Kaposi's sarcoma in pregnant women

HIV and cancer in Africa: mutual collaboration between HIV and cancer programs may provide timely research and public health data

The eruption of Kaposi sarcoma (KS) and aggressive non-Hodgkin lymphoma (NHL) in young homosexual men in 1981 in the West heralded the onset of the human immunodeficiency virus (HIV) infection epidemic, which remains one of the biggest challenges to global public health and science ever. Because KS and NHL were increased >10,000 and 50-600 times, respectively, with HIV, they were designated AIDS defining cancers (ADC). Cervical cancer (CC), increased 5-10 times was also designated as an ADC. A few other cancers are elevated with HIV, including Hodgkin lymphoma (10 times), anal cancer (15-30 times), and lung cancer (4 times) are designated as non-AIDS defining cancers (NADCs). Since 1996 when combination antiretroviral therapy (cART) became widely available in the West, dramatic decreases in HIV mortality have been observed and substantial decrease in the incidence of ADCs. Coincidentally, the burden of NADCs has increased as people with HIV age with chronic HIV infection. The impact of HIV infection on cancer in sub-Saharan Africa, where two thirds of the epidemic is concentrated, remains poorly understood. The few studies conducted indicate that risks for ADCs are also increased, but quantitatively less so than in the West. The risks for many cancers with established viral associations, including liver and nasopharynx, which are found in Africa, do not appear to be increased. These data are limited because of competing mortality, and cancer is under diagnosed, pathological confirmation is rare, and cancer registration not widely practiced. The expansion of access to life-extending cART in sub-Saharan Africa, through programs such as the Global Fund for AIDS, Malaria, and Tuberculosis and the US President's Emergency Program for AIDS Relief (PEPFAR), is leading to dramatic lengthening of life of HIV patients, which will likely influence the spectrum and burden of cancer in patients with HIV. In this paper, we review current literature and explore merits for integrating cancer research in established HIV programs to obtain timely data about the incidence and burden of cancer in HIV-infected persons in Africa.

Gender differences in clinical presentation and outcomes of epidemic Kaposi sarcoma in Uganda

Introduction

The incidence of Kaposi sarcoma (KS) has increased dramatically among women in sub-Saharan Africa since the onset of the HIV pandemic, but data on KS disease in women are limited. To identify gender-related differences in KS presentation and outcomes, we evaluated the clinical manifestations and response in men and women with AIDS-associated KS in Uganda.

Methods and Findings

HIV-infected adults with KS attending the Infectious Diseases Institute (IDI) and Uganda Cancer Institute (UCI) in Kampala, Uganda between 2004 and 2006 were included in a retrospective cohort. Evaluation of KS presentation was based on the clinical features described at the initial KS visit. Response was evaluated as the time to “improvement”, as defined by any decrease in lesion size, lesion number, or edema. The cohort consisted of 197 adults with HIV and KS: 55% (108/197) were women. At presentation, the median CD4 T-cell count was significantly lower in women (58 cells/mm³; IQR 11–156 cells/mm³) than men (124 cells/mm³; IQR 22–254 cells/mm³) (p = 0.02). Women were more likely than men to present with lesions of the face (OR 2.8, 95% CI, 1.4, 5.7; p = 0.005) and hard palate (OR 2.0, 95% CI, 1.1, 3.7; p = 0.02), and were less likely than men to have lower extremity lesions (OR 0.54, 95% CI, 0.3, 0.99; p = 0.05). Women were less likely than men to demonstrate clinical improvement (HR = 0.52, CI 0.31, 0.88; p = 0.01) in multivariate analysis.

Conclusions

The clinical presentation and response of KS differs between men and women in Uganda. These data suggest that gender affects the pathophysiology of KS, which may have implications for the prevention, diagnosis, and treatment of KS in both men and women. Prospective studies are needed to identify predictors of response and evaluate efficacy of treatment in women with KS, particularly in Africa where the disease burden is greatest.

