodeficiency Virus (HIV)
Although the number of HIV-associated NHL is now decreasing
with improvement of treatment of HIV infection
in industrialized countries, this virus has led to a
major increase in BL cases. For example, the National
Cancer Institute of Italy recently reported, during an
8-year period, 131 cases of HIV-associated NHL, of
which 46 (35%) were BL. During the same time, only
29 of the 1004 (2.8%) negative NHL diagnosed at the
same institution were BL [48]. Large studies have shown
that, in HIV-positive patients, BL tended to develop at a
stage when immune functions are still relatively preserved,
whereas other types of HIV-associated NHL (including
large cell NHL, immunoblastic NHL, and Burkitt-like
NHL), tend to develop at a stage of profound
immunodeficiency. EBV infection is also found less often
in HIV-associated BL than in HIV-associated immunoblastic
NHL [49].
Bone marrow involvement is reported in 20–60% of
HIV-associated BL. However, it is unclear from most
published series how many of those patients fulfilled
criteria for L3ALL [49]. Only occasional cases clearly described
as HIV-associated L3ALL have been reported
[17–19].
The outcome of HIV-associated NHL is generally
poorer than that of NHL occurring in HIV-negative patients,
due both to greater aggressiveness of the disease
and to the underlying poor general condition and immune
deficiency. In HIV-associated BL, CR rates of
20–45%, and median survival of 3–6 months have generally
been reported with chemotherapy [19, 50–51]. Details
regarding patients with bone marrow involvement
were not available in those reports, however. In the report
of the Italian NCI [48], treatment results in HIVpositive
adult BL, regardless of disease stage, were less
favorable than in HIV-negative BL: CR rate of 40% vs.
65% (p = 0.03). The difference was due to a higher incidence
of deaths from opportunistic infections in
HIV-associated BL, but also to the fact that HIV-positive
cases were generally treated less intensively. Survival
was also poorer in HIV-positive BL (median 7 months)
as compared to HIV-negative BL (median not reached).
DFS at 4 years was, however, identical in the two groups
(74 vs. 73%). The French BL study group also reported
18 cases of BL, among 103 cases of HIV-positive NHL
[52]. Only two of the 18 patients met criteria for AIDS
before the diagnosis of NHL. Bone marrow involvement
was reported in seven of them, but the degree of marrow
infiltration was not known. Those seven patients received
high-dose CHOP plus CNS prophylaxis. Only
two of them achieved CR, and they both had prolonged
response.
Treatment results in the rare cases of precisely described
L3ALL in HIV-positive patients were uniformly
poor [17–19]. The possible impact of highly active antiretroviral
therapy (HAART) in combinations with intensive
Burkitt protocols has recently been investigated