Burkitt lymphoma at Chris Hani Baragwanath Academic Hospital: a decade long audit
Date
2018
Authors
Rahman, Farah
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Abstract
Introduction
Non-Hodgkin Lymphoma (NHL) is the most common haematological malignancy encountered in adults in South Africa. After diffuse large B-cell lymphoma (DLBCL), Burkitt Lymphoma (BL) is the most frequent histological subtype seen. The incidence of NHL including BL has increased significantly in the era of the HIV pandemic. Burkitt Lymphoma is an aggressive, high grade B-cell malignancy, with a very high proliferative index and an aggressive clinical course. In adults, almost all the patients with BL, in the South African context are HIV sero-positive, presenting with the immunodeficiency related variant of BL. This retrospective study aims to determine the demographic, clinical, laboratory and therapeutic outcome of patients with BL, as seen at Chris Hani Baragwanath Academic Hospital (CHBAH), over a 10 year period.
Patients and Methods
Data was collected retrospectively on the demographic, clinical, and laboratory features, as well as the therapeutic interventions and outcome of patients with BL, from the haematology records of patients attending the Clinical Haematology Unit, Department of Medicine, CHBAH. Descriptive statistical methods were used to analyze the data. The Chi² test was utilized to evaluate the significance of observed differences in survival between different categories. Patients were considered to be evaluable if they survived longer than 4 weeks.
Results
A total of 137 patients were evaluable for the study. There were 75 females and 62 males, with a female to male ratio of 1.2:1. The mean age of the study population was 38 years. Ninety eight and a half percent of the patients were HIV sero-positive. The overwhelming majority of the patients
(98.5%) were black Africans, in keeping with the demographics of the hospital. Most of the patients presented with a relatively good performance status (≤ 2). However, in contrast to this, the majority of the patients also had advanced stage disease, with bulky disease and extra-nodal disease being common. Lymphadenopathy was the most common clinical manifestation, occurring in more than 80% of the patients at presentation.
The most common contributors to morbidity and mortality were disease progression, sepsis (often neutropaenic sepsis), and renal dysfunction.
Discussion
Females tended to outlive their male counterparts. Age and year of diagnosis did not confer any obvious advantage. A favourable performance status was the only demographic factor that showed a statistically significant survival advantage at diagnosis.
The presence of Tuberculosis exposure seemed to confer a worse outcome. Patients on cART seemed to survive longer, and those with “B” symptoms tended to perform less favourably. Somewhat counterintuitively, the presence of CNS disease and bulk disease seemed to improve survival.
Patients with classical Burkitt Lymphoma fared better than patients with “Intermediate” disease. Patients treated with a “Burkitt” protocol performed statistically significantly better than patients who were given a standard CHOP-based regimen. The use of Rituximab was shown to be beneficial.
Conclusion
The outcomes in this aggressive, high grade, B-cell NHL, occurring almost exclusively in HIV sero-positive individuals was poor, with a 2-year survival rate of only 7%. However, with better education, a high index of suspicion and expedited referral, timeous workup and staging, better attention to and prevention of complications, as well as an intensive multimodality approach to therapy, together with early and ongoing use of cART in HIV sero-positive individuals, the outlook is likely to be much brighter, with higher sustained response rates and improved long term outcomes. This should be the future goals in this devastating malignancy, until novel and significantly improved therapy for the disease, becomes a reality.
Description
A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Medicine (Internal Medicine).
Johannesburg, 2018.