Identification of placental transforming growth factor-beta and bikunin metabolites as contaminants of pharmaceutical human chorionic gonadotrophin preparations by proteomic techniques

A contaminant protein complex found in pharmaceutical urinary human chorionic gonadotrophin preparations is reported to have anti-human immunodeficiency virus-associated Kaposi's sarcoma activity. The aim of this study was to isolate and characterize this protein complex by proteomic approaches. Size exclusion chromatography was used in the isolation of these human chorionic gonadotrophin-associated fragments. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis showed the presence of a protein complex that dissociated into two protein bands under reducing conditions. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry of this complex showed three polypeptides at approximately 6.2, 11.4, and 15.8 kDa. Peptide mass mapping and N-terminal amino acid sequencing identified two polypeptides as metabolites of placental transforming growth factor-beta (11.4 kDa) and bikunin (15.8 kDa). Subsequent matrix-assisted laser desorption/ionization time-of-flight mass spectrometric analysis of the anti-human immunodeficiency virus-associated Kaposi's sarcoma active preparations CG-10 (Sigma), Pregnyl (Organon), and Profasi (Serono) revealed the presence of metabolites of placental transforming growth factor-beta in all three; no other non-human chorionic gonadotrophin-related protein species were observed in these preparations. Our findings present evidence that urinary human chorionic gonadotrophin preparations are contaminated with metabolites of placental transforming growth factor-beta, which may have transforming growth factor-beta agonist actions, and metabolites of bikunin, which is a protease inhibitor. In combination these molecules may be responsible for the anti-human immunodeficiency virus-associated Kaposi's sarcoma activity demonstrated for these urinary human chorionic gonadotrophin preparations.

Epidemiology of AIDS-related malignancies an international perspective

Patients with HIV infection are at increased risk for developing Kaposi's sarcoma, non-Hodgkin's lymphoma, and several other cancers. The relative risks for the most common epithelial cancers in the general population--lung, breast, colon/rectum, stomach, liver, and prostate--are not increased substantially in people with AIDS, however. Accumulating data suggest that HIV-infected patients also are at increased risk for developing Hodgkin's lymphoma, cervical carcinoma in situ (CIS), other anogenital neoplasms (invasive cancer and CIS), leiomyosarcoma, and conjunctival squamous cell carcinoma. There is inconclusive evidence, however, with regard to HIV infection being associated with invasive cervical cancer, testicular seminoma, or hepatocellular carcinoma. Notably, other viral infections have been implicated in the etiology of many of these conditions. The introduction of highly active antiretroviral therapy (HAART) has decreased the incidence of AIDS-associated cancers in Western countries, but less than 1% of AIDS patients are receiving HAART in the HIV epicenter of sub-Saharan Africa. Further therapeutic advances that extend survival with HIV infection with varying reconstitution of immune competence may lead to additional alterations in cancer risk.

Factors associated with human herpesvirus type 8 infection in an injecting drug user cohort

BACKGROUND

Human herpesvirus type 8 (HHV-8) has been infrequently studied in injecting drug user (IDU) populations.

GOAL

To estimate the seroprevalence of HHV-8 and risk factors for infection in a cohort of 2,946 IDUs.

STUDY DESIGN

In this nested cross-sectional study of 390 IDUs, lytic HHV-8 indirect immunofluorescence assay (IFA) was utilized to estimate the HHV-8 seroprevalence. Multivariate logistic regression was used to assess risk factors for infection.

RESULTS

The HHV-8 seroprevalence among the IDUs examined in 1988 was 11.5% (95% confidence interval, 8.5-15.13). HHV-8 seroprevalence in this population was associated with being female (OR = 2.2; = 0.080), having a larger body mass index (OR = 3.0; = 0.053), and history of genital warts (OR = 4.0; = 0.023). Injection of any drug more than daily exhibited an inverse effect on HHV-8 seropositivity (OR = 0.5; = 0.085).

CONCLUSION

The seroprevalence of HHV-8 in this population is similar to that seen in the general population, with risk factors being more consistent with sexual behaviors than injection drug use.

