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Brownlee AJ, Dewey M, Chagomerana MB, Tomoka T, Mulenga M, Khan S, Kampani C, Chimzimu F, Gastier-Foster JM, Westmoreland KD, Ozuah NW, Krysiak R, Malamba-Banda C, Painschab MS, Gopal S, Fedoriw Y. Update on pathology laboratory development and research in advancing regional cancer care in Malawi. Front Med (Lausanne) 2024; 11:1336861. [PMID: 38298817 PMCID: PMC10829605 DOI: 10.3389/fmed.2024.1336861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 01/02/2024] [Indexed: 02/02/2024] Open
Abstract
The pathology laboratory at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi was established in 2011. We published our initial experiences in laboratory development and telepathology in 2013 and 2016, respectively. The purpose of this paper is to provide an update on our work by highlighting the positive role laboratory development has played in improving regional cancer care and research. In addition, we provide a summary of the adult pathology data from specimens received between July 1, 2011, and May 31, 2019, with an emphasis on malignant diagnoses. We compare these summaries to estimates of cancer incidence in this region to identify gaps and future needs.
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Affiliation(s)
- Amy J. Brownlee
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, United States
| | - Morgan Dewey
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Maganizo B. Chagomerana
- University of North Carolina (UNC) Project-Malawi, Lilongwe, Malawi
- Division of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, United States
| | - Tamiwe Tomoka
- University of North Carolina (UNC) Project-Malawi, Lilongwe, Malawi
| | - Maurice Mulenga
- Kamuzu Central Hospital, Malawi Ministry of Health, Lilongwe, Malawi
| | - Shiraz Khan
- University of North Carolina (UNC) Project-Malawi, Lilongwe, Malawi
- Kamuzu Central Hospital, Malawi Ministry of Health, Lilongwe, Malawi
| | - Coxcilly Kampani
- University of North Carolina (UNC) Project-Malawi, Lilongwe, Malawi
| | - Fred Chimzimu
- University of North Carolina (UNC) Project-Malawi, Lilongwe, Malawi
| | - Julie M. Gastier-Foster
- Departments of Pediatrics and Pathology & Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Kate D. Westmoreland
- University of North Carolina (UNC) Project-Malawi, Lilongwe, Malawi
- Division of Pediatric Hematology Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC, United States
| | - Nmazuo W. Ozuah
- Section of Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Robert Krysiak
- University of North Carolina (UNC) Project-Malawi, Lilongwe, Malawi
| | - Chikondi Malamba-Banda
- University of North Carolina (UNC) Project-Malawi, Lilongwe, Malawi
- Malawi University of Science and Technology, Limbe, Malawi
- Malawi-Liverpool-Wellcome Trust Clinical Research Program, Blantyre, Malawi
| | - Matthew S. Painschab
- University of North Carolina (UNC) Project-Malawi, Lilongwe, Malawi
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC, United States
- Division of Hematology, Department of Medicine, University of North Carolina, Chapel Hill, NC, United States
| | - Satish Gopal
- Center for Global Health, National Cancer Institute (NIH), Bethesda, MD, United States
| | - Yuri Fedoriw
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, United States
- University of North Carolina (UNC) Project-Malawi, Lilongwe, Malawi
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC, United States
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Moorad R, Kasonkanji E, Gumulira J, Gondwe Y, Dewey M, Pan Y, Peng A, Pluta LJ, Kudowa E, Nyasosela R, Tomoka T, Tweya H, Heller T, Gugsa S, Phiri S, Moore DT, Damania B, Painschab M, Hosseinipour MC, Dittmer DP. A prospective cohort study identifies two types of HIV+ Kaposi Sarcoma lesions: proliferative and inflammatory. Int J Cancer 2023; 153:2082-2092. [PMID: 37602960 PMCID: PMC11074775 DOI: 10.1002/ijc.34689] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/15/2023] [Accepted: 06/29/2023] [Indexed: 08/22/2023]
Abstract
Kaposi sarcoma (KS) is the most common cancer in people living with HIV (PLWH) in many countries where KS-associated herpesvirus is endemic. Treatment has changed little in 20 years, but the disease presentation has. This prospective cohort study enrolled 122 human immunodeficiency virus (HIV) positive KS patients between 2017 and 2019 in Malawi. Participants were treated with bleomycin, vincristine and combination antiretroviral therapy, the local standard of care. One-year overall survival was 61%, and progression-free survival was 58%. The 48-week complete response rate was 35%. RNAseq (n = 78) differentiated two types of KS lesions, those with marked endothelial characteristics and those enriched in inflammatory transcripts. This suggests that different KS lesions are in different disease states consistent with the known heterogeneous clinical response to treatment. In contrast to earlier cohorts, the plasma HIV viral load of KS patients in our study was highly variable. A total of 25% of participants had no detectable HIV; all had detectable KSHV viral load. Our study affirms that many KS cases today develop in PLWH with well-controlled HIV infection and that different KS lesions have differing molecular compositions. Further studies are needed to develop predictive biomarkers for this disease.
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Affiliation(s)
- Razia Moorad
- Lineberger Comprehensive Cancer Centre, School of Medicine, University of North Carolina at Chapel Hill; Chapel Hill, USA
- Department of Immunology and Microbiology, University of North Carolina at Chapel Hill; Chapel Hill, USA
| | | | | | | | | | - Yue Pan
- Lineberger Comprehensive Cancer Centre, School of Medicine, University of North Carolina at Chapel Hill; Chapel Hill, USA
- Department of Biostatistics, The University of North Carolina at Chapel Hill; Chapel Hill
| | - Alice Peng
- Lineberger Comprehensive Cancer Centre, School of Medicine, University of North Carolina at Chapel Hill; Chapel Hill, USA
| | - Linda J. Pluta
- Lineberger Comprehensive Cancer Centre, School of Medicine, University of North Carolina at Chapel Hill; Chapel Hill, USA
| | - Evaristar Kudowa
- Department of Immunology and Microbiology, University of North Carolina at Chapel Hill; Chapel Hill, USA
| | | | | | | | | | | | | | - Dominic T Moore
- Lineberger Comprehensive Cancer Centre, School of Medicine, University of North Carolina at Chapel Hill; Chapel Hill, USA
| | - Blossom Damania
- Lineberger Comprehensive Cancer Centre, School of Medicine, University of North Carolina at Chapel Hill; Chapel Hill, USA
- Department of Immunology and Microbiology, University of North Carolina at Chapel Hill; Chapel Hill, USA
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill; Chapel Hill, USA
| | - Matthew Painschab
- Lineberger Comprehensive Cancer Centre, School of Medicine, University of North Carolina at Chapel Hill; Chapel Hill, USA
- UNC Project Malawi, Lilongwe, Malawi
| | - Mina C. Hosseinipour
- Lineberger Comprehensive Cancer Centre, School of Medicine, University of North Carolina at Chapel Hill; Chapel Hill, USA
- UNC Project Malawi, Lilongwe, Malawi
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill; Chapel Hill, USA
| | - Dirk P. Dittmer
- Lineberger Comprehensive Cancer Centre, School of Medicine, University of North Carolina at Chapel Hill; Chapel Hill, USA
- Department of Immunology and Microbiology, University of North Carolina at Chapel Hill; Chapel Hill, USA
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill; Chapel Hill, USA
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Diakite M, Shaw-Saliba K, Lau CY. Malignancy and viral infections in Sub-Saharan Africa: A review. FRONTIERS IN VIROLOGY (LAUSANNE, SWITZERLAND) 2023; 3:1103737. [PMID: 37476029 PMCID: PMC10358275 DOI: 10.3389/fviro.2023.1103737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
The burden of malignancy related to viral infection is increasing in Sub-Saharan Africa (SSA). In 2018, approximately 2 million new cancer cases worldwide were attributable to infection. Prevention or treatment of these infections could reduce cancer cases by 23% in less developed regions and about 7% in developed regions. Contemporaneous increases in longevity and changes in lifestyle have contributed to the cancer burden in SSA. African hospitals are reporting more cases of cancer related to infection (e.g., cervical cancer in women and stomach and liver cancer in men). SSA populations also have elevated underlying prevalence of viral infections compared to other regions. Of 10 infectious agents identified as carcinogenic by the International Agency for Research on Cancer, six are viruses: hepatitis B and C viruses (HBV and HCV, respectively), Epstein-Barr virus (EBV), high-risk types of human papillomavirus (HPV), Human T-cell lymphotropic virus type 1 (HTLV-1), and Kaposi's sarcoma herpesvirus (KSHV, also known as human herpesvirus type 8, HHV-8). Human immunodeficiency virus type 1 (HIV) also facilitates oncogenesis. EBV is associated with lymphomas and nasopharyngeal carcinoma; HBV and HCV are associated with hepatocellular carcinoma; KSHV causes Kaposi's sarcoma; HTLV-1 causes T-cell leukemia and lymphoma; HPV causes carcinoma of the oropharynx and anogenital squamous cell cancer. HIV-1, for which SSA has the greatest global burden, has been linked to increasing risk of malignancy through immunologic dysregulation and clonal hematopoiesis. Public health approaches to prevent infection, such as vaccination, safer injection techniques, screening of blood products, antimicrobial treatments and safer sexual practices could reduce the burden of cancer in Africa. In SSA, inequalities in access to cancer screening and treatment are exacerbated by the perception of cancer as taboo. National level cancer registries, new screening strategies for detection of viral infection and public health messaging should be prioritized in SSA's battle against malignancy. In this review, we discuss the impact of carcinogenic viruses in SSA with a focus on regional epidemiology.
