AIDS and non-AIDS-related malignancies: a new vexing challenge in HIV-positive patients. Part I: Kaposi's sarcoma, non-Hodgkin's lymphoma, and Hodgkin's lymphoma

African genetic diversity and adaptation inform a precision medicine agenda

The deep evolutionary history of African populations, since the emergence of modern humans more than 300,000 years ago, has resulted in high genetic diversity and considerable population structure. Selected genetic variants have increased in frequency due to environmental adaptation, but recent exposures to novel pathogens and changes in lifestyle render some of them with properties leading to present health liabilities. The unique discoverability potential from African genomic studies promises invaluable contributions to understanding the genomic and molecular basis of health and disease. Globally, African populations are understudied, and precision medicine approaches are largely based on data from European and Asian-ancestry populations, which limits the transferability of findings to the continent of Africa. Africa needs innovative precision medicine solutions based on African data that use knowledge and implementation strategies aligned to its climatic, cultural, economic and genomic diversity.

A case of Kaposi’s sarcoma of tonsil with profuse bleeding in an HIV-positive patient

Kaposi’s sarcoma is the most common AIDS-associated malignancy. Kaposi’s sarcoma in the oral cavity and oropharynx present as a macular, papular, or nodular lesion on the palate, gingiva, or tongue which may look pink, reddish, or purplish. Kaposi’s sarcoma of the tonsils is relatively less common compared with other sites in the oral cavity and oropharynx. We report a case of Kaposi’s sarcoma of tonsil with profuse bleeding requiring emergency tracheostomy to protect the airway followed by tonsillectomy to control the bleeding. Our initial diagnosis was hemangioma or a pyogenic granuloma. The patient tested positive for a retroviral infection and the histopathology report was compatible with Kaposi’s sarcoma. Antiretroviral therapy and radiotherapy were given after stabilizing the patient. Kaposi’s sarcoma of tonsils is relatively uncommon and it is unusual to cause profuse bleeding. Various treatment options are available but there are no standard treatment protocols. Treatments options depend on the site, size, stage, and immune status of the patient.

People living with human immunodeficiency virus and gestational trophoblastic neoplasm

The World Health Organization (WHO) estimates that sub-Saharan Africa compromises 64% of the global human immunodeficiency virus (HIV) burden. Over the last decade, there has been steady progress in the reduction of acquired immunodeficiency syndrome (AIDS)-related deaths and a more gradual progress in the reduction of new HIV infections globally. The largest reduction in HIV infections and AIDS-related deaths occurred in Southern and Eastern Africa. Gestational trophoblastic disease (GTD) comprises a spectrum of pregnancy-related illnesses with cure rates near 90%. To date, no clear association exists between HIV and GTD. Response to treatment for gestational trophoblastic neoplasm is favorable, but in HIV-positive patients, the extent of metastatic disease, low CD4 counts and poor performance status compromise treatment outcome and survival.

Differences in Virological and Immunological Risk Factors for Non-Hodgkin and Hodgkin Lymphoma

Background

Non-Hodgkin lymphoma (NHL) and Hodgkin lymphoma (HL) are increased in populations with immune dysfunction, including people living with HIV; however, there is little evidence for to what degree immunological and virological factors differently affect NHL and HL risk.

Methods

Data from the Data Collection on Adverse events of Anti-HIV Drugs Study cohort were analyzed to identify independent risk factors for NHL and HL using hazard ratios (HRs), focusing on current and cumulative area under the curve (AUC) measures of immunological and virological status. Variables with different associations with NHL and HL were identified using marginal Cox models. All statistical tests were two-sided.

Results

Among 41 420 people followed for 337 020 person-years, 392 developed NHL (incidence rate = 1.17/1000 person-years of follow-up [PYFU], 95% confidence interval [CI] = 1.06 to 1.30) and 149 developed HL (incidence rate = 0.44/1000 PYFU, 95% CI = 0.38 to 0.52). Higher risk of both NHL and HL was associated with lower current CD4 cell count (adjusted HR [aHR] of NHL for CD4 <100 vs > 599 cells/mm3 = 8.08, 95% CI = 5.63 to 11.61; HL = 4.58, 95% CI = 2.22 to 9.45), whereas higher current HIV viral load (aHR of NHL for HIV-VL >1000 vs < 50 copies/mL = 1.97, 95% CI = 1.50 to 2.59) and higher AUC of HIV-VL (aHR of NHL for highest vs lowest quintile = 2.91, 95% CI = 1.92 to 4.41) were associated with NHL only. Both current and AUC of HIV-VL were factors that had different associations with NHL and HL, where the hazard ratio for NHL was progressively higher than for HL with increasing HIV-VL category. Lower current CD4 cell count had a strong but similar association with both NHL and HL.

