AIDS: incidence and management of malignant disease

The Role of Radiation Therapy in Palliative Care

Radiation therapy plays a significant role in the palliation of symptoms of patients with malignant disease. This article looks at the scientific and clinical rationales for its use and discusses some of the current controversies in palliative radiotherapy. The utility of radiation therapy is discussed and potential side effects are described. Radiation oncologists are important members of the multidisciplinary team providing palliative care. Their involvement in the care of patients with advanced or metastatic malignant disease allows patients to benefit from a modality of treatment which can be both effective and minimally inconvenient when used appropriately.

[The role of radiotherapy in the management of bucopharyngeal epidemic Kaposi's sarcoma]

PURPOSE

This study is presented to help define the role of radiotherapy in the management of buccopharyngeal epidemic Kaposi's sarcoma.

MATERIAL AND METHODS

Between January 1999 and December 2004, we treated 17 patients who had acquired inmunodeficiency syndrome related to mucous Kaposi's sarcoma. Kaposi's sarcoma lesions were in the oral cavity in 12 patients (70%), oropharynx in 3 patients (18%) and larynx in 2 patients (12%). All the patients were treated by radiotherapy using a Cobalt Unit beam energy, the treatment doses ranged from 15 to 30 Gy.

RESULTS

Tolerance was generally satisfactory, with an effective palliation of symptoms (88,4% overall rate of objective responses). Nevertheless an enhanced mucosal reaction was noted in patients receiving doses close to 30 Gy (mucositis grade 3).

CONCLUSIONS

We conclude that radiotherapy is an efficient treatment for mucous epidemic Kaposi's sarcoma; a dose of 15 Gy may be enough to shrink the tumour and obtain a good palliation of symptoms. Prophylactic measures with antifungal treatment should be systematically associated with oropharyngeal irradiation in order to improve tolerance to the treatment.

Multiple primary malignant tumors in a national cancer registry--reliability of reporting

During the years 1958-1988, 808,522 individuals were registered in the Swedish national population-based cancer register with a total of 933,900 primary malignant tumors. Roughly 11% of the tumors reported to the Swedish Cancer Registry in 1988 were found in persons earlier registered for another primary malignancy. One hundred of the individuals registered with multiple primary malignant tumors were randomly selected for a study of the reliability of reporting of multiple malignancies. Medical records and when necessary histopathological slides and other relevant diagnostic material for each malignancy were collected and the diagnoses reevaluated. Three persons had to be excluded; thus 97 cases with 209 reported malignancies were analysed. Of these, 94% of the first, 98% of the second and 79% of the third malignancy were accepted. Twelve of the reported tumors were not accepted as malignant, five were benign or cancer in situ, five were incorrectly reported as new primaries and two were a second incorrect registration of a previously registered malignancy. All 97 persons had at least one malignant tumor, in 90% of the persons all reported diagnoses were accepted and 93% had multiple primary malignancies. The results of this quality control study indicate that suitable data are available in the Swedish Cancer Registry for investigations related to the occurrence of multiple primary malignancies in a large unselected population. The Swedish Cancer Registry, to which all newly diagnosed malignancies by law have to be reported, comprise today close to one million individuals with registered malignancies.

Cutaneous T-cell lymphoma associated with HIV infection

BACKGROUND

Mycosis fungoides-type cutaneous T-cell lymphoma is uncommon in association with human immunodeficiency virus type 1 (HIV-1) infection. Reported patients have a high incidence of CD8+ T-cell lymphomas and erythroderma, are usually severely immunocompromised, and rapidly die. Chronic, more typical patch-plaque mycosis fungoides-type cutaneous T-cell lymphoma in association with HIV-1 infection has not been reported.

OBJECTIVE

We report two cases of stage 1B epidermotropic mycosis fungoides-type cutaneous T-cell lymphoma in HIV-1-infected men with no history of the acquired immunodeficiency syndrome.

METHODS

Clinical and laboratory data, including lesional immunophenotypic and immunogenotypic findings of two patients with HIV-1-associated cutaneous T-cell lymphoma, were studied.

RESULTS

Immunohistochemical analysis of skin determined the lesional infiltrate of one patient to be CD8+ (Leu-2+), CD7- (Leu-9-), and Leu-8- with germline lesional skin and blood T-cell receptor genes. The other was CD4- (Leu-3+), CD2- (Leu-5-), CD7- (Leu-9-), and Leu-8- with beta-chain T-cell receptor gene rearrangement in lesional skin and blood. Circulating Sézary cells were not detected in either patient. Peripheral CD4/CD8 T lymphocyte numbers did not appear to correlate with cutaneous disease activity or the predominant lesional T-cell subtype. Both patients were responsive to standard therapies and have experienced prolonged survival in excess of that generally reported for HIV-1-associated systemic peripheral and cutaneous T-cell lymphomas.

CONCLUSION

In the absence of severe immunodeficiency, HIV-1-infected patients with concomitant cutaneous T-cell lymphoma may follow a more typical slowly progressive course.

Non-Hodgkin's lymphoma of the testis

Primary non-Hodgkin's lymphoma of the testis is rare. From 1976 to 1989 32 patients have been registered with the British National Lymphoma Investigation and two with the Institute of Urology. All 34 patients had disease of high grade histology (BNLI) although in four patients there were some areas with features similar to those described in lymphomas of Mucosal Associated Lymphoid Tissue (MALT). Twenty-three of 34 (67.5%) patients had early stage disease (I/II); 17/34 (50%) achieved complete remission from their initial treatment, and the relapse-free survival of these patients was 66% at 5 years. The disease-free survival for the 34 patients as a whole was 33% and their overall survival 39% at 5 years. The life expectancy for those presenting with advanced (stage III/IV) disease was very poor (median survival 9 months) with a low complete remission rate from chemotherapy. The salvage rate from recurrent disease (17%) was poor. Bilateral testicular involvement (18%) and a high rate of central nervous system disease (21%) occurred in the series, and two patients were HIV positive. Stage at presentation was the most important prognostic factor.

Radiotherapy in the management of cutaneous epidemic Kaposi's sarcoma

Between June 1986 and December 1988, we treated 149 patients who had AIDS-related epidemic Kaposi's sarcoma with cutaneous irradiation. According to Mitsayasu's staging, 34 patients (23%) had Stage I disease, 82 (55%) Stage II, 0 Stage III, and 33 (22%) Stage IV. Fifty-eight patients (39%) had previously presented with one or more opportunistic infections. Ninety-four patients (63%) had received previous treatment of their Kaposi's sarcoma: 85 (57%) with interferon and 43 (29%) with vinblastine. Among the 149 patients, we treated 88 (59%) with extended cutaneous irradiation using 4- and/or 8-MeV electron beam energy and 61 patients (41%) with localized irradiation using 45-kVp x-ray energy. The total prescribed dose was 30 Gy: 20 Gy in 2 weeks (2.5 Gy/fraction, 4 times/week), followed by 2 weeks of no irradiation, and then 10 Gy in one week by the same dose schedule. Twenty patients (13%) with edema of the lower limbs were treated using 4-Mv photon therapy with bolus. Of the 131 evaluable patients, 63% achieved a complete remission (CR) and 30% a partial remission (PR) after a mean period of 1.5 months (range: 0.5-3 months). The clinical disease stage, anatomic site, and irradiation technique did not significantly influence the remission rates, although we noticed a higher CR rate when localized irradiation was used (71% vs 55.5% for localized and extended irradiation, respectively; p = 0.08). The overall tolerance was acceptable. Complications were severe epidermitis with skin ulcerations (8% of patients), exudative epidermitis (26%), dry epidermitis (60%), and varying degrees of erythema (6%). Of the 87 patients whose AIDS remained relatively clinically stable during the observation period, recurrences occurred in 56 (64%) after an average of 5.5 months (range: 1.5-12 months). We conclude that radiotherapy is useful and can be recommended as a palliative treatment to relieve pain and physical discomfort or to achieve cosmetic improvements for patients with epidemic Kaposi's sarcoma. We also conclude that radiotherapy is most beneficial in the early stages of disease, when localized treatment is practical.

Nodular cutaneous B-cell lymphoma of the scalp in the acquired immunodeficiency syndrome

Aggressive B-cell non-Hodgkin's lymphoma frequently complicates human immunodeficiency virus type 1 infection. Although extranodal disease is an important feature of this condition, the incidence of cutaneous involvement has not been determined. A review of 754 published cases of B-cell non-Hodgkin's lymphoma associated with human immunodeficiency virus type 1 revealed an incidence of cutaneous extranodal involvement of 8.2%, approximately equal to that seen in non-Hodgkin's lymphoma not associated with human immunodeficiency virus. Lymphoma was the initial manifestation of acquired immunodeficiency syndrome in two thirds of these cases. In particular, although the head and neck are commonly involved in non-Hodgkin's lymphoma not associated with human immunodeficiency virus, scalp involvement is uncommon in human immunodeficiency virus-associated B-cell non-Hodgkin's lymphoma, and we report the second case. The natural history and proposed pathogenesis of human immunodeficiency virus-associated non-Hodgkin's lymphoma are discussed.

Value of needle biopsy in directing management of parotid lesions in HIV-positive patients

Fourteen human immunodeficiency virus (HIV)-positive patients with parotid enlargement were reviewed retrospectively in order to elucidate the natural history of this clinical entity. The efficacy of fine-needle aspiration (FNA) in predicting benign nonsurgical disease was evaluated. The most common findings on FNA were proteinaceous fluid and/or epithelial cells consistent with cyst contents in 71% of the patients, followed by reactive lymphadenitis (50%), and chronic or granulomatous inflammation (21%). No evidence of malignancy was seen in any patient. These results correlated well with the histopathologic diagnosis in all operated patients. Surgery did not affect the ultimate clinical outcome. This study suggests that HIV-positive patients with isolated asymptomatic parotid swelling in the absence of other clinical features suggestive of malignancy can be followed conservatively with FNA, avoiding the risks of surgery.

Acquired immunodeficiency syndrome and Epstein-Barr virus

Epstein-Barr virus is an important aetiological factor in certain HIV-related syndromes, with its opportunist expression related to the level of host immunodeficiency. In asymptomatic people co-infected with HIV, EBV activity is reflected by increased viral shedding and rises in anti-EBV titres; as immunodeficiency ensues EBV manifests as epithelial hyperproliferation in OHL, and later as B-cell lymphoma in AIDS. The suggested role of EBV as a co-factor in the progression of HIV infection and development of AIDS has not been established, although another herpesvirus, cytomegalovirus, might play such a role. Advances in our understanding of HIV regulation and its interaction with other latent (herpes) viruses should provide important molecular and pharmacological approaches to the clinical management of advanced HIV disease.