Salvage chemotherapy for adults with relapsed or refractory lymphoma in Malawi

Bongani Kaimila, Toon van der Gronde, Christopher Stanley, Edwards Kasonkanji, Maria Chikasema, Blessings Tewete, Paula Fox, Satish Gopal, Bongani Kaimila, Toon van der Gronde, Christopher Stanley, Edwards Kasonkanji, Maria Chikasema, Blessings Tewete, Paula Fox, Satish Gopal

Abstract

Background: Lymphoma is highly associated with HIV in sub-Saharan Africa (SSA), which contributes to worse outcomes relative to resource-rich settings, and frequent failure of first-line chemotherapy. However, there are no second-line treatment descriptions for adults with relapsed or refractory lymphoma (RRL) in SSA.

Methods: We describe HIV+ and HIV- patients with RRL receiving salvage chemotherapy in Malawi. Patients were prospectively treated at a national teaching hospital in Lilongwe, with the modified EPIC regimen (etoposide, prednisolone, ifosfamide, cisplatin) between June 2013 and May 2016, after failing prior first-line chemotherapy.

Results: Among 21 patients (18 relapsed, 3 refractory), median age was 40 years (range 16-78), 12 (57%) were male. Thirteen patients (62%) were HIV+, of whom 12 (92%) were on antiretroviral therapy (ART) at initiation of salvage chemotherapy, with median CD4 cell count 139 cells/μL (range 12-529) and 11 (85%) with suppressed HIV RNA. Median number of EPIC cycles was 3 (range 1-6), and the commonest toxicity was grade 3/4 neutropenia in 19 patients (90%). Fifteen patients responded (3 complete, 12 partial, overall response rate 71%), but durations were brief. Median overall survival was 4.5 months [95% confidence interval (CI) 2.4-5.6]. However, three patients, all HIV+, experienced sustained remissions. Tolerability, response, and survival did not differ by HIV status.

Conclusions: The appropriateness and cost-effectiveness of this approach in severely resource-limited environments is uncertain, and multifaceted efforts to improve first-line lymphoma treatment should be emphasized, to reduce frequency with which patients require salvage chemotherapy.

Trial registration: NCT02835911. Registered 19 January 2016.

Keywords: Chemotherapy; HIV; Hodgkin lymphoma; Non-Hodgkin lymphoma; Sub-Saharan Africa.

Conflict of interest statement

Ethics approval and consent to participate

All patients provided written informed consent for participation in the Kamuzu Central Hospital Lymphoma Study, which was approved by the Malawi National Health Sciences Research Committee (Federal Wide Assurance #5976) and University of North Carolina Biomedical Institutional Review Board (Federal Wide Assurance #4801).

Consent for publication

Written consent to publish was obtained from all patients.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Overall survival for patients with relapsed/refractory lymphoma receiving salvage chemotherapy in Lilongwe. a Overall cohort. b Stratified by HIV status

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