Neoplastic complications of HIV infection

Differential survival of Brazilian patients with diffuse large B-cell lymphoma with and without HIV infection

OBJECTIVE

Combinatorial antiretroviral therapy provided improvement of HIV patients' immune function and a decrease in the incidence of non-Hodgkin lymphoma (NHL). Diffuse large B-cell lymphoma (DLBCL) is one of the most common NHL forms affecting HIV+ patients. The present study aimed to evaluate the impact of HIV infection on the prognosis of patients treated for DLBCL in a reference cancer treatment center in Brazil.

METHODS

A retrospective case-control study was developed with patients followed-up at the Brazilian National Cancer Institute, in which 243 DLBCL patients (91 HIV+ and 152 HIV-) were enrolled. HIV- controls were matched to HIV+ according to date of cancer diagnosis, clinical staging, primary cancer treatment and date of birth. Sociodemographic and cancer treatment data were extracted from medical charts. Kaplan-Meier analyses were carried out to estimate survival, while univariate and multiple Cox regression analyses were used to determine factors associated with mortality.

RESULTS

A total of 98 deaths were observed in a 5-year period after cancer diagnosis. A negative association of HIV infection with both overall and disease-specific survival 1 year after cancer diagnosis was observed [hazard ratio (HR) = 1.98 and 1.96, respectively]. The negative association with HIV infection with disease-specific survival remained significant for a 5-year period after cancer diagnosis (HR = 1.53). HIV viral load above 1000 copies/ml at study entry was also associated with shorter overall and cancer-specific survival.

CONCLUSIONS

HIV infection negatively impacted prognosis and mortality of DLBCL patients irrespective of cancer-related clinical factors.

First Extensive Analysis of 18F-Labeled Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography in a Large Cohort of Patients With HIV-Associated Hodgkin Lymphoma: Baseline Total Metabolic Tumor Volume Affects Prognosis

PURPOSE

¹⁸F-labeled fluorodeoxyglucose positron emission tomography with computed tomography (¹⁸F-FDG PET-CT) data in HIV-associated Hodgkin lymphoma (HIV-HL) are scarcely reported. In addition to the description of the characteristics of both baseline and interim ¹⁸F-FDG PET-CT examinations (PET1 and iPET, respectively), the aim of this study was to assess the prognostic value of PET1 and previously identified clinical parameters in this population.

PATIENTS AND METHODS

PET1 of 109 patients with HIV-HL, treated with doxorubicin, bleomycin, vinblastine, and dacarbazine chemotherapy regimen since 2007, and 104 iPET were centrally reviewed. All the patients were enrolled in an ongoing prospective single-center cohort of HIV-associated lymphoma.

RESULTS

Most patients had a disseminated disease according to the Ann Arbor classification (30% stage III and 43% stage IV), with especially bone marrow and liver as extranodal localizations. After a median follow-up of 6.7 years, 12 patients relapsed (11%) and 13 died (12%). Five-year progression-free survival (PFS) was 75.1%, and 5-year overall survival was 86.1%. Median total metabolic tumor volume (TMTV) was 121.4 cm³. The optimal TMTV cutoff identified for prognostic analysis was 527 cm³, with a 2-year PFS of 71% in the 20 patients with TMTV > 527 cm³, compared with 91% in the 89 patients with TMTV ≤ 527 cm³ (P = .004). On multivariate analysis, a high TMTV was the only parameter independently associated with PFS.

CONCLUSION

In this large series of HIV-HL patients with a homogeneous management, high TMTV on PET1 examination was associated with a poor prognosis.

Infectious diseases as a cause of death among cancer patients: a trend analysis and population-based study of outcome in the United States based on the Surveillance, Epidemiology, and End Results database

Background

Infectious diseases are a major cause of morbidity and mortality among cancer patients. We aimed to determine the incidence of infectious diseases as a cause of death among cancer patients and analyze the trends and risk factors associated with mortality.

