Having HIV (human immunodeficiency virus) can increase the risk of developing lymphoma and affect the way lymphoma is treated. This information is about the diagnosis and treatment of HIV-related lymphoma.
This information should ideally be read with our general information about the type of lymphoma you have.
We hope this information answers your questions. If you have any further questions, you can ask your doctor or nurse at the hospital where you are being treated.
Lymphoma is a cancer of the lymphatic system. The lymphatic system is part of the body’s immune system and helps us fight infection. It is a complex system made up of organs such as the bone marrow, thymus, spleen and lymph nodes (sometimes called lymph glands). These are connected by a network of tiny lymphatic vessels that contain lymph fluid. Lymphatic tissue can also be found in other organs, such as the lungs, stomach and skin.
Lymph is a colourless fluid that circulates through the lymphatic system. It contains cells known as lymphocytes. Lymphocytes are a type of white blood cell that help the body fight infection and disease.
There are lymph nodes all over the body. As lymph fluid flows through the lymph nodes, the nodes collect and filter out anything harmful or anything the body doesn't need. This includes bacteria, viruses, damaged cells and cancer cells.
There are two main types of lymphocytes, called B-cells and T-cells. Most lymphocytes start growing in the spongy material in the centre of our bones where blood cells are made (the bone marrow). T-cells later move to the thymus gland (behind the breast bone) to mature, while B-cells develop in the bone marrow. When they are mature, both B-cells and T-cells help fight infections.
Lymphoma is a disease in which either B-cells or T-cells grow in an uncontrolled way. A lymphoma can cause various parts of the lymphatic system to enlarge and stop working effectively.
There are two main types of lymphoma:
Although they're both types of lymphoma, Hodgkin and non-Hodgkin lymphomas are treated in different ways.
HIV attacks T-cell lymphocytes called CD4 cells, which help the immune system respond to infections. This makes people with the virus more prone to developing serious infections and different types of cancer, including lymphoma. Lymphoma can develop at any time, but it is more common when the number of CD4 cells (the CD4 count) is low.
The number of people with HIV that develop lymphoma has dropped in recent years. We believe this is because of the introduction of new HIV treatment called highly active antiretroviral therapy (HAART), which is more effective at controlling the HIV infection.
There are different types of Hodgkin and non-Hodgkin lymphoma. People with HIV tend to develop:
aggressive (high-grade) B-cell non-Hodgkin lymphoma
mixed cellularity or lymphocyte-depleted Hodgkin lymphoma.
Rarely, a non-Hodgkin lymphoma will develop in the brain. This is called a CNS (central nervous system) lymphoma.
HIV-related lymphomas tend to be more aggressive than lymphomas in people who are HIV negative (doesn’t have HIV). However, research has shown that treatment for HIV (HAART) has helped improve survival in people with HIV-related lymphomas.
When someone with HIV develops certain types of cancer, the HIV is said to have progressed to Aids (acquired immune deficiency syndrome). Aggressive non-Hodgkin lymphoma is one of these cancers, so it is known as an Aids-defining cancer. Although the HIV is then classed as Aids, anti-HIV treatments (HAART) can help people to live well after treatment for non-Hodgkin lymphoma.
Hodgkin lymphoma is not an Aids-defining cancer.
The cause of most lymphomas is unknown. Some types of lymphoma are more common in people who have lowered immunity due to conditions such as HIV.
The HIV infection reduces the number of T-cells, which leads to an increase in the production of B-cells. The overproduction of B-cells can develop into non-Hodgkin lymphoma in people with reduced immunity (known as B-cell non-Hodgkin lymphoma).
Many HIV-related lymphomas are closely linked to other viruses, which also increase the risk of developing lymphoma. These viruses are both common in people with HIV-related lymphoma:
the Epstein-Barr virus (EBV), which causes glandular fever
the human herpes virus type 8 (HHV-8).
Like other cancers, lymphomas themselves are not infectious and can’t be passed on.
Signs and symptoms of lymphoma
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The first symptom is often a painless swelling in the neck, armpit or groin, caused by enlarged lymph nodes. Sometimes more than one group of nodes is affected. The lymphoma may spread to other organs in the body, such as the liver, spleen, bone marrow, skin, testicles or brain. Some people experience a loss of appetite and tiredness.
Other symptoms may include night sweats, unexplained high temperatures and weight loss. These are known as B symptoms.
If the lymphoma is affecting the brain (called CNS lymphoma), it can cause headaches, sickness (vomiting) and changes in eyesight. Other symptoms of CNS lymphoma may include fits (seizures), confusion, changes in behaviour and personality, weakness on one side of the body (hemiparesis), and loss of coordination and balance.
We have more information about the signs and symptoms of cancer.
How lymphoma is diagnosed
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Lymphomas are diagnosed by removing some of the affected tissue and examining the cells under a microscope. This is called a biopsy. You will be referred to a surgeon for this procedure. It’s a small operation and may be done under local or general anaesthetic.
Additional tests are used to get more information about the type of lymphoma and how far it has spread in the body. These may include:
a lumbar puncture to examine the cerebrospinal fluid (which protects your brain and spinal cord)
bone marrow samples.
The results of these tests are used to help decide which treatment is most appropriate for you.
Staging and grading of lymphoma
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The stage of a lymphoma describes how many groups of lymph nodes are affected, where they are in the body, and whether other organs such as the bone marrow or liver are affected.
The lymphoma is only in one group of lymph nodes, in one particular area of the body.
More than one group of lymph nodes is affected, but all of the involved nodes are contained within either the upper half or the lower half of the body. The upper half of the body is above the diaphragm (the sheet of muscle below the lungs), and the lower half is below the diaphragm.
Lymphoma has affected lymph nodes in both the upper and lower parts of the body (both above and below the diaphragm). The spleen is considered a lymph node in this staging system.
The lymphoma has spread beyond the lymph nodes to other organs, for example to the bone marrow, liver or lungs.
The stage usually includes the letter A or B, which describes whether the B symptoms are present or not. (For example, stage 2B.) Sometimes a lymphoma can start in areas outside the lymphatic system. This is represented by the letter E, which stands for extranodal. (For example, stage 3AE.)
Approximately two thirds (66%) of HIV-related lymphomas are at an advanced stage (stage 3 or 4) when first diagnosed. It is fairly common for HIV-related lymphoma to start outside the lymph nodes (extranodal) and to affect parts of the body such as the bone marrow, liver and lungs. HIV-related lymphoma may also affect unusual places in the body, such as the rectum (back passage), muscles or heart.
Non-Hodgkin lymphomas are usually divided into two groups:
indolent lymphomas (sometimes called low-grade lymphomas), which are usually slow-growing
aggressive lymphomas (sometimes called high-grade lymphomas), which are fast-growing and usually need treatment soon after they are diagnosed.
Almost all HIV-related non-Hodgkin lymphomas are aggressive. The two main types are diffuse large B-cell lymphoma (DLBCL) and Burkitt lymphoma (BL).
Treatment for HIV-related lymphoma
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The treatment for HIV-related lymphoma depends on a number of factors, including:
the type of lymphoma
your general health.
The treatment of HIV-related lymphoma is very specialised. It’s important that your cancer doctors and HIV doctors work together. You may be treated in a hospital that specialises in treating both people with HIV and people with cancer, and you may need to travel some distance for this.
Once your doctors have your test results, they will discuss with you the treatment they recommend.
Non-Hodgkin and Hodgkin lymphoma are treated differently. Non-Hodgkin lymphoma is usually treated with a combination of chemotherapy drugs, steroids and a monoclonal antibody. Radiotherapy is also sometimes used. Hodgkin lymphoma is usually treated with a combination of chemotherapy drugs and steroids. Radiotherapy is sometimes used for early-stage Hodgkin lymphoma.
As well as treatments for the lymphoma, you will be advised to start or continue taking highly active antiretroviral therapy (HAART) to treat the HIV.
The HAART will help boost your immune system and improve the chance of treatment for the lymphoma working. Your doctor may need to change the antiretroviral drugs that you've been taking, as some of them can react with chemotherapy. You should discuss this with your HIV doctors.
Chemotherapy for HIV-related lymphoma
Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. The type of chemotherapy used will depend on the stage and grade of the lymphoma as well as your general health. Usually a combination of chemotherapy drugs is used.
A commonly used treatment for non-Hodgkin lymphoma is called the R-CHOP regimen. This includes:
Burkitt lymphoma is commonly treated with a regimen called CODOX-M/IVAC. This includes the chemotherapy drugs cyclophosphamide, vincristine, doxorubicin, methotrexate, ifosfamide, etoposide and cytarabine.
Hodgkin lymphoma is often treated with the ABVD regimen, which includes the chemotherapy drugs doxorubicin, bleomycin, vinblastine and dacarbazine.
Usually you will have a number of cycles of treatment. A cycle usually consists of a few days of chemotherapy treatment followed by a rest period of about 2-4 weeks.
You may be given more chemotherapy if the lymphoma comes back after initial treatment.
Side effects of chemotherapy for HIV-related lymphoma
One of the main side effects of chemotherapy is a lowered resistance to infection. This happens because the chemotherapy temporarily reduces the number of white blood cells made by the bone marrow. People with HIV may already have a reduced immune system, so you will be closely monitored throughout your treatment.
The chemotherapy will also temporarily reduce the number of CD4 cells. Your CD4 count will begin to rise again once you finish the complete course of chemotherapy treatment. The chemotherapy shouldn’t affect the suppression of the HIV infection (viral load) as long as you are able to take the HAART medication.
Occasionally, the doses of chemotherapy may need to be reduced if the number of your white blood cells is too low. You may be given injections of G-CSF (granulocyte-colony stimulating factor) to boost the number of white blood cells produced by the bone marrow. These injections are given under the skin (subcutaneously).
During the chemotherapy treatment, and for a time afterwards, you may be given treatment to prevent infections that commonly affect people with HIV and lymphoma. Treatment to prevent an infection is called prophylaxis.