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Affiliation(s)
- Mahamadou Diakite
- University Clinical Research Center, University of Sciences, Techniques, and Technologies, Bamako, Mali
| | - Kathryn Shaw-Saliba
- Collaborative Clinical Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Chuen-Yen Lau
- HIV Dynamics and Replication Program, National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD, United States
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Men's Sexual Experiences with the Dapivirine Vaginal Ring in Malawi, South Africa, Uganda and Zimbabwe. AIDS Behav 2021; 25:1890-1900. [PMID: 33389318 DOI: 10.1007/s10461-020-03119-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2020] [Indexed: 01/20/2023]
Abstract
The dapivirine vaginal ring has been well-tolerated and shown to prevent HIV in clinical trials. The ring is female initiated, yet endorsement for use is sought from male partners in many relationships. In clinical studies, participants have expressed worries about men detecting rings during vaginal sex, which introduces concerns about product use disclosure, sexual pleasure, penile harm, inter-partner dynamics, and ring removals. This study reports African men's firsthand sexual experiences with the ring. Qualitative data were captured through 11 focus group discussions and one in-depth interview with 54 male partners of ring-users at six research sites in Malawi, South Africa, Uganda and Zimbabwe. Following a semi-structured guide, and using demonstration rings, vulva and penis models, men were asked to discuss the ring's impact on sex and views on male engagement and ring use. Interviews were facilitated by local male social scientists, audio-recorded, translated into English, and analyzed thematically. 22 (41%) of the male partners reported feeling the ring during sex, often attributed to perceived incorrect insertion. Many men described the ring as "scratching" the tip of their penises, and sensations of "prodding" something that "blocked" the vagina and prohibited "full entry". In most cases, feelings dissipated with time or when sexual fluids increased. Less common descriptions included perceiving the vaginal texture, wetness and size as different, which increased pleasure for some, and decreased for others. Over half (59%) never noticed the ring; some attempting and failing to feel it during intercourse. A majority of men reported that the ring did not lead to changes in sexual positions, feelings, frequency or experience of sex, although some were initially afraid that the ring was a "magic snake" or "potion". Male partners expressed strong opinions that ring use was a shared prevention responsibility that men should be engaged in, especially for maintaining trust and open communication in relationships. The ring was noticed by many male partners, particularly during women's initial stages of ring use, although this led to few sexual problems or changes. Nevertheless, results suggest that risk of ring discovery should be discussed with women to mitigate any potential negative reactions or social harm. Strategies to increase male partner engagement will enhance support of this prevention method for women.
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Kimani SM, Painschab MS, Horner MJ, Muchengeti M, Fedoriw Y, Shiels MS, Gopal S. Epidemiology of haematological malignancies in people living with HIV. Lancet HIV 2020; 7:e641-e651. [PMID: 32791045 PMCID: PMC10199168 DOI: 10.1016/s2352-3018(20)30118-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 04/14/2020] [Accepted: 04/16/2020] [Indexed: 12/19/2022]
Abstract
People living with HIV or AIDS are at increased risk of Hodgkin and non-Hodgkin lymphoma compared with HIV-negative individuals. Data on the risk of multiple myeloma or leukaemia are inconsistent and of low quality but the risk does not seem to be increased. Specific haematological malignancies occur in different contexts of age, CD4 cell count, HIV control, viral co-infections, or chronic inflammation, and the expansion of combination antiretroviral therapy has led to varied demographic and epidemiological shifts among people with HIV. Increased use of combination antiretroviral therapy has substantially reduced the risks of diffuse large B-cell lymphoma, Burkitt lymphoma, and primary CNS lymphoma, and to a lesser extent, Hodgkin lymphoma. There is no effect of combination antiretroviral therapy use on multiple myeloma or leukaemia. Although many cases of HIV are in low-income and middle-income countries, high-quality epidemiological data for haematological malignancies from these regions are scarce. Closing this gap is an essential first step in decreasing mortality from HIV-associated haematological malignancies worldwide. Finally, although multicentric Castleman disease is not a neoplastic condition, it is an emerging precursor to neoplastic high-grade B-cell lymphoproliferation among people with HIV, especially for individuals on long-term combination antiretroviral therapy with well controlled HIV.
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Affiliation(s)
- Stephen M Kimani
- Division of Hematology and Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Matthew S Painschab
- Division of Hematology and Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Marie-Josèphe Horner
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | | | - Yuri Fedoriw
- Division of Hematology and Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Meredith S Shiels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Satish Gopal
- Division of Hematology and Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; University of North Carolina Project-Malawi, Lilongwe, Malawi.