Methods

In total, 151,440 cancer patients who died from infectious diseases in the US diagnosed between 1973 and 2014 from the Surveillance, Epidemiology, and End Results program were enrolled. A trend analysis of annual cancer deaths caused by infectious diseases was conducted. Cox proportional hazards model and survival decision tree model were performed.

Result

The most common infectious diseases were pneumonia and influenza (n = 72,133), parasitic and other infectious (n = 47,310) diseases, and septicemia (n = 31,119). The patients’ mean age was 66.33 years; majority of them were male (62%). The overall incidence from 1973 to 2014 showed an insignificant decrease (annual percentage change =  − 0.3, 95% confidence interval [CI] =  − 2.2–1.7, P = 0.8). Parasitic and other infectious diseases, including HIV (standardized incidence ratio [SIR] = 1.77, 95% CI = 1.69–1.84), had the highest incidence, followed by septicemia (SIR = 0.84, 95% CI = 0.81–0.88), tuberculosis (SIR = 0.72, 95% CI = 0.51–0.99), and pneumonia (SIR = 0.63, 95% CI = 0.61–0.64). Based on the Cox regression analysis, old black male patients with intrahepatic tumor or acute leukemia of different grades, except the well-differentiated grade, had the highest risk of dying from infectious diseases.

Conclusion

Infectious diseases remain the major cause of morbidity and mortality among cancer patients. Early recognition of risk factors and timely intervention may help mitigate the negative consequences on patients’ quality of life and prognosis, improving the prognosis and preventing early death from infection, which is preventable in most cases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13027-021-00413-z.

The role of F-18 FDG PET/CT in evaluating the impact of HIV infection on tumor burden and therapy outcome in patients with Hodgkin lymphoma

BACKGROUND

To evaluate the impact of HIV infection on tumor burden and therapy outcome following treatment with chemotherapy in patients with Hodgkin lymphoma.

METHODS

A total of 136 patients with classical Hodgkin lymphoma were studied (mean age ± SD = 32.31 ± 1.39 years, male = 86, female = 50). Advanced disease (stage III and IV) was present in 64% of patients. HIV infection was present in 57 patients while 79 patients were HIV-negative. Baseline F-18 FDG PET/CT was obtained in all patients. SUVmax, MTV and TLG were determined on the baseline scan to evaluate for tumor burden. All patients completed a standard regimen of adriamycin, bleomycin, vinblastine and dacarbazine (ABVD). After a median period of 8 weeks (range = 6 to 17 weeks), a repeat F-18 FDG PET/CT scan was obtained to evaluate response to therapy using Deauville 5-point scoring system.

RESULTS

The HIV-positive and HIV-negative groups were similar with regards to age and disease stage. The groups were heterogeneous with respect to gender (p = 0.029). The SUVmax, MTV and TLG of lesions were not significant different between the two groups. Complete response was seen in 72.8% of the study population. Presence of HIV infection was associated with higher rate of treatment failure with 40.4% of the HIV-positive patients having treatment failure while only 17.7% of the HIV-negative patients had treatment failure (p = 0.0034). HIV infection was a significant predictor of response to chemotherapy. Effects of SUVmax, MTV, TLG and Ann Arbor stage of the disease were not statistically significant as predictors of therapy outcome. In a multiple logistic regression, presence of HIV infection still remained an independent predictor of therapy outcome in the presence of other factors such as SUVmax, MTV, TLG and the Ann Arbor stage of the disease.

CONCLUSIONS

HIV infection is not associated with a higher tumor burden in patients with Hodgkin lymphoma. HIV infection is, however, a strong predictor of poor therapy outcome in patients treated with standard regimen of ABVD.