Conclusions

CD4 depletion increased risk of both types of lymphomas while current and accumulated HIV-VL was associated with NHL only. This suggests that NHL development is related to both CD4 cell depletion and added immune dysfunction derived from ongoing HIV replication. This latter factor was not associated with HL risk.

Outcomes of Programmed Cell Death Protein 1 (PD-1) and Programmed Death-Ligand 1(PD-L1) Inhibitor Therapy in HIV Patients with Advanced Cancer

Due to HAART and consequent decline in mortality from infectious complications, HIV patients have an increasing burden of non-AIDS defining cancers. Data on their safety and efficacy is unknown as these patients were excluded from clinical trials due to concern of unforeseen side effects. Objectives. The main objective of our study was to evaluate the efficacy and safety profile of PD-1 and PD-L1 inhibitors in HIV patients being treated for advanced cancers and to assess the impact of these drugs on HIV status of the patients specifically CD4 count and HIV viral load. Materials and Methods. This was a retrospective analysis of data of 17 patients HIV treated with one of the PD-1/PD-L1 inhibitors (Nivolumab, Pembrolizumab, Atezolizumab, Durvalumab, or Avelumab) for advanced cancer. Results. 10 out of 17 patients responded to therapy. 7 patients, all of whom had shown response to therapy, were alive and 4 were still on checkpoint inhibitor. 10 patients including all 7 nonresponders had died. Responders had minimum of 15 weeks of response while one had ongoing continued response at 34 weeks. Side effects were seen in 7 patients and only one patient needed cessation of therapy. CD4 counts were stable on treatment while HIV RNA remained undetectable. Conclusion. PD-1 and PD-L1 inhibitors appear to have comparable efficacy and tolerable side effect profile and have no effect on HIV markers when used in HIV patients with advanced cancers.

The extent of B-cell activation and dysfunction preceding lymphoma development in HIV-positive people

OBJECTIVES

B-cell dysfunction and activation are thought to contribute to lymphoma development in HIV-positive people; however, the mechanisms are not well understood. We investigated levels of several markers of B-cell dysfunction [free light chain (FLC)-κ, FLC-λ, immunoglobulin G (IgG), IgA, IgM and IgD] prior to lymphoma diagnosis in HIV-positive people.

METHODS

A nested matched case-control study was carried out within the EuroSIDA cohort, including 73 HIV-positive people with lymphoma and 143 HIV-positive lymphoma-free controls. Markers of B-cell dysfunction were measured in prospectively stored serial plasma samples collected before the diagnosis of lymphoma (or selection date in controls). Marker levels ≤ 2 and > 2 years prior to diagnosis were investigated.

RESULTS

Two-fold higher levels of FLC-κ [odds ratio (OR) 1.84; 95% confidence interval (CI) 1.19, 2.84], FLC-λ (OR 2.15; 95% CI 1.34, 3.46), IgG (OR 3.05; 95% CI 1.41, 6.59) and IgM (OR 1.46; 95% CI 1.01, 2.11) were associated with increased risk of lymphoma > 2 years prior to diagnosis, but not ≤ 2 years prior. Despite significant associations > 2 years prior to diagnosis, the predictive accuracy of each marker was poor, with FLC-λ emerging as the strongest candidate with a c-statistic of 0.67 (95% CI 0.58, 0.76).

CONCLUSIONS

FLC-κ, FLC-λ and IgG levels were higher > 2 years before lymphoma diagnosis, suggesting that B-cell dysfunction occurs many years prior to lymphoma development. However, the predictive value of each marker was low and they are unlikely candidates for risk assessment for targeted intervention.

