Non-AIDS-defining malignancies

Human immunodeficiency virus and cancer. A population of HIV-infected patients at Hospital de Santa Maria and predictors of cancer

BACKGROUND

Cancer has become a growing burden on morbidity and mortality in human immunodeficiency virus (HIV)-infected individuals in the era of highly active antiretroviral therapy (HAART). The objectives of this study were to determine the rates and cancer predictors of a population of HIV-infected individuals and to draw some recommendations for cancer screening in these patients.

METHODS

This retrospective case-control study describes malignant cancers diagnosed in HIV-infected subjects at Hospital de Santa Maria and assesses cancer predictors in HIV-infected subjects using HIV-infected controls without cancer. A total of 225 patients were included in this study: 25 cancer cases and 200 controls. Eight HIV-infected controls without cancer diagnosis were selected for each cancer case. Besides cancer´s date of diagnosis and its histological type, we also recorded demographic data, medical history and HIV-related information. Cancers were grouped as AIDS-defining cancers (ADCs), and non-ADCs. Non-ADCs were further categorized as being infection related (NADC-IR) and unrelated (NADC-IUR).

RESULTS

The majority of cancer cases were diagnosed in male patients (84%). The mean age of patients was higher in NADCs, mostly in NADCs-IUR, where almost half (43%) were infected with type 2 HIV. About half (52%) of cancer cases were ADCs (32% Kaposi sarcoma, 16% non-Hodgkin's lymphoma, and 4% cervical cancer). The most common NADCs were: lung, skin and hepatocellular carcinoma (8% each). In univariate analyses, immunosuppression, HBV coinfection, smoking and alcoholism were associated with ADCs. In multivariate analysis, alcoholism and higher HIV viral load remained independent predictors of ADCs. Longer duration of HIV infection, type 2 HIV and a longer history of HAART were associated with NADCs, in univariate analyses.

CONCLUSIONS

Besides the evident multifactorial etiology, in this study ADCs appeared to be associated with immunosuppression, while NADCs seemed to be correlated by other oncogenic mechanisms such as chronic inflammation. Based on this study, cancer screening should be performed in these patients in Portugal.

Treatment for leiomyosarcoma and leiomyoma in children with HIV infection

BACKGROUND

Smooth muscle tumour (SMT) composed of leiomyoma and leiomyosarcoma recently has been described in many HIV-infected children. Leiomyosarcoma has become the second most frequent malignancy in children with HIV infection or other immunodeficiency diseases in the United States. Although leiomyosarcoma accounts for only 2% to 4% of childhood soft tissue sarcomas, the prognosis is poor in HIV-infected compared with non-infected patients. The development of Epstein-Barr virus (EBV)-associated SMT in children with acquired immunodeficiency virus (AIDS) decreases health, reduces quality of life, and often results in death. Some researchers, therefore, ascribe cause of death to SMT in the majority of these cases, not to AIDS. Currently, the optimal therapeutic strategy is controversial and there is a need to identify the efficacy and safety of different interventions for AIDS-associated SMT on overall survival and disease-free survival in children.

OBJECTIVES

To assess the effectiveness of current therapeutic interventions for previously untreated children with AIDS-associated leiomyoma and leiomyosarcoma

SEARCH STRATEGY

We searched the following electronic databases by subject headings and text words:Cochrane HIV/AIDS Group trials register (November 2009); Cochrane Central Register of Controlled Trials on Cochrane Library (Issue 4, 2009); MEDLINE (January 1966 to November 2009); EMBASE (January 1985 to November 2009); NLMGateway database and AEGIS; Chinese Biomedical Disc (CBMDisc 1978 to November 2009); VIP (1989 to present); and China National Knowledge Infrastructure (CNKI 1994 to 2009). We also searched physicians data query protocols, proceedings, and abstracts from AIDS and cancer conferences, and the reference lists from identified trials for unidentified trials to discover any unpublished or currently on-going relevant trials. All the trials were searched by comprehensive electronic databases or hand searching. The search was not limited by language.

SELECTION CRITERIA

We searched for published or unpublished randomised controlled trials (RCTs) or controlled clinical trials (CCTs) of therapy for leiomyosarcoma and leiomyoma in children with AIDS.

DATA COLLECTION AND ANALYSIS

Two authors screened the results of the search independently to select relevant studies. The full text of all potentially relevant studies was retrieved and the qualities were assessed by the two authors using predetermined criteria. No eligible RCTs or CCTs were identified.

MAIN RESULTS

We were unable to find any RCTs or CCTs of interventions for treating AIDS-associated SMT in children.

IMPLICATIONS FOR CLINICAL PRACTICE

We could not find any RCTs or CCTs of intervention for treating AIDS-associated SMT in children with HIV infection, and currently, the clinical practice of treating SMT in HIV-infected children is based on descriptive studies and simply situational analyses. Thus there is insufficient evidence to establish the efficacy and acceptability of these interventions, and we recommend a case-by-case treatment of patients until evidence becomes available.

