Testicular cancer in homosexual men with cellular immune deficiency: report of 2 cases

Etiologic factors in testicular germ-cell tumors

Globally, testicular cancer incidence is highest among men of northern European ancestry and lowest among men of Asian and African descent. Incidence rates have been increasing around the world for at least 50 years, but mortality rates, at least in developed countries, have been declining. While reasons for the decreases in mortality are related to improvements in therapeutic regimens introduced in the late 1970s, reasons for the increase in incidence are less well understood. However, an accumulating body of evidence suggests that testicular cancer arises in fetal life. Perinatal factors, including exposure to endocrine-disrupting chemicals, have been suggested to be related to risk.

Testicular lymphoma: an update for clinicians

Testicular lymphoma is a lethal disease with a median survival of approximately 12 to 24 months. It is the most common testicular malignancy in men older than 60 years of age. Testicular lymphoma has a predilection for widespread dissemination to unusual sites, including the central nervous system, contralateral testis, Waldeyer's ring, skin, and lung. Doxorubicin based chemotherapy with prophylactic intrathecal chemotherapy and radiation to the contralateral testis seems most promising. This review article will focus on the presentation, pathology, patterns of relapse and challenges in improving the outcome of this disease.

Increasing incidence of testicular germ cell tumors among black men in the United States

PURPOSE

There has been marked disparity in the incidence of testicular germ cell tumors (TGCT) among white and black men for a number of decades in the United States. Since at least the beginning of the Surveillance, Epidemiology, and End Results (SEER) Program in 1973, incidence rates among white men have been five times higher than rates among black men. In addition, rates among white men have been increasing, whereas rates among black men have remained stable. However, a recent examination of ethnic-specific rates suggested that the incidence among black men may have begun to change in the 1990s.

PATIENTS AND METHODS

TGCT incidence data from nine registries of the SEER Program were analyzed for the years 1973 to 2001. Trends were examined separately for seminoma and nonseminoma.

RESULTS

Analyses found that the incidence of TGCT began to increase among black men between the 1988 to 1992 and 1993 to 1997 periods. Before that time, incidence among black men had decreased by 14.8%. Between 1988 to 1992 and 1998 to 2001, however, the incidence increased by 100%, with the incidence of seminoma increasing twice as much (124.4%) as the incidence of nonseminoma (64.3%). Over the 29-year time period, there was no evidence of a change in the proportion of tumors diagnosed at earlier stages among black men. In contrast, the proportion of tumors diagnosed at localized stages significantly increased among white men.

CONCLUSION

The incidence of TGCT among black men has increased since 1988 to 1992. Although the reasons for this increase are unclear, screening and earlier diagnosis of TGCT do not seem to be factors.

Outcome of patients with HIV-related germ cell tumours: a case-control study

Testicular germ cell tumour (GCT) is not an AIDS-defining illness despite an increased incidence in men with HIV infection. We performed a matched case-control study comparing outcomes in HIV-positive men and the general population with GCT, using three age and stage matched controls for each case. There was no difference in the 5-year GCT-free survival between cases and controls. However, overall survival was significantly decreased in the cases (log rank P=0.03). HIV was responsible for 70% of this mortality. The relapse-free survival for stage I patients treated with orchidectomy and surveillance was not affected by HIV status (log rank P=0.68). There was no difference in disease free survival in patients with metastatic disease (log rank P=0.78). The overall survival has not improved since the introduction of highly active antiretroviral therapy (log rank P=0.4). Thus, HIV-related GCT is not more aggressive than GCT in the general population.

Multicenter study of human immunodeficiency virus-related germ cell tumors

PURPOSE

Testicular germ cell tumors (GCT) occur at increased frequency in men with human immunodeficiency virus (HIV). This multicenter study addresses the characteristics of these tumors.

PATIENTS AND METHODS

Patients with HIV-related GCT were identified from six HIV treatment centers. The incidence was calculated from the center with the most complete linked oncology and HIV databases.