The Prevalence of HIV in Cancer Patients at the Surgical Oncology Unit of Donka University Hospital of Conakry (Guinea)

Aim. To determine the prevalence of HIV infection among patients seen at the surgical oncology unit of Donka (Conakry, Guinea). Method. We conducted a retrospective and descriptive study of HIV infection in cancer patients from May 2007 to December 2012. Social characteristics (age, gender, marital status, and education) and immune status (HIV type, CD4 count) were reviewed. Results. Out of 2598 cancer patients, 54 (2.1%) tested positive for HIV. There were 11 (20.4%) defining AIDS and 43 (79.6%) nondefining AIDS cancers. The most frequent cancers were breast (14) (26.0%), non-Hodgkin lymphoma (6) (11.1%), liver (6) (11.1%), eye and annexes (6) (11.1%), and cervical cancer (5) (9.3%). These patients were female in 34 (63.0%) and had a median age of 39 years and body mass index was 20,3 Kg/m². They were unschooled in 40 (74.1%) and married in 35 (64.8%). CD4 count showed a median of 317 cells/mL. Antiretroviral treatment was performed in 40 (74.1%). Conclusion. HIV prevalence is higher in patients in our unit of surgical oncology. Breast cancer was the most common in this association. A national survey of a large sample is needed to determine the true prevalence and impact of HIV on cancer prognosis.

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.

Inflammation and cancer: interweaving microRNA, free radical, cytokine and p53 pathways

Chronic inflammation and infection are major causes of cancer. There are continued improvements to our understanding of the molecular connections between inflammation and cancer. Key mediators of inflammation-induced cancer include nuclear factor kappa B, reactive oxygen and nitrogen species, inflammatory cytokines, prostaglandins and specific microRNAs. The collective activity of these mediators is largely responsible for either a pro-tumorigenic or anti-tumorigenic inflammatory response through changes in cell proliferation, cell death, cellular senescence, DNA mutation rates, DNA methylation and angiogenesis. As our understanding grows, inflammatory mediators will provide opportunities to develop novel diagnostic and therapeutic strategies. In this review, we provide a general overview of the connection between inflammation, microRNAs and cancer and highlight how our improved understanding of these connections may provide novel preventive, diagnostic and therapeutic strategies to reduce the health burden of cancer.

AIDS malignancies

Among individuals with HIV-infection, coinfection with oncogenic viruses including EBV, HHV-8, and HPV cause significant cancer-related morbidity and mortality. It is clear that these viruses interact with HIV in unique ways that predispose HIV-infected individuals to malignant diseases. In general, treatment directed specifically against these viruses does not appear to change the natural history of the malignant disease, and once the malignancy develops, if their health permits, HIV-infected patients should be treated using similar treatment protocols to HIV-negative patients. However, for the less frequent HIV-related malignancies, such as PEL, or MCD, optimal treatments are still emerging. For certain AIDS-defining malignancies, it is clear that the widespread access to HAART has significantly decreased the incidence, and improved outcomes. However, for other cancers, such as the HPV-related tumors, the role of HAART is much less clear. Further research into prevention and treatment of these oncogenic virally mediated AIDS-related malignancies is necessary.

Current trends of HIV disease of the mouth

HIV infection affects residents of all countries of the world, but the greater majority of affected individuals reside in the developing world. In the past decade there have been substantial changes in the management of HIV disease, particularly the introduction of highly active antiretroviral therapy (HAART). Such agents have reduced significantly the morbidity and mortality associated with HIV disease, however, they are not available for most HIV-infected individuals in the developing world. There is now considerable understanding of the molecular epidemiology, transmission and therapy of the common opportunistic oral infections of HIV disease, and as a consequence of improved anti-HIV strategies, the frequency and severity of oral disease associated with HIV infection have reduced considerably, although HAART may predispose to human papilloma virus infection of the mouth and potentially increase the risk of later oral squamous cell carcinoma. Despite advances in clinical care the majority of individuals with HIV disease worldwide will continue to develop oral disease, as they are resident in the developing world and do not have ready access to even simple therapies.

