Granulocytic sarcoma (chloroma) in HIV patient: a report

Sarcomas other than Kaposi sarcoma occurring in immunodeficiency: interpretations from a systematic literature review

PURPOSE OF REVIEW

In immunodeficiency, an increased sarcoma risk is confirmed for Kaposi's sarcoma. Whether rates of other sarcoma subtypes are elevated in the setting of immunodeficiency is not known. We therefore reviewed published case reports on HIV and AIDS patients and organ transplant recipients with sarcomas. For comparison, we assessed sarcomas in the U.S. general population using Surveillance Epidemiology End Results (SEER) data.

RECENT FINDINGS

A total of 176 non-Kaposi sarcoma were identified, 75 in people with HIV and AIDS and 101 in transplant recipients. Leiomyosarcomas (n = 101) were the most frequently reported sarcomas, followed by angiosarcomas (n = 23) and fibrohistiocytic tumors (n = 17). Leiomyosarcomas were reported with two age peaks, in children and young adults. Epstein-Barr virus (EBV) was detected in the tumor cells in 85 and 88% of leiomyosarcomas in HIV-infected people and transplant recipients, respectively. Angiosarcomas and fibrohistiocytic tumors were most frequently reported in men. Among kidney transplant recipients, 20% of sarcomas arose at the site of an arteriovenous fistula. In comparison, leiomyoscarcomas, angiosarcomas, and fibrohistiocytic tumors comprised 16.9, 3.8, and 18.7% of sarcomas in the U.S. general population.

SUMMARY

Leiomyosarcoma and angiosarcoma may occur disproportionately in immunodeficiency. Leiomyosarcomas appear causatively linked to EBV, whereas angiosarcomas might be correlated with an arteriovenous fistula. Additional studies are necessary to understand the contribution of immunodeficiency to the cause of these sarcomas.

Granulocytic sarcoma and HIV

Hematopoietic neoplasms are known to occur in the setting of HIV. Excluding Kaposi's sarcoma, the neoplasms are generally high-grade lymphoproliferative disorders. Granulocytic sarcoma, an extramedullary hematopoietic malignancy that may precede or occur during the course of acute myeloid leukemia, has rarely been described in the HIV population. We present the fourth documented case, to our knowledge, of a granulocytic sarcoma occurring in an HIV-positive individual. This has been associated with a very poor prognostic outcome.

Alveolar granulocytic sarcoma of the mandible in a patient with HIV

BACKGROUND

Granulocytic sarcoma (chloroma) occurs primarily in patients with acute myelogenous leukemia although it can also appear in connection with other myeloproliferative disorders.

CASE REPORT

We present the case of a 52-year-old human immunodeficiency virus (HIV)-positive female patient with a CD4+ count of 321 cells/ml, who developed an alveolar granulocytic sarcoma of the mandible. Pathological analysis of the tumor mass showed an infiltrate of immature cells which were positive for CD13, CD33, CD15, CD11b, and CD64, and negative for CD34, CD117, and HLA-DR. The patient achieved complete remission following a 1-week course of chemotherapy, however, 7 months later she developed a second granulocytic sarcoma in the left soleus muscle. The absolute CD4+ count had now reduced to 3 cells/ml with an inversion in the Th/Ts index (0.01), and she died of gram-negative sepsis 1 month later.

CONCLUSIONS

Granulocytic sarcoma is extremely rare in patients with HIV. The case is discussed with reference to the literature.

[Granulocytic sarcoma in the mandibular gingiva of an HIV+ patient]

INTRODUCTION

The association between malignant tumors and HIV infection is well known. We report a rare case of gingival granulocytic sarcoma (GS) associated to HIV infection.

OBSERVATION

A 31 year-old HIV patient consulted for left maxillary tumefaction. His viral load was high (40,112 copies/ml) and CD4 count low (287cells/mm(3)). After biopsy-exeresis, histology and an immunohistochemical study confirmed the diagnosis of GS. Chemotherapy similar to that of acute myeloid leukemia (AML) completed the treatment. The remission was complete at 5 years.

DISCUSSION

Only one case of intra-oral GS associated to HIV infection has been reported so far. The clinical and radiological presentation is unspecific. Histology proves the diagnosis. The treatment is comparable to that of AML. The prognosis is usually bad.

The growing problem of non-AIDS-defining malignancies in HIV

PURPOSE OF REVIEW

The incidence and spectrum of non-AIDS-defining cancers has continued to grow. As HIV-infected individuals live longer due to highly active antiretroviral therapy, their risk of dying from one of these cancers is increased. The recent literature pertaining to non-AIDS-defining cancers is reviewed.

RECENT FINDINGS

Recent epidemiological studies have identified higher rates of carcinoma of the anus, lung, breast, skin, conjunctiva, liver and prostate; hematopoietic malignancies such as Hodgkin's lymphoma, plasma-cell neoplasia and leukemia; and other neoplasms like melanoma and leiomyosarcoma in HIV-positive patients. The role of HIV-induced immunosuppression in the development of these non-AIDS-defining cancers appears less important than lifestyle habits like smoking and sun exposure, as well as coinfection with human papilloma, hepatitis B, hepatitis C and Epstein-Barr viruses.

SUMMARY

It is unclear whether the growing number of reports on non-AIDS-defining cancers reflects a true increased incidence or merely the product of increased surveillance, detection and reporting. Highly active antiretroviral therapy not only promotes longevity in the HIV-positive population, but may increase their risk of developing cancer like Hodgkin's lymphoma. Assertive prevention strategies are needed to adequately deal with non-AIDS-defining cancers in an aging and growing HIV-positive population.