RESULTS

Thirty-five patients with HIV-related GCT were identified. The median age at GCT diagnosis was 34 years (range, 27 to 64 years). The median CD4 cell count was 315/mm3 (range, 90 to 960/mm3) at this time. The histologic classification was seminoma in 26 patients (74%) and nonseminomatous GCT in nine patients (26%). Twenty-one patients (60%) had stage I disease and 14 patients had metastatic disease. Overall six patients relapsed, three died from GCT, and seven died from HIV disease, resulting in a 2-year overall survival rate of 81%. HIV-related seminoma occurred more frequently than in the age- and sex-matched HIV-negative population, with a relative risk of 5.4 (95% confidence interval, 3.35 to 8.10); however, nonseminomatous GCT did not occur more frequently, and there was no change in the incidence of GCT since the introduction of highly active antiretroviral therapy.

CONCLUSION

Testicular seminoma occurs significantly more frequently in HIV-positive men than in the matched control population. Patients with HIV-related GCTs present and should be treated in a similar manner to those in the HIV-negative population. After a median follow-up of 4.6 years, 9% of the patients died from GCT. Most of the mortality relates to HIV infection.

Trends in the incidence of testicular germ cell tumors in the United States

BACKGROUND

Recent reports have suggested that the increasing rates of testicular germ cell tumors in some populations have begun to plateau. This study was conducted to examine whether rates among white men in the United States have begun to stabilize and whether rates among black men in the United States have remained low.

METHODS

Testicular germ cell tumor incidence data from in the Surveillance, Epidemiology, and End Results Program were analyzed for the years 1973-1998. Trends were examined separately for seminoma and nonseminoma. Using age-period-cohort analyses with 5-year age intervals and 5-year calendar-period intervals, changes in the slope of the trends in birth-cohort and calendar-period effects were examined.

RESULTS

Among white men, rates of seminoma continued to increase, but the rate of increase steadily declined throughout the 26-year time span. Nonseminoma rates among whites increased more slowly during the first three time intervals, then plateaued in the final interval. Rates of both seminoma and nonseminoma in black men fluctuated throughout the first three time intervals. In the final interval, the rates of seminoma increased almost 100%, whereas the rates of nonseminoma increased more modestly. Age-period-cohort modeling of the incidence data in white men found that, whereas the dominant effect was that of birth cohort, there also was a period effect.

CONCLUSIONS

Among white men in the United States, the incidence of testicular germ cell tumors varied by histology, with a continuing increase in risk only for seminoma. Among black men in the United States, the surprising increases seen between 1988 and 1998 were likely to be a calendar-period effect.

Germ cell tumors in patients infected by the human immunodeficiency virus

BACKGROUND

The objective of this study was to assess the natural history of the two disease courses, patient immune system tolerance, and results of therapy in human immunodeficiency virus (HIV)-infected patients with germ cell tumors (GCT).

METHODS

From 1985 to 1996, 34 HIV-infected men received a diagnosis of GCT. Their charts were analyzed retrospectively.

RESULTS

Sixteen patients had seminomas, and 18 had nonseminomatous GCTs (NSGCT); 71% had International Union Against Cancer (UICC), 1997 Stage I-II GCTs. At the time of chemotherapy, 69%, 6%, and 25% of patients with advanced NSGCT were in the International Germ Cell Consensus Classification (IGCCC) good, intermediate, and poor prognostic group, respectively. All except 1 of the 10 patients with advanced seminomas were in the IGCCC good prognostic group. At diagnosis of GCT, 85% of patients were classified as having asymptomatic HIV infection or only persistent generalized lymphadenectomy. The median CD4 cell count was 325/microL (range, 6-1125). Overall, 26 patients were given chemotherapy, but the planned dose intensity was respected in only 15 (57%) patients. Severe toxic effects included febrile neutropenia in 35% of patients. During chemotherapy, zidovudine, prophylactic granulocyte colony-stimulating factor (G-CSF), and a Pneumocystis carinii prophylaxis were given in 19%, 23%, and 35% of cases, respectively. CD4 cell count decreased in 7 (64%) of 11 patients during chemotherapy. Infradiaphragmatic radiotherapy was given in 10 cases and was clinically well tolerated. At a median follow-up of 27 months (range, 3-150), 50% of patients were alive, and only 18% of patients died of GCT. Two patients developed a non-GCT malignancy while in complete remission, namely, Hodgkin disease and an acute leukemia.