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Kamiyango W, Villiera J, Silverstein A, Peckham-Gregory E, Campbell LR, El-Mallawany NK. Navigating the heterogeneous landscape of pediatric Kaposi sarcoma. Cancer Metastasis Rev 2020; 38:749-758. [PMID: 31845111 DOI: 10.1007/s10555-019-09823-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Vivid descriptions of Kaposi sarcoma (KS) occurring in children and adolescents from central and eastern Africa originated over 50 years ago. Unique clinical characteristics of pediatric KS in Africa were well described within these geographic regions that were eventually understood to be endemic for human herpesvirus-8/Kaposi sarcoma herpesvirus (HHV-8/KSHV) infection, the causative agent of KS. Having catapulted in incidence with the HIV epidemic, KS is currently among the top five most common childhood cancers in numerous countries throughout the region. The main feature that differentiates the childhood form of KS from adult disease is clinical presentation with primarily bulging lymphadenopathy. This group of patients represents the most common clinical subtype of pediatric KS in KSHV-endemic regions. Lymphadenopathic KS in children is associated with other distinct features, such as sparse occurrence of prototypical hyperpigmented cutaneous lesions, frequent presentation with severe cytopenias and a normal CD4 count, and a fulminant clinical course if untreated with chemotherapy. Increased awareness and improved recognition of lymphadenopathic KS are critically important, particularly because this subset of patients typically experiences a favorable response to chemotherapy characterized by durable complete remission. Clinical phenotypes typically observed in adult KS also occur in children-mild/moderate disease limited to cutaneous and oral involvement, woody edema, and visceral disease. This review summarizes the heterogeneous patterns of disease presentation and treatment response observed among the divergent clinical phenotypes of pediatric KS, highlights additional KSHV-related malignancies, and explores some of the potential biological drivers of such clinical phenomena.
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Affiliation(s)
- William Kamiyango
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.,Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi
| | - Jimmy Villiera
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.,Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi
| | - Allison Silverstein
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.,Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi.,Baylor College of Medicine, Houston, TX, USA
| | - Erin Peckham-Gregory
- Baylor College of Medicine, Houston, TX, USA.,Global HOPE (Hematology-Oncology Pediatric Excellence), Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, 1102 Bates Street, Feigin Tower, Room 1025.16, Houston, TX, 77030, USA
| | - Liane R Campbell
- Baylor College of Medicine, Houston, TX, USA.,Baylor College of Medicine Children's Foundation Tanzania, Mbeya, Tanzania
| | - Nader Kim El-Mallawany
- Baylor College of Medicine, Houston, TX, USA. .,Global HOPE (Hematology-Oncology Pediatric Excellence), Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, 1102 Bates Street, Feigin Tower, Room 1025.16, Houston, TX, 77030, USA.
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Human Herpesvirus 8 and Lymphoproliferative Disorders. Mediterr J Hematol Infect Dis 2018; 10:e2018061. [PMID: 30416693 PMCID: PMC6223575 DOI: 10.4084/mjhid.2018.061] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 10/02/2018] [Indexed: 12/12/2022] Open
Abstract
The spectrum of lymphoproliferative disorders linked to human herpesvirus 8 (HHV-8) infection has constantly been increasing since the discovery of its first etiologic association with primary effusion lymphoma (PEL). PEL is a rapidly progressing non-Hodgkin’s B-cell lymphoma that develops in body cavities in an effusional form. With the increase in the overall survival of PEL patients, as well as the introduction of HHV-8 surveillance in immunocompromised patients, the extracavitary, solid counterpart of PEL was later identified. Moreover, virtually all plasmablastic variants of multicentric Castleman’s disease (MCD) developing in HIV-1-infected individuals harbor HHV-8, providing a strong etiologic link between MCD and this oncogenic herpesvirus. Two other pathologic conditions develop in HIV-1-infected persons concomitantly with MCD: MCD with plasmablastic clusters and HHV-8-positive diffuse large B-cell lymphoma not otherwise specified (HHV-8+ DLBCL NOS), the first likely representing an intermediate stage preceding the full neoplastic form. MCD in leukemic phase has also been described, albeit much less commonly. The germinotropic lymphoproliferative disorder (GLPD) may resemble extracavitary PEL, but develops in immune competent HHV8-infected individuals, and, unlike the other disorders, it responds well to conventional therapies. Almost all HHV-8-mediated lymphoproliferative disorders are the result of an interaction between HHV-8 infection and a dysregulated immunological system, leading to the formation of inflammatory niches in which B cells, at different developmental stages, are infected, proliferate and may eventually shift from a polyclonal state to a monoclonal/neoplastic disorder. Herein, we describe the association between HHV-8 and lymphoproliferative disorders and highlight the predominant distinctive features of each disease.
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