Stimulation of Kaposi's sarcoma cell growth by urine from women in early pregnancy, the current source for clinical-grade human chorionic gonadotropin preparations

Clinical-grade preparations of human chorionic gonadotropin (hCG) have been shown to be toxic to Kaposi's sarcoma (KS) cells. However, the results of clinical studies using commercial hCG preparations KS remain highly contradictory. More particularly, some hCG preparations could have a paradoxical growth effect on KS. Such discrepant results may be explained by the fact that the anti-KS activity is not associated with hCG itself but with one or more factors that are co-purified with the hormone. We found here that crude urine from first trimester pregnant women, the current source for commercial hCG, had a growth stimulatory effect on KS cells. By contrast, urine from last trimester pregnant women, from non-pregnant young women, from menopausal women and from men exhibited neither a growth stimulatory nor a growth inhibitory effect on KS cells. The amplitude of this pregnancy urine-associated pro-KS activity/hCG unit was higher than that achieved with clinical-grade hCG preparations. Partial co-purification of pregnancy-associated factors during the extraction procedure of commercial hCG from urine may explain the pro-KS activity achieved with some hCG preparations. We, therefore, suggest a cautious use of hCG purified from pregnancy urine for the treatment of KS.

AIDS-associated Kaposi's sarcoma is more aggressive in women: a study of 54 patients

OBJECTIVE

To describe the epidemiologic and clinical features of AIDS-associated Kaposi's sarcoma (KS) in women compared with men.

METHODS

In a retrospective study, within the Italian Cooperative Group on AIDS and Tumors (GICAT), we compared selected characteristics of 54 women and 108 men with AIDS-associated KS, matched by date of KS diagnosis and referral hospital. The chi2 test was used to test differences among proportions; the Kaplan-Meier method to estimate the survival time, and the Cox proportional hazard model was used to assess the role of gender, age, and CD4 cell count on death's risk.

RESULTS

KS occurred at an earlier age (p = .001), was associated with a more severe immunodeficiency (p = .03), more advanced stages of HIV disease (p = .05), and had more aggressive presentation and course in women than in men. At KS diagnosis, women had a significantly increased proportion of visceral disease (p = .009), in particular pulmonary involvement (p = .002) and atypical sites of involvement (p = .008). The number of deaths due to KS was significantly higher (p = .01) in female patients. Both the higher proportion of visceral disease and of KS-related deaths observed in women did not change after adjusting for CD4 cell count and age. Women showed a decreased overall survival compared with men (8.9 and 14.4 months, respectively; p = .07), and the CD4 cell count at diagnosis significantly influenced survival.

CONCLUSIONS

This study suggests that KS is more aggressive and life threatening in female than in male patients. This peculiar clinical behavior may reflect an inherently more aggressive biology of KS in women, possibly mediated by the level of immunodeficiency.

Induction of programmed cell death in Kaposi's sarcoma cells by preparations of human chorionic gonadotropin

BACKGROUND

Isolation of the first neoplastic acquired immunodeficiency syndrome-related Kaposi's sarcoma (KS) cell line (KS Y-1) has furthered understanding of the pathogenesis of KS. Studies with KS Y-1 cells have indicated that inhibition of KS cell proliferation occurs in early pregnancy in mice and after treatment with certain commercial preparations of human chorionic gonadotropin (hCG, a pregnancy hormone purified from urine). The activity of the commercial preparations has been attributed to an hCG-associated factor(s) (HAF). While several clinical benefits of HAF are clearly evident, the basis for its anti-KS properties remains unknown. We investigated the apoptosis-inducing effects of HAF and the expression of apoptosis-related proteins in KS cells.

METHODS

KS Y-1 and KS SLK cells were treated with clinical-grade crude preparations of hCG, recombinant hCG, or urine fractions exhibiting anti-KS activity and then examined for features of apoptosis. Levels of proteins associated with apoptosis were monitored by western blot analysis, and cell DNA content was assessed by flow cytometry. Tumors induced in mice by inoculation of KS Y-1 cells were treated with preparations of hCG, and the tumors were examined for cell morphology and also for DNA fragmentation by use of the terminal deoxynucleotidyl transferase-mediated digoxigenin-deoxyuridine triphosphate nick-end-labeling (TUNEL) assay.