CONCLUSIONS

The prognosis of GCT in HIV-infected patients is mostly dictated by the HIV infection. Patients should be treated according to stage and histologic subtype, although dose reduction of chemotherapy might be necessary in approximately half of the patients. Close surveillance of neutrophil and CD4 cells counts, as well as the use of G-CSF and systematic anti-Pneumocystis carinii prophylaxis are recommended during chemotherapy. The use of highly active antiretroviral therapy during chemotherapy for GCT requires a prospective assessment.

Clinical aspects and management of Hodgkin's disease and other tumours in HIV-infected individuals

As the AIDS epidemic advances, the spectrum of malignancies encountered is expanding. Several non-AIDS defining cancers, i.e. Hodgkin's disease (HD), anal and testicular cancer, are increasing in incidence in HIV-infected patients. The widespread use of highly active antiretroviral therapy (HAART) in industrialised countries has resulted in substantial improvement in the survival of HIV-infected patients. It is likely that in the future, cancers associated with long-term mild immune suppression will occur at an increased rate in long-term survivors of HIV infection. The natural history of the majority of non-AIDS defining tumours differs from that of the general population. Unusual aspects of tumour localisation, growth behaviour and therapeutical responses distinguish tumours in patients with HIV infection from those without. This paper reviews the most relevant data on the epidemiology, pathology, clinical features and treatment of the most frequently reported non-AIDS defining tumours, i.e. HD, lung, testicular and skin cancers.

Advanced testicular germ cell tumor in a hemophilic patient with human immunodeficiency virus infection

A stage IIIB anaplastic seminoma which occurred in an HIV-infected hemophilia is reported. The patient with hemophilia A was 36 years old and had been seropositive for HIV antibody for 3 years. Inguinal orchiectomy and subsequent chemoradiotherapy for retroperitoneal lymphadenopathy were performed and a marker negative partial response was obtained. In spite of a low initial CD4+ lymphocyte count (90/microliter), the patient tolerated the treatment well without life-threatening opportunistic infection. Although factor VIII supplement was performed, continuous bleeding from the operative wound made postoperative care difficult.

Non-AIDS-defining cancers

As the AIDS epidemic advances, the spectrum of malignancies encountered is expanding. Several non-AIDS-defining cancers are seen in increased incidence in HIV-infected patients. These include basal cell carcinoma of the skin, squamous cell carcinoma of the anus, Hodgkin's disease, seminoma, and pediatric leiomyosarcoma. There appears to be an emerging role for various concurrent viral infections in the HIV-infected host that are likely implicated in the pathogenesis of AIDS-related neoplasms. It will be important to track the epidemiologic and biologic features of non-AIDS cancers in HIV-infected patients. It is likely that further clues about malignant transformation and oncogenesis unraveled in this setting will have broader clinical implications.

Endocrine implications of human immunodeficiency virus infection

Endocrine abnormalities occur frequently in HIV-infected patients. Although the majority of endocrine disorders reflect chronic infection, stress, and malnutrition, some disorders are characteristic of HIV infection or AIDS and deserve particular clinical attention. Identification of HIV patients at risk of frank endocrine disorders, rapid and correct diagnosis, and appropriate management are essential steps to minimize morbidity and mortality. Finally, increasing evidence from in vitro studies suggests that various hormones may influence HIV replication as well as the course of HIV disease and associated disorders. Future studies on the molecular mechanisms of hormones on HIV action and clinical studies on the effects of hormones as adjunctives to established forms of therapy may stimulate development of novel therapeutic strategies that will benefit HIV-infected patients.

Testicular germ cell tumors in patients with human immunodeficiency virus infection

BACKGROUND

There has been evidence of a higher incidence of testicular germ cell tumors (GCT) in human immunodeficiency virus (HIV)-seropositive men than in the non HIV-infected male population. Most authors recommend standard therapy for HIV-positive patients with GCT but the immumosuppressive effects of chemotherapy and/or radiotherapy must be considered.

METHODS

The records of all patients in whom testicular cancer was diagnosed and/or treated at a single institution between January 1986 and July 1995 were reviewed with regard to HIV seropositivity. Tumor histology, initial staging, treatment, and the patients' outcomes were analyzed in connection with a review of the literature.

RESULTS

Six patients with GCT and documented HIV seropositivity at the time of tumor diagnosis (four homosexuals, one bisexual, and one heterosexual former intravenous drug abuser) of 192 documented cases of testicular cancer are reported. In addition, 1 patient proved to be HIV seropositive 34 months after completing chemotherapy (vinblastine, ifosfamide, and cisplatin) for Stage IIB (minimal disease) seminoma. Intensified platinum-based chemotherapy was administered to two patients with clinical Stage IIIC (advanced disease) nonseminomatous germ cell tumors (NSGCT). Both patients achieved a transient partial response but suffered from progressive HIV disease and died 24 and 7 months, respectively, after orchiectomy. One patient with Stage IIIA (moderate disease) seminoma received four courses of chemotherapy (etoposide, ifosfamide, and cisplatin) and has remained in complete remission for 40 months. One patient with bilateral Stage I seminoma underwent adjuvant radiotherapy but was lost to follow-up. One patient with clinical Stage IIA (minimal disease) NSGCT refused any further treatment after hemiorchiectomy, but four courses of chemotherapy (cisplatin, etoposide and bleomycin) had to be given 32 months later because of symptomatic abdominal disease. A partial remission was obtained and there was no evidence of active tumor 16 months after the completion of chemotherapy. A retroperitoneal lymph node dissection was performed in 1 patient with Stage I NSGCT who was free of disease 111 months after diagnosis. The Centers for Disease Control classification for HIV infection and acquired immune deficiency syndrome (AIDS) did not change after therapy in two patients, whereas three patients suffered from progressive HIV disease.

CONCLUSIONS

HIV infection should be considered in patients with testicular cancer who belong to an urban population. Oncologic therapy based on a patient's individual situation is recommended.

Leydig cell tumour in a man with human immunodeficiency virus

We report a case of Leydig-cell testicular tumour in a 32-year-old intravenous drug abuser bearing HIV-infection and pulmonary tuberculosis. The testicular mass was initially interpreted as genital tuberculosis and the diagnosis was made by aspiration cytology. Radical orchiectomy was performed and pathology revealed a Leydig-cell tumour. Gynecomastia was found as a possible sign of endocrine activity. Although testicular malignancies in men with human immunodeficiency virus are increasingly reported, this is the first case of Leydig-cell neoplasia associated to HIV-infection.

Testicular tumors in men with human immunodeficiency virus

During a 2-year period 5 men positive for the human immunodeficiency virus (HIV) presented with 6 testis tumors among a total of 3,015 men seen at our hospital acquired immunodeficiency syndrome (AIDS) clinic. This testis tumor incidence of 0.2% is 57 times that of the United States average of 3.5 cases per 100,000 men. Two patients were only HIV positive and 3 others already had AIDS-related complex for 2 to 15 months at the time of tumor diagnosis. Tumor histology was mixed germ cell tumor in 4 patients, pure seminoma in 1 and Burkitt's lymphoma in 1. Patients underwent routine staging evaluations. Three patients had low stage mixed germ cell tumor (clinical stage 1 or 2A) and underwent retroperitoneal lymphadenectomy, which revealed pathological stage 1 or 2A disease in 1 and 2, respectively. These patients did not receive adjuvant chemotherapy. Two patients had advanced mixed germ cell tumor (clinical stage 2C) or Burkitt's lymphoma (clinical stage 4) and received combination chemotherapy from the onset. Outcome was evaluated with regard to progression of HIV disease and tumor status. The 2 patients who were only HIV positive remained so for 9 and 48 months. The 3 patients with AIDS-related complex had progression to AIDS within 1 to 9 months and 2 of these patients died 1 1/2 and 7 months after tumor diagnosis. All 3 patients with resected low stage disease had tumor recurrence within 1 to 9 months and were begun on platinum-based combination chemotherapy. The risk of false low clinical staging and early tumor progression may be higher in HIV positive men than in other testis tumor patients. Patient ability to tolerate chemotherapy and to obtain a satisfactory tumor response appeared to be primarily related to lack of progression of HIV disease to frank AIDS.