Steroid-exacerbated HIV-associated cutaneous Kaposi's sarcoma immune reconstitution inflammatory syndrome: 'Where a good intention turns bad'

A 51-year-old man with head and neck skin lesions was diagnosed with Kaposi's sarcoma (KS) as his initial presentation of acquired immunodeficiency syndrome. Following initiation of antiretroviral therapy and subsequent full virologic suppression, his facial lesions worsened, consistent with immune reconstitution inflammatory syndrome (IRIS). He was started on glucocorticoids in an attempt to ameliorate the KS-IRIS but experienced paradoxical worsening of the KS lesions. Steroids were subsequently discontinued and he required chemotherapy for severe and cosmetically disfiguring skin lesions. This article describes the potential for worsening of KS lesions in individuals started on glucocorticoids for KS-IRIS as this has been reported rarely in published literature. The mechanisms underlying this phenomenon remain poorly understood but potential explanations are offered in the case discussion. This article aims to raise clinician awareness on the harms of steroid use in patients with KS-IRIS.

A review of the pattern of AIDS defining, HIV associated neoplasms and premalignant lesions diagnosed from 2000-2011 at Kenyatta National Hospital, Kenya

Background

Sub-Sahara Africa hosts up to 71 % of all HIV infected people in the world. With this high incidence of Human immunodeficiency virus ( HIV) comes the burden of co-morbidities such as malignant and premalignant lesions. Aids defining malignancies have been listed as Kaposi’s sarcoma, Non-Hodgkin’s lymphoma and invasive squamous cell carcinoma of the cervix. People with HIV/AIDS(PLWAS) have a higher risk of developing these neoplasms than the rest of the population. The pathogenesis of these neoplasms in people with HIV has been linked to immune suppression, persistent antigenic stimulation and cytokine dysregulation.

Current study analyzes and presents the patterns and trends in the presentation of HIV related malignancies in patients diagnosed through histopathology at Kenyatta National Hospital.

Aim

To describe the patterns of AIDS- defining and non-AIDS- defining malignancies and premalignant lesions 10 years pre- and post HAART period at Kenyatta National hospital, Kenya.

Methods and techniques

This was a hospital based descriptive cross sectional study. The Formalin fixed paraffin embedded (FFPE) blocks and histological reports of patients diagnosed between 2000 and 2011 were traced from archives. The patients’ demographic data and clinical presentation was entered in an excel spreadsheet and the diagnosis and coding confirmed by a histopathologist. The data was then cleaned and analyzed using SSPS version 17.0 Ink.

Results

A total of 173 lesions were reviewed and analyzed. Of these 118 (68 %) were from females and 55 from males (32 %). The male to female ratio was 1:2. The age range was from two to 56 years with a median of 36 years. Kaposi sarcoma is the leading AIDS defining malignancy in Kenya while invasive squamous cell carcinoma of the conjunctiva is the leading non-AIDS defining malignancy. This is closely followed by invasive squamous cell carcinoma of the cervix and NHL.

Conclusion

Kaposi sarcoma is the leading AIDS associated neoplasm in Kenya. Physicians and caretakers managing and following up on HIV/AIDS patients should look out for Kaposi sarcoma as a form of IRIS following the institution of HAART in all HIV/AIDS patients. The incidence of invasive squamous cell carcinoma of the conjunctiva is increasing in PLWAS in Kenya. There is therefore a need to introduce early screening programs for squamous intraepithelial neoplasm of the conjunctiva in HIV/AIDS patients.

A collaborative nationwide lymphoma study in Lebanon: incidence of various subtypes and analysis of associations with viruses

Incidence of various Hodgkin (HL) and non-Hodgkin lymphoma (NHL) subtypes and association with viruses in Lebanon are not known. We undertook a nationwide study of 272 patients diagnosed with lymphoma in 2007. HL comprised 32.7 % (n = 89) of cases while NHL represented 67.3 % (n = 183). Consistent with the literature, nodular sclerosis was the most predominant HL subtype (n = 57/89). Among NHL, B-cell NHL represented 88 % (n = 161/183), T-cell NHL 9 % (n = 17/183), whereas in 2.7 % it was not classifiable. The B-cell NHL comprised predominantly diffuse large B-cell lymphoma (46 %) and follicular lymphoma (23 %). 81 cases were reviewed by a panel of pathologists with 87.6 % concordance rate. Serology was negative for hepatitis C in 122 tested cases. HIV was positive in 2 cases. Two adult T-cell leukemia/lymphoma were HTLV-I positive. EBV IgG were positive in 88.5 % of cases. 38 EBV seropositive cases [27 NHL (24 B-cell, 3 T-cell) and 11 HL] were studied for EBV genome expression using EBV-encoded RNA (EBER)-in situ hybridization. EBER expression was positive in 8 (21 %) cases (6 HL, 2 T-cell NHL). The distribution of lymphoma subtypes in Lebanon appears similar to that of Western countries. The high rate of EBV positivity in HL and T-cell lymphoma by EBER deserves further investigation.