Detection of hepatitis C virus RNA in paraffin-embedded tissues from patients with non-Hodgkin's lymphoma

The aim of this study is to detect the possible role of hepatitis C Virus (HCV) in lymphomagenesis. HCV-RNA and anti-HCV antibodies were studied in tissue and serum samples taken from patients with non-Hodgkin's Lymphoma (NHL). The prevalence of HCV, the clinical presentation of these cases, and association with histologic subtypes were determined. RT-PCR was used to detect the HCV-RNA in serum and tissue samples. The anti-HCV antibodies were tested with microparticle enzyme immunoassay. Immunohistochemistry with the ABC method was used to detect the HCV core protein in HCV-RNA(+) cases. RNA could be detected in 30 of 35 cases, and other tests were performed in these 30 samples. HCV-RNA was detected in 11 tissue samples (11/30, 37%). HCV core protein was studied in 10 of 11 HCV-RNA(+) cases, and 1-3% nuclear staining was found in only 2 samples. Serologically, HCV-RNA was detected in 7 of 30 samples (23.3%) and anti-HCV antibody was detected in 3 of 30 samples (10%). Detection of HCV-RNA in 37% of the lymphoma tissue samples suggests that HCV may have a role or is a contributing factor in the pathogenesis of lymphoma. The very low HCV core protein in lymphoma tissues may be due to the low viral load in lymphoid tissues and/or higher sensitivity of the PCR method. Detection of anti-HCV antibody in only three cases may be associated with undetectable levels of antibodies due to the immune deficiency in cases with NHL.

Therapeutic approaches to AIDS-related malignancies

The introduction of highly active antiretroviral therapy (HAART) has changed dramatically the landscape of HIV disease. Deaths from AIDS-related diseases have been reduced by 75% since protease inhibitor therapy and combination antiretroviral therapy came into use in late 1995. While KS is declining, the situation for non-Hodgkin's lymphoma is more complex with a reduced incidence of primary central nervous system lymphoma, but a relatively stability in the number of patients developing systemic NHL. AIDS related NHL appears not to be markedly decreased by the introduction of HAART and it is the greatest therapeutic challenge in the area of AIDS oncology. The emphasis has now shifted to cure while maintaining vigilance regarding the unique vulnerability of HIV-infected hosts. Furthermore, also for the prolongation of the survival expectancy of these patients, other non AIDS-defining tumors, such as Hodgkin's disease, anal and head and neck, lung and testicular cancer, and melanoma have been recently reported with increased frequency in patients with HIV infection.

AIDS and non-AIDS-related malignancies: a new vexing challenge in HIV-positive patients. Part II. Cervical and anal squamous epithelial lesions, lung cancer, testicular germ cell cancers, and skin cancers

As the AIDS epidemic progresses, more and more HIV-infected patients will develop malignancies. The natural history of a malignancy may change dramatically in the presence of HIV infection. Among the AIDS and non-AIDS malignancies, the most frequently reported solid tumors are cervical and anal cancer, testicular germ cell tumors, lung cancer, and skin cancer. Regardless of epidemiology and outcome, the natural history of the majority of non-AIDS-defining tumors changes in the setting of HIV infection. Physicians who treat patients with AIDS and non-AIDS-related cancers need to become familiar with antiretroviral agents, drug-drug interactions, and the prophylaxis and management of opportunistic infections.

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

HIV-infected patients are at an increased risk for developing cancers. Three, in particular, are considered to be AIDS-defining malignancies: Kaposi's sarcoma (KS), non-Hodgkin's lymphoma (NHL), and cervical cancer. Other non-AIDS-defining malignancies have been reported in the setting of HIV infection as having an increased frequency compared with their incidence in the general population. One of those most frequently reported is Hodgkin's disease. As with KS and NHL, the problem of diagnosing and treating immunocompromised patients with cancer represents a formidable challenge. Moreover, a newly discovered human gamma-herpes virus, human herpes virus-8 (HHV-8), has been identified in over 90% of KS lesions from patients with and without AIDS, suggesting its etiological importance in the development of KS and new therapeutic approaches.

AIDS-related tumors: integrating antiviral and anticancer therapy

The introduction of highly active antiretroviral therapy (HAART) has changed dramatically the landscape of HIV disease. Deaths from AIDS-related diseases have been reduced by 75% since protease inhibitor therapy and combination antiretroviral therapy came into use in late 1995. While KS is declining, the situation for non-Hodgkin's lymphoma is more complex with a reduced incidence of primary central nervous system lymphoma, but a relative stability in the number of patients developing systemic NHL. AIDS-related NHL appears not to be markedly decreased by the introduction of HAART and it is the greatest therapeutic challenge in the area of AIDS oncology. The emphasis has now shifted to cure while maintaining vigilance regarding the unique vulnerability of HIV-infected hosts. Furthermore, also for the prolongation of the survival expectancy of these patients, other non-AIDS-defining tumors, such as Hodgkin's disease, anal, head and neck, lung and testicular cancer, and melanoma have been recently reported with increased frequency in patients with HIV infection.

Cancer incidence in women with or at risk for HIV

The purpose of our study was to identify the types and rates of cancers seen in high-risk human immunodeficiency virus (HIV)-infected and HIV-uninfected women. From 1993 to 1995, 1,310 women enrolled at four urban U.S. research sites in the HIV Epidemiology Research Study and were interviewed biannually to identify interval diagnoses and hospitalizations until study closure in March 2000. Cancer incidence data were collected through abstraction of medical records and death certificates. Of 871 HIV-infected and 439 HIV-uninfected women, 85% had a history of smoking and 50% a history of injection drug use. For our analysis, 4,180 person-years were contributed by HIV-infected women, and 2,308 person-years by HIV-uninfected women. HIV-infected women had 8 non-Hodgkin's lymphomas, 5 invasive cervical cancers (ICC), 1 Kaposi's sarcoma and 12 non-AIDS defining cancers, including 4 lung cancers, compared with 4 cancers in HIV-uninfected women including 1 lung cancer (all cancers, 6.22/1000 person-years vs. 1.73/1000 person-years, p = 0.01). CD4+ cell counts were above 200/mm3 in all women with ICC. HIV-infected women with lung cancer were young smokers (mean age, 40 years), and all died within 6 months of diagnosis. Lung cancer occurred at twice the rate in HIV-infected vs. uninfected women in the cohort and severalfold above expected in age- and race-matched women in U.S. national data (incidence relative risk 6.39; 95% confidence interval 3.71, 11.02; p < 10(-7)). The frequent occurrence of cervical and lung cancers have important implications for the counseling (cigarette cessation), screening (PAP smears) and care of women with HIV infection, as they live longer because of current antiretroviral therapies.

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.

Impact of HAART on the clinical management of AIDS-related cancers

The development of HIV-related disease has changed dramatically since the introduction of highly active antiretroviral therapy (HAART) into clinical practice. Since the use of protease inhibitors became widespread, a 30-50% reduction in Kaposi's sarcoma (KS) has been observed. The results of recent studies indicate that HAART may be a useful alternative both to immune response modifiers during less aggressive stages of KS disease and to systemic cytotoxic drugs in the long-term maintenance therapy of advanced KS. The impact of HAART regimens on the incidence of systemic lymphoma (NHL-HIV) remains unclear, but it can be hypothesised that patients treated with HAART may survive longer with continued B cell stimulation and dysregulation resulting in an increased incidence of lymphoma over time. The impact of HAART on survival in patients affected by NHL-HIV has recently been evaluated and a positive correlation between HAART and outcome in these patients has been found. The spectrum of cancers in patients with HIV infection may develop further since these patients survive longer with HAART and with a better control of opportunistic infections. With the increasing use of HAART, the dilemma is whether to institute or continue protease inhibitors use during chemotherapy. Based on the advances in our understanding of HIV-related disease and the availability of new antiretroviral therapies, the choice for anti-HIV agents in patients receiving chemotherapy is important.

Current issues in the biology of AIDS-related lymphoma

Three important issues have been the focus of much recent attention in the biology of AIDS-related lymphomas. The altered epidemiology in the era of highly active antiretroviral therapy, the role of herpesviruses including human herpesvirus 8 and the molecular genetics of HIV-associated T-cell lymphomas. These topics are covered in this article and their potential application to the clinical management of AIDS-related lymphomas are discussed.