RESULTS

The HAF present in some preparations of hCG and in urine fractions has the ability to induce apoptosis in KS cells in vitro and in vivo. HAF-triggered apoptosis was preceded by increased levels of the apoptosis-related proteins c-Myc and c-Rel and cell accumulation in Go/G1 phase of the cell cycle. KS Y-1 cells transfected with a c-Myc complementary DNA showed elevated rates of apoptosis.

CONCLUSION

The anti-KS activity of HAF appears to induce apoptosis. Such activity suggests a role for HAF in pregnancy-related regulation of cell death.

HHV8 and female Kaposi's sarcoma

Kaposi's sarcoma (KS) is an enigmatic tumour of uncertain histogenesis. Epidemiological data have long suggested that KS may be caused by an infectious agent, possibly sexually transmitted. Following the documentation of human herpesvirus 8 (HHV8) and its strong association with all forms of KS, it now appears that the putative agent has at last been identified. As KS is rare in females, a unique group was screened for the presence of HHV8 using both conventional solution-phase polymerase chain reaction (PCR) and the newly described technique of TaqMan PCR. The presence of HHV8 was demonstrated in 10/12 of these female patients. This further supports the direct role of HHV8, in conjunction with cytokines and other factors, in the pathogenesis of KS.

Women and HIV. Epidemiology and global overview

The global HIV-1 epidemic in women continues to expand at an alarming rate. More than 11 million women are currently estimated to be HIV-infected, with the majority living in sub-Saharan Africa. The primary risk factor for HIV infection in women is unprotected heterosexual intercourse. Several cofactors may influence a woman's risk for HIV acquisition. These include the presence of other STDs, the prevalence of HIV in the population, engagement in high-risk sexual behaviors at a young age, an increased number of sexual partners, HIV illness severity in an infected partner, host immunogenetic responses, hormonal and other local effects in the female genital tract, and viral characteristics. The general clinical findings in women with HIV disease are similar to those in HIV-infected men. Some studies have noted higher rates of esophageal candidiasis and decreased rates of Kaposi's sarcoma in women when compared with men. Overall disease progression and survival in women and men are similar once an adjustment is made for other important risk factors such as the time of seroconversion, the receipt of antiretrovirals, and baseline CD4 cell counts. Women with HIV have a high frequency of a number of diseases of the reproductive tract, including low-grade cervical dysplasia and vulvovaginal candidiasis. Despite progress in understanding the risk factors for HIV transmission to women and the variables related to disease progression, major research questions remain. These include the role of hormonal contraceptives in the risk for HIV acquisition, the primary mechanism of infection, and host systemic as well as local hormonal and immune responses in the female reproductive tract that may alter the risk of HIV infection. Over the next decade, it is anticipated that the quality of life and length of survival will improve dramatically for both HIV-infected women and men in settings in which new highly active combination antiretroviral therapy is available and affordable. Unfortunately, in most of the world, these antiretroviral drugs are not available for the treatment of the vast numbers of individuals infected by HIV. Therefore, development of successful strategies for primary prevention of HIV infection in women must be a top public health priority.

Effects of hCG and beta-hCG on IL-2 and sIL-2R secretion from human peripheral blood mononuclear cells: a dose-response study in vitro