Interleukin-8 in the pathogenesis of primary central nervous system lymphoma in association with HIV infection

The pathogenesis of acquired immunodeficiency syndrome-associated primary central nervous system lymphoma (AIDS-associated PCNSL) remains unclear. However, cell adhesion molecules have been reported to be strongly associated with PCNSL. In this study, we established Epstein-Barr virus (EBV)-transformed lymphoblastoid cell lines (LCLs) from HIV-positive patients (LCL(HIV)) and normal individuals (LCL(N)). The expression of CD18 antigen by LCL(HIV) was stronger than that by LCL(N). We performed a cell adhesion assay using ISO-HAS, which is the human hemangiosarcoma cell line and expresses intercellular adhesion molecule 1 (CD54). The binding rates of LCL(HIV) and ISO-HAS without stimulation were higher than those of LCL(N). Further, we demonstrated that azidothymidine or simvastatin inhibited the binding rates of LCL(HIV) and ISO-HAS more significantly than those of LCL(N). Further, the levels of interleukin (IL)-8, a CD18 inducer, were higher in LCL(HIV) than in LCL(N). We conclude that interaction between IL-8 and CD18 may be critical to AIDS-related PCNSL.

Gestational Trophoblastic Neoplasia and Human Immunodeficiency Virus Infection: A 10-Year Review

Objectives

The objective of the study was to describe the management of gestational trophoblastic neoplasia (GTN), with particular reference to concurrent human immunodeficiency virus (HIV) infection.

Methods

This retrospective descriptive study comprised all cases of GTN managed at Groote Schuur Hospital over a 10-year period (1999–2008).

Results

Seventy-six patients, with a median age of 30 years at presentation, were included in the study. Only 36 patients (47.4%) had known HIV status. Fourteen (18.4%) were HIV positive, and of these, 4 (28.6%) were on antiretroviral treatment (ARV). The mean CD4 count was 142 cells/μL for those on ARV and 543 cells/μL for those not on ARV (P= 0.001). Histologically, 44 patients (58%) had hydatidiform mole, and 21 (28%) had choriocarcinoma. In the remaining 10 cases, a clinical diagnosis was made. Based on the revised International Federation of Gynecology and Obstetrics (FIGO)/modified World Health Organization scoring, 43 patients (56.6%) were low risk, and 33 (43.4%) were high risk. Thirty-eight patients (50%) were staged as FIGO stage I. Of 73 patients who received chemotherapy, 56 (76.7%) achieved complete remission, 9 (12.3%) did not achieve any remission, 7 (9.6%) had a relapse, and 1 (1.4%) was lost to follow-up. Patients who never went into remission had frequent treatment delays due to poor compliance or inadequate blood counts. The overall survival at 60 months was 81.9%. Of the 13 patients (17.1%) who have died, 5 (38.5%) were HIV positive. The overall 5-year survival rates for FIGO stages I, II, III, and IV were 97.4%, 66.7%, 77.8%, and 46.2%, respectively. The overall 5-year survival for HIV-positive patients was 64.3% versus more than 85% for both the HIV-negative and HIV-unknown groups.

Conclusions

Apart from more advanced stage, HIV seropositivity and poor compliance with treatment also portend poorer outcome in GTN patients. In HIV-positive patients with poor CD4, little clarity is available whether ARV should be commenced speedily, and the administration of chemotherapy delayed until immune reconstitution occurs.

NK/T-Cell Lymphoma Associated with Epstein-Barr Virus in a Patient Infected with Human Immunodeficiency Virus: An Autopsy Case

Natural killer (NK)/T-cell lymphoma associated with Epstein-Barr virus (EBV) in a patient infected with human immunodeficiency virus (HIV) is very rare. The authors encountered a case of NK/T-cell lymphoma in a 36-year-old man who presented with an ulcerative mass on both tonsils. During assessment, HIV positivity was noted. The EBV was detected by EBV-encoded RNA 1 messenger RNA in situ hybridization and polymerase chain reaction for EBV-encoded nuclear antigen 1. On immunohistochemical staining, the infiltrated lymphoid cells of the tonsils demonstrated positvity for CD3, CD56, UCHL1, and granzyme, a finding compatible with NK/T-cell lymphoma. The patient received radiation therapy and chemotherapy, but died as a result of opportunistic infection of invasive aspergillosis after tumor recurrence. An autopsy was done with the consent of the patient's family. To our knowledge, this is the first case in an HIV patient of NK/T-cell lymphoma of the tonsils associated with EBV, confirmed by autopsy. NK/T-cell lymphoma should be considered in the HIV-positive patients with an ulcerating tonsillar mass.

A concept of essentially secondary factors central to definitive subtype characterization of Hodgkin's disease

Conceptually, Hodgkin's disease would appear to constitute a neoplasm that integrally incorporates responsive cellular elements in terms strictly of morphologic patterns of interaction resulting especially in a predictable scale of therapeutic and prognostic implications as related particularly to pathobiologic course and response to treatment. In this sense, Hodgkin's disease might in a real sense constitute a valid point of reference in terms of processes not only in the generation of the neoplastic process but particularly in terms of how such a neoplastic process interacts with host systems in specifically characterizing the very nature of the intrinsic neoplastic process itself. In this manner, therefore, it might be valid to consider the totality of manifestations of Hodgkin's disease as a fundamental series of processes that integrally determines the genesis and nature of the neoplastic process as a function especially of various host systems in response to that neoplasm. In terms strictly related to a viral or Epstein-Barr virus-related development of Hodgkin's disease, it might perhaps be true that transcription factor NF-kappaB might induce the signaling of a CD30 receptor pathway that is intrinsically linked with anti-apoptosis of germinal center lymphocytes. In overall terms, perhaps, the Epstein-Barr viral nuclear antigens such as Latent membrane protein 1 would activate NF-kappaB as a mechanism that induces anti-apoptotic effect by multiple pathways in the added context particularly of a concerted series of cytokines that secondarily regulate T lymphocyte response. Indeed, in simple terms, Hodgkin's disease would appear to involve a basic mechanism of induced transcription as an effective anti-apoptotic mechanism as exerted on Reed-Sternberg cells. The Epstein-Barr viral nuclear antigens might be pivotal in orchestrating a full series of cytokine and T lymphocyte responses that would perhaps contribute significantly to the effective perpetuation of such anti-apoptotic effect or effects as exerted on the Reed-Sternberg cells.

Population-based patterns of human immunodeficiency virus-related Hodgkin lymphoma in the Greater San Francisco Bay Area, 1988-1998

BACKGROUND

Epidemiologic characteristics of human immunodeficiency virus (HIV)-related Hodgkin lymphoma (HL) have not been examined in the Greater San Francisco Bay Area, a center of the HIV/acquired immunodeficiency syndrome (AIDS) epidemic, for a decade, despite changes in AIDS-associated diseases after the availability of highly active antiretroviral therapies (HAART).

METHODS

With population-based cancer registry data for 1988-1998, the authors examined risk factors, Epstein-Barr virus (EBV) association, incidence rates, and survival probabilities for 1752 patients with HL who were classified as HIV-positive or HIV-negative by a cancer registry-based method.

RESULTS

One hundred twenty-eight patients with HL (7%) were classified with HIV/AIDS; 95% were male. Among males, multivariate analysis (n=514 patients) found that HIV-related HL was associated strongly at diagnosis with ages 30-49 years, San Francisco residence, late-stage disease, lymphocyte depletion and unspecified histologic subtypes, and tumor cell EBV but not with other clinical features or mixed cellularity histology. Survival among patients with HIV-related HL, although it was poor, did not differ by race/ethnicity but was worse for patients with the nonnodular sclerosis histologic subtypes. Patients who were HIV-positive with HAART era (1996-1998) diagnoses were slightly older, were less likely to live in San Francisco, and were much more likely to be Hispanic compared with HIV-positive patients who were diagnosed before the HAART era; they had somewhat less aggressive disease and better survival. Incidence rates were higher for patients with HL overall compared with patients who had HIV-unrelated HL by 11% for white patients, 22% for black patients, and by 14% for Hispanic patients; excesses were greater in young adults.

CONCLUSIONS

Among males in the San Francisco Bay Area, HIV-related HL had distinctive demographic features, more aggressive clinical characteristics, stronger EBV association, and poorer survival and contributed to elevated regional HL incidence rates, particularly in young adults. Patients with HIV-related HL who were diagnosed after HAART was introduced appeared to have less aggressive disease and better survival.