A review of the fine-needle aspiration cytology findings in human immunodeficiency virus infection

Patients infected with the human immunodeficiency virus (HIV) are subject to infections and neoplasms, which frequently result in palpable or radiologically identified masses. Fine-needle aspiration (FNA) offers a rapid, simple, and cost effective approach for diagnosis of these masses. During a 2-yr period, 396 aspirates were performed on 362 HIV-infected patients within the LAC-USC Medical Center. Adequate material was obtained from 84% of the FNA, allowing the etiology of the mass to be determined in 90% of the cases by means of a combination of cytologic, microbiologic, and immunocytochemical procedures. Significant pathologic processes identified in these patients by means of FNA included reactive lymphoid proliferations (35%), abnormal lymphoid proliferations (12%), infections (12.5%), cystic (5.5%) and inflammatory processes (5%), nonlymphoid malignancies (4%), and salivary gland pathology (1%). We conclude that FNA is an appropriate initial diagnostic procedure in HIV positive patients presenting with mass lesions.

Testicular carcinoma in patients positive and at risk for human immunodeficiency virus

Patients with the acquired immunodeficiency syndrome are at increased risk for certain malignancies. Because acquired immunodeficiency syndrome and testicular cancer affect primarily young men, the potential complications that acquired immunodeficiency syndrome might impose raise significant concern. To address this question we performed a retrospective review of all cases of testicular cancer during an 11-year period. Of 140 patients 6 had human immunodeficiency virus infection and 7 were from human immunodeficiency virus risk groups. All cases were either stage I or II disease with seminoma in 8, teratocarcinoma in 3, embryonal cell carcinoma in 1 and teratoma in 1. The clinical presentations of these patients were comparable to those of patients without human immunodeficiency virus risk factors. The majority of the patients received standard therapy, including orchiectomy followed by lymphadenectomy, radiation therapy or chemotherapy depending on stage and pathological subtype. Patients tolerated therapy well with only 1 course of radiation therapy complicated by Pneumocystis carinii pneumonia. All patients achieved complete remission and none died of testicular cancer. Since treatment of these patients may worsen the immunosuppression, surveillance is recommended after orchiectomy for acquired immunodeficiency syndrome patients with stage I disease. However, the majority of patients with human immunodeficiency virus infection should receive standard therapy.

Bilateral synchronous testis tumors of different histology in a patient with the acquired immunodeficiency syndrome related complex

The incidence of bilateral testis tumors is approximately 1.5%. Of these cases the majority have the same histological status and few occur synchronously. Recently, an increased number of nonseminomatous germ cell tumors have been reported in the acquired immunodeficiency syndrome population. We describe a rare case of bilateral synchronous testis tumors of different histological status (seminoma and embryonal cell carcinoma) in a patient with the acquired immunodeficiency syndrome related complex. The patient was managed with bilateral orchiectomy and retroperitoneal lymph node dissection. Pathological stage was B1. The treatment was complicated by the fact that the patient is on azidothymidine, a drug that causes bone marrow suppression as a side effect. Because of persistent neutropenia no chemotherapy was given. The patient had no evidence of disease almost 1 year after retroperitoneal lymph node dissection.

Testicular seminoma associated with the acquired immunodeficiency syndrome and acquired immunodeficiency syndrome related complex: 2 case reports

Two homosexual men positive for human immunodeficiency virus with evidence of acquired cellular immunodeficiency were diagnosed recently to have seminoma of the testis. One man has the acquired immunodeficiency syndrome with lymphopenia, a low CD4:CD8 ratio, condylomata accuminata, pneumocystis carinii and cerebral toxoplasmosis, and 1 has an acquired immunodeficiency syndrome related complex with generalized lymphadenopathy showing follicular hyperplasia on biopsy, recurrent Herpes simplex infections and lymphopenia but a supranormal CD4:CD8 ratio. Neither patient has a known risk factor for testicular seminoma. Our report provides supportive evidence for the presence of an increased risk of seminoma of the testis in patients with acquired immunodeficiency syndrome and acquired immunodeficiency syndrome related complex.