The effects of human chorionic gonadotropin (hCG) as well as beta-subunit of hCG (B-hCG) in concentrations of: 80,000/25,000; 500; 50; 5 mIU/ml on in vitro release of interleukin-2 (IL-2) and soluble interleukin-2 receptor (sIL-2R) from resting or phytohemagglutinin (PHA) activated human peripheral blood mononuclear cells (PBMC) were studied. Both the interleukins were measured in supernatants of human PBMC by quantitative sandwich enzyme immunoassay method (ELISA). We found that hCG in the dilutions of 80,000 mIU/ml (P < 0.01) and 5 mIU/ml (P < 0.05) diminished IL-2 secretion only from PHA activated PBMC. beta-hCG in concentrations of 5 mIU/ml (P < 0.05), 500 mIU/ml (P < 0.01) and 25,000 mIU/ml (P < 0.05) also diminished IL-2 secretion from PHA activated PBMC, and only in a dilution of 25,000 mIU/ml (P < 0.05) from resting PBMC. Simultaneously, hCG in concentration of 80,000 mIU/ml (P < 0.01) potentiated the release of sIL-2R into supernatants from resting and PHA activated PBMC, but in concentration of 50 mIU/ml (P < 0.05) slightly depressed the secretion of IL-2 from PHA activated PBMC cultures. beta-hCG in dilution of 25,000 mIU/ml (P < 0.001) stimulated the release of sIL-2R from resting or PHA activated PBMC. beta-hCG had also inhibitory effect on sIL-2R secretion from resting (in a dilution of 50 mIU/ml; P < 0.05) and PHA activated (500 mIU/ml; P < 0.01) PBMC. The inhibitory effect of very high concentrations of hCG and beta-hCG on IL-2 secretion together with their stimulatory effect on sIL-2R release from PBMC may be an important event during the human pregnancy and various cancers.

Human immunodeficiency virus (HIV)-related pulmonary complications in pregnancy

With changes in the demographics of human immunodeficiency virus (HIV) infection, women and children are becoming the fastest growing group of newly infected patients. With longer survival after HIV infection, more women infected with HIV are becoming pregnant. Pulmonary disease is one of the most common presenting conditions in an AIDS-defining illness. Pneumocystis carini pneumonia and tuberculosis are the most common disorders that herald the onset of AIDS. They are also the most frequently encountered HIV-related pulmonary complications during pregnancy. Others have been rarely reported during pregnancy and include fungal infections (Cryptococcus neoformans, Histoplasma capsulatum, and Coccidioides immitus), bacterial infections (Haemophilus influenzae and Streptococcus pneumoniae along with Pseudomona aeruginosa), viral infections (CMV), opportunistic neoplasms (Kaposi's sarcoma, lymphoma) and miscellaneous conditions peculiar to HIV-infected individuals (nonspecific interstitial pneumonitis, lymphoid interstitial pneumonitis, isolated pulmonary hypertension, and pulmonary edema secondary to cardiac disease or drug abuse). Most of the data regarding the pulmonary complications of HIV infection come from studies in nonpregnant patients. The extent to which pregnancy affects the course of respiratory disease in HIV infection and vice versa is not well documented. Clinical presentation is usually not altered by pregnancy. Except for minor modifications mainly related to potential fetal effects, the diagnostic work-up and management are similar to those in the nonpregnant patient. The most important effect of pregnancy on these conditions remains the delay in diagnosis and treatment. A high index of suspicion should, therefore, be maintained. In addition, most prophylactic measures recommended in nonpregnant HIV-infected individuals also apply to pregnant women.

Acquired immunodeficiency syndrome-associated Kaposi's sarcoma. Biology and management

Kaposi's Sarcoma (KS), the most common AIDS-associated malignancy, occurs with increased frequency in all HIV transmission groups, but at a particularly high rate in homosexual men. Recent studies suggest that KS pathogenesis involves exposure to an infectious agent, altered expression and response to cytokines, and modulation of growth by HIV gene products. KS varies in its clinical presentation from a relatively indolent process to a widely disseminated, aggressive disease. A variety of local and systemic treatments provide effective, but usually temporary, disease palliation. Insights into KS pathogenesis suggest a number of targeted therapeutic approaches that may eventually lead to improved disease management and disease cure.

The epidemiology of AIDS--related neoplasms

The magnitude for and risk factors of the two most important AIDS neoplasm, Kaposi's sarcoma and non-Hodgkin's lymphoma, are reviewed in detail. The association between AIDS and other cancers is mostly speculative because surveillance biases tend to favor detecting associations that may be spurious. The overall relative risk of other cancers appears, however, to be only twofold above that in the general population, with associations being most convincing for anal (but not cervical) cancer and leiomyosarcoma and possible also for Hodgkin's disease, testicular cancer, and conjunctival cancers.