IMPLICATIONS FOR RESEARCH

In future, high-quality RCTs are urgently needed before any final conclusion can be drawn. Rigorously designed, multicenter, randomised, double-blind controlled trials are required to evaluate these interventions as a way of improving the survival and decreasing mortality in that population. Policy makers and researchers should prioritise funding for these trials to increase the quantity and quality of such studies and provide strong evidence for the effectiveness of therapies for AIDS-associated SMTs. Meanwhile, safety and adverse events should be critically assessed by standardized monitoring or an effective self-report system, and attention should be paid to long-term adverse effects in children with HIV infection.

Incidence and risk factors for the occurrence of non-AIDS-defining cancers among human immunodeficiency virus-infected individuals

BACKGROUND

The objective of this study was to determine the rates and predictors of non-AIDS-defining cancers (NADCs) among a cohort of human immunodeficiency virus (HIV)-infected individuals.

METHODS

The authors conducted a retrospective study of 4144 HIV-infected individuals who had 26,916 person-years of follow-up and who had open access to medical care at 1 of the United States military HIV clinics during the years 1988-2003. Cancer incidence rates were race specific and were adjusted for age; these were compared with national rates using logistic regression to assess predictors of NADC development.

RESULTS

One hundred thirty-three NADCs were diagnosed with a rate of 980 diagnoses per 100,000 person-years. The most frequent NADCs were skin carcinomas (basal cell and squamous cell), Hodgkin disease, and anal carcinoma. The results showed that there were higher rates of melanoma, basal and squamous cell skin carcinomas, anal carcinoma, prostate carcinoma, and Hodgkin disease among the HIV-infected cohort compared with age-adjusted rates for the general United States population. Predictors of NADCs included age older than 40 years (odds ratio [OR], 12.2; P < 0.001), Caucasian/non-Hispanic race (OR, 2.1; P < 0.001), longer duration of HIV infection (OR, 1.2; P < 0.001), and a history of opportunistic infection (OR, 2.5; P < 0.001). The use of highly active antiretroviral therapy (HAART) was associated with lower rates of NADCs (OR, 0.21; P < 0.001). A low CD4 nadir or CD4 count at diagnosis (< 200 cells/mL) was not predictive of NADCs.

CONCLUSIONS

The most frequent NADCs were primary skin malignancies. Melanoma, basal and squamous cell skin carcinomas, anal carcinoma, prostate carcinoma, and Hodgkin disease occurred at higher rates among HIV-infected individuals. The implementation of screening programs for these malignancies should be considered. Most risk factors for the development of NADCs are nonmodifiable; however, the use of HAART appeared to be beneficial in protecting against the development of malignant disease.

HIV and plasmablastic lymphoma manifesting in sinus, testicles, and bones: a further expansion of the disease spectrum

Patients with HIV infection are at increased risk for B-cell neoplasms and plasma cell dyscrasias. Both B cell and plasma cell tumors tend to be intermediate or high grade and are frequently associated with Epstein-Barr virus. Patients with HIV infection are also at higher risk of acquiring plasmablastic lymphoma. Until this time, only sinus, oral gastrointestinal, and lung manifestation have been noted. In this report we describe a 41-year-old male with HIV infection who developed multiple pleomorphic, extramedullary plasmablastic lymphomas associated with Epstein-Barr virus. We review the clinical and immunological features of his malignancy and thereby expand the spectrum of disease to include additional sites (bones, testicles) not previously reported.

Update on non-acquired immunodeficiency syndrome-defining malignancies

PURPOSE OF REVIEW

Since the introduction of highly active antiretroviral therapy (HAART), the natural history of human immunodeficiency virus (HIV) infection has changed. Early in the acquired immunodeficiency syndrome (AIDS) epidemic, epidemiologic studies showed that HIV-infected patients were at higher risk for developing specific AIDS-defining malignancies. More recent studies linking HIV/AIDS databases to cancer registries have shown that HIV-infected patients are also at higher risk of developing non-AIDS-defining malignancies. We review the most recent data regarding clinical presentation, pathology, and treatment outcomes for these non-AIDS-defining malignancies.

RECENT FINDINGS

Recent large cohort studies linking HIV/AIDS databases to cancer registries have shown that HIV-infected patients are also at higher risk of developing non-AIDS-defining malignancies. Besides anal cancer and Hodgkin disease, the cohort studies have identified other malignancies that appear to occur at a higher rate in the HIV-infected population as compared with the general population. These malignancies include lung cancer, skin cancer, germ cell tumors, leiomyosarcomas, cancers of the head and neck, conjunctival cancer, multiple myeloma, and leukemias.

SUMMARY

As the epidemiology of non-AIDS-defining malignancies continues to evolve, it is unclear whether the appropriate treatments and outcomes for these or other malignancies are changed for HIV-infected patients treated with HAART.