You may be given:
an antibiotic called co-trimoxazole (Septrin®), to prevent a type of pneumonia called PCP (pneumocystis carinii)
an antifungal drug, such as fluconazole (Azocan®) or itraconazole (Sporanox®), to prevent thrush (candida)
the antibiotic azithromycin (Zithromax®), to prevent an infection called mycobacterium avium complex (MAC)
an antiviral drug called acyclovir, to prevent the herpes simplex virus (which causes cold sores) becoming active.
Your doctor will tell you when to stop taking these medications.
Steroids are drugs that are often given with chemotherapy to help treat lymphomas. They also help you feel better and can reduce feelings of sickness.
Monoclonal antibody therapy
Monoclonal antibodies are drugs that recognise, target and attach to specific proteins on the surface of cancer cells. They can stimulate the body’s immune system to destroy these cancer cells.
Rituximab (Mabthera®) is a monoclonal antibody commonly used to treat B-cell lymphomas. It is usually given with chemotherapy as part of the R-CHOP regimen. Not all lymphomas respond to rituximab. Before treatment your doctor will test the lymphoma cells for a protein called CD20 that is found on the surface of some lymphoma cells. If the CD20 protein is not present, the rituximab won't work.
Radiotherapy is the use of high-energy rays to destroy cancer cells, while doing as little harm as possible to healthy cells. It may be used to treat a lymphoma affecting the brain (CNS lymphoma). It may be given in combination with chemotherapy. Radiotherapy is sometimes given to help relieve symptoms such as pain.
High-dose treatment with stem cell support
High-dose chemotherapy with stem cell support is used for a small number of people with HIV-related lymphoma. It is mainly used if the lymphoma comes back after initial treatment (known as recurrence).
It involves having high doses of chemotherapy. This destroys the lymphoma cells, but also destroys the stem cells in your bone marrow. Stem cells are blood cells at their earliest stage of development. All mature blood cells develop from stem cells.
Before you have the chemotherapy, some of your own stem cells will be taken and stored. These are then given back to you (like a blood transfusion) after your chemotherapy. The stem cells make their way back to your bone marrow and start to produce new blood cells.
Your doctor will take into account your general health before considering this treatment. This is because the intensity of the treatment increases the risk of serious side effects.
Clinical trials for HIV-related lymphoma
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New treatments for HIV-related lymphomas are being researched all the time. Your doctor might invite you to take part in a clinical trial to compare a new treatment against the best standard treatment. They will discuss the treatment with you, so that you have a full understanding of what it means to take part. You can decide not to take part, or to withdraw from a trial, at any stage. You will then receive the best standard treatment available.
Being diagnosed with a lymphoma can be very difficult, especially when you are already coping with HIV. The new diagnosis may make you revisit many of the issues you had to cope with when you were first diagnosed with HIV.
Some people are diagnosed with lymphoma at the same time as finding out that they have HIV. It can be especially hard to cope with two new illnesses at the same time.
Everyone has their own way of dealing with illness and the different emotions they have. Some people find it helpful to talk things over with family and friends, or with their doctor or specialist nurse. Some prefer to seek help from people who are not involved in their situation, while others prefer to keep their feelings to themselves. There is no right or wrong way to cope, but help is available if you need it. You can contact the organisations listed below or our cancer support specialists for information and support.
Other useful organisations
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JAT (Jewish Action and Training)
JAT is a charity providing support and information on HIV and Aids to the Jewish community.
The Lymphoma Association
The Lymphoma Association gives emotional support, advice and information on all aspects of non-Hodgkin lymphoma. It has a national network of people with lymphoma, and local groups.
NAM Aidsmap provides information for people living and working with HIV and Aids.
Positively UK offers peer support services, including men's and women’s support groups, support groups for African people, counselling, a children and family service, and a helpline for people living with HIV.
National African Aids Helpline
The National African Aids Helpline is a free and confidential helpline offering information, support, counselling and advice. Languages available: English, Portuguese, French, Shona, Swahili and Luganda.
Sexual Health and National Aids Helpline
Tel 0800 567 123 (daily, 24 hours)
Minicom 0800 521 361 (daily, 10am–10pm)
This helpline provides free information, advice and counselling on all aspects of HIV, Aids and sexual health.
Terrence Higgins Trust
The Trust offers advice and information on all aspects of HIV and Aids, including counselling and support, health promotion and benefits advice.
This information has been compiled using information from a number of reliable sources, including:
National Cancer Institute. AIDS-related lymphoma treatment (PDQ®). www.cancer.gov (accessed September 2012).
Bower M, et al. HIV associated malignancies. British HIV Association Guidelines. HIVMedicine. 2008.
Lee, et al. Wintrobe’s Clinical Haematology. 12th edition. Lippincott Williams and Wilkins. 2009
Aidsmap. Non-Hodgkin’s lymphoma. National Aids Manual. www.aidsmap.com/cms1044727.aspx (accessed September 2012).
With thanks to Professor Mark Bower, Consultant Medical Oncologist; and the people affected by cancer who reviewed this edition. Reviewing information is just one of the ways you could help when you join our Cancer Voices network.