Cancer among New York men at risk of acquired immunodeficiency syndrome

In the United States, New York City has had the greatest number of subjects at risk of AIDS for the longest period of time. This population therefore serves as an indicator of changes in cancer risk which may emerge among persons at risk from AIDS. Using a proportional incidence method, we surveyed cancers occurring among single (a surrogate for homosexual) young men and married young men in Manhattan, the rest of New York City, and the remainder of New York State. The baseline period was established earlier to be 1973-76, during which time no cases of Kaposi's sarcoma were observed among single men in Manhattan. By 1985, the frequency of Kaposi's sarcoma in this group was increased 1,850-fold (compared with expected cases derived from other registries). In the same group, the increase of non-Hodgkin's lymphoma was 6.2-fold (p for trend less than 0.0001), with excesses of Burkitt's lymphoma and immunoblastic lymphoma being most noticeable. Diagnoses of Hodgkin's disease increased markedly in 1985 but not earlier. Since this pattern did not follow that of the AIDS epidemic in this area, we suggest that Hodgkin's disease is not an AIDS-associated tumor. Hepatoma was diagnosed more frequently in single young men during the 1980s but similar increases also were observed in married men and thus may be unrelated to AIDS. Thus, only Kaposi's sarcoma and non-Hodgkin's lymphoma appear to be AIDS-associated tumors, at least so far. With better treatment and longer survival, it remains possible that other tumors will emerge as part of the AIDS epidemic.

Effects of antineoplastic treatment of HIV-positive patients with testicular cancer

Among 101 patients with testicular cancer referred to the Department of Oncology ONB, Finsen Institute, four were proven HIV-positive before admission. Three of these patients were treated with cisplatin, 4-epi-podophyllotoxin (VP-16, Etoposide) and bleomycin. One patient with stage I of the testicular cancer was observed, after orchiectomy, without medical antineoplastic treatment. In the HIV-positive patients treated with cytotoxic drugs, leucopenia was seen after one (8%), fever after three (23%) and thrombocytopenia after two (15%) courses. Amongst patients not proven HIV-positive leucopenia, fever and thrombocytopenia were seen after 11 (9%), 21 (18%) and 27 (29%) courses. Two patients had stage II and two patients stage III of the HIV infection prior to treatment. The clinical stage of the disease did not change during the course of chemotherapy. We suggest that HIV-positive patients (stage II and III) with germ cell tumours should be treated with the same aggressive chemotherapy as given to other patients, not proven HIV-positive.

Malignant melanoma associated with human immunodeficiency virus infection in three homosexual men

This report concerns three patients with human immunodeficiency virus (HIV) infection in whom malignant melanoma developed. One patient had metastatic malignant melanoma, one had iris melanoma, and one had a single skin melanoma. All three had lower absolute numbers of CD4+ cells than a control group, and the severity of their disease was inversely proportional to the absolute number of CD4+ cells. This report suggests an association between the immunodeficiency resulting from HIV infection and the development of malignant melanoma.

Pathology of the testis in acquired immunodeficiency syndrome

The acquired immunodeficiency syndrome (AIDS) is most often a sexually transmitted disease acquired via male genital tract secretions. We performed a retrospective controlled study of testicular tissue taken from 100 AIDS patients at autopsy to determine the nature and spectrum of macroscopic and microscopic changes associated with AIDS in the testis. The AIDS patients showed a highly significant constellation of findings that included lymphocytic infiltration, perivasculitis, germ-cell loss, interstitial fibrosis, decreased mean tubular diameter and increased mean tubular wall thickness. Only four cases showed evidence of testicular involvement with opportunistic infectious agents. In 48 cases gross pathological findings were present. Only four cases had histologically normal testes. We conclude that AIDS should be part of the differential diagnosis of testicular atrophy.

Malignancies in the acquired immunodeficiency syndrome

Malignancies frequently arise in patients infected with human immunodeficiency virus (HIV), including those patients classified as having the acquired immunodeficiency syndrome (AIDS). Currently, Kaposi's sarcoma and certain types of lymphoma are considered to develop as a result of HIV infection, and other cancers have also been reported in these patients. For the most part, ultrastructural study of HIV-associated malignancies has been limited to Kaposi's sarcoma; the ultrastructural features of the epidemic form of this disease are generally the same as those of the classical form. The occurrence of these cancers in HIV-infected individuals appears to be related to the immunodeficiency caused by this virus, but the basic etiologic mechanisms remain unknown. In general, only palliative treatments are presently available for HIV-associated malignancies.

Malignancies in the acquired immunodeficiency syndrome

Aside from opportunistic infections, several neoplasms have been identified as part of the spectrum of acquired immunodeficiency syndrome (AIDS) as defined by the Centers for Disease Control. Kaposi's sarcoma (KS) was the first such neoplasm to be recognized within the spectrum of AIDS. Although the classic form of Kaposi's sarcoma had been well recognized prior to the epidemic of AIDS, it was quite distinct from the illness that was seen in its "epidemic" form in young homosexual males. In this setting, Kaposi's sarcoma is an aggressive disease, with extensive involvement of skin and mucous membranes, early dissemination to lymph nodes, impressive development of extreme lymphedema, even in the absence of bulky adenopathy, and rapid spread to visceral organs, including lungs and gastrointestinal tract, among others. Although rapid clinical progression and short median survival have been the rule, a spectrum of disease has been seen such that some patients have survived for many years with disease limited to the skin. Certain clinical and laboratory features, such as presence of unexplained fever, night sweats, weight loss ("B" symptoms), or significant T-4-lymphocytopenia, have been identified as indicators of poor prognosis. Various therapeutic interventions have been employed in epidemic KS, and although partial and complete remissions have occurred, no regimen yet reported has significantly improved the survival of treated patients. High-dose recombinant alpha interferon has produced response rates in approximately 30% of treated patients, although toxicity has been observed in approximately 30% as well. Likewise, vinblastine has produced similar response rates with no evidence of long-term efficacy or "cure." Aside from Kaposi's sarcoma, lymphoma primary to the central nervous system was recognized early in the AIDS epidemic as a criterion for inclusion within AIDS in patients less than sixty years of age. Several years after the initial reports of disease, it became apparent that specific types of systemic lymphoma were also quite extraordinary, and the definition of AIDS was amended in June 1985 to include high-grade B-cell lymphomas in individuals who had positive serology or virology for the human immunodeficiency virus (HIV). The AIDS-related lymphomas are characteristic, both pathologically and clinically. The vast majority of these cases have been high-grade B-lymphoid tumors of either immunoblastic or small-non-cleaved type (also known as "undifferentiated," Burkitt, or Burkitt-like).(ABSTRACT TRUNCATED AT 400 WORDS)

Neoplastic complications of HTLV-III infection. Lymphomas and solid tumors

Neoplastic disease arose in 29 of 200 patients infected with human T lymphotropic virus type III (HTLV-III) seen at a suburban hospital. Seventeen patients had Kaposi's sarcoma, one of whom also had colon carcinoma. Nine patients had lymphoproliferative disorders (seven lymphomas, one T suppressor cell chronic lymphocytic leukemia, and one multiple myeloma), including three with concomitant Kaposi's sarcoma and one with colon cancer. One other patient had colon cancer, one had a seminoma, and one had pancreatic cancer. Kaposi's sarcoma as a complication of AIDS occurred mainly in homosexuals (17 of 42 homosexuals, one of 17 drug abusers, one of five heterosexually promiscuous patients, and one of six patients who had previously received transfusions). The high-grade lymphomas did not show a predilection for any particular AIDS risk group. Three of four solid tumors arose in elderly AIDS patients. Twenty-five of 75 patients with CDC-defined AIDS had a neoplastic disorder (26 are still alive and may yet demonstrate malignancy). Few other diseases of man have been associated with as high an incidence of neoplastic transformation as occurs with HTLV-III infection.

Testicular cancer and antecedent diseases

A case-control study of the aetiology of testicular cancer was conducted using information obtained by interview and from case-notes of 259 cases with testicular cancer and two sets of control patients -238 men with diagnoses other than testicular cancer attending the same radiotherapy centres as those attended by the cases, and 251 hospital in-patients not attending radiotherapy departments. Logistic regression analyses were performed, after stratifying by age and region of residence, to estimate the relative risks (RRs) associated with various aspects of prior medical history. The risk of testicular cancer was found to be raised for men with a history of cryptorchidism (RR based on comparison with all controls = 6.3; P less than 0.001), inguinal hernia (RR = 1.6; P = 0.14), mumps orchitis (RR = 12.7; P = 0.006), atopy (RR = 1.8; P = 0.03), and meningitis (RR = 3.0; P = 0.21). Inguinal herniorrhaphy before the age of 15 years was particularly a risk factor for seminoma, whereas the relative risks were similar for seminoma and teratoma for the other factors. The results add to the growing evidence that congenital abnormalities involving the process of testicular descent and closure of the processus vaginalis are risk factors for testicular cancer, and that some types of testicular damage later in life may also be important. The findings of associations with previous atopy and certain infections suggest a possible second aetiological mechanism - that immunological abnormalities may be associated with an increased risk of testis cancer.