Approach to the treatment of cutaneous malignancy in HIV-infected patients

Non-Melanoma Skin Cancer in People Living With HIV: From Epidemiology to Clinical Management

Skin cancers represent the most common human tumors with a worldwide increasing incidence. They can be divided into melanoma and non-melanoma skin cancers (NMSCs). NMSCs include mainly squamous cell (SCC) and basal cell carcinoma (BCC) with the latest representing the 80% of the diagnosed NMSCs. The pathogenesis of NMSCs is clearly multifactorial. A growing body of literature underlies a crucial correlation between skin cancer, chronic inflammation and immunodeficiency. Intensity and duration of immunodeficiency plays an important role. In immunocompromised patients the incidence of more malignant forms or the development of multiple tumors seems to be higher than among immunocompetent patients. With regards to people living with HIV (PLWH), since the advent of combined antiretroviral therapy (cART), the incidence of non-AIDS-defining cancers (NADCs), such as NMSCs, have been increasing and now these neoplasms represent a leading cause of illness in this particular population. PLWH with NMSCs tend to be younger, to have a higher risk of local recurrence and to have an overall poorer outcome. NMSCs show an indolent clinical course if diagnosed and treated in an early stage. BCC rarely metastasizes, while SCC presents a 4% annual incidence of metastasis. Nevertheless, metastatic forms lead to poor patient outcome. NMSCs are often treated with full thickness treatments (surgical excision, Mohs micro-graphic surgery and radiotherapy) or superficial ablative techniques (such as cryotherapy, electrodesiccation and curettage). Advances in genetic landscape understanding of NMSCs have favored the establishment of novel therapeutic strategies. Concerning the therapeutic evaluation of PLWH, it’s mandatory to evaluate the risk of interactions between cART and other treatments, particularly antiblastic chemotherapy, targeted therapy and immunotherapy. Development of further treatment options for NMSCs in PLWH seems needed. We reviewed the literature after searching for clinical trials, case series, clinical cases and available databases in Embase and Pubmed. We review the incidence of NMSCs among PLWH, focusing our attention on any differences in clinicopathological features of BCC and SCC between PLWH and HIV negative persons, as well as on any differences in efficacy and safety of treatments and response to immunomodulators and finally on any differences in rates of metastatic disease and outcomes.

Cutaneous Head and Neck Cancers in the High-Risk Immunosuppressed Population

The immunosuppressed (IS) population encompasses a diverse cohort of patients to include iatrogenically immunocompromised organ transplant recipients as well as patients with chronic lymphoid malignancies, human immunodeficiency virus/acquired immunodeficiency syndrome, and autoimmune disorders. Cutaneous cancers in this high-risk patient group are clinically distinct from the general immunocompetent population, showing aggressive behavior with associated poor outcomes. This article reviews the pathogenesis, epidemiology, incidence, prognosis, and special considerations required in managing cutaneous cancers in the IS patient population.

Malignant melanoma in HIV: Epidemiology, pathogenesis, and management

People affected by immunodeficiency, and especially those infected by HIV, are burdened by a higher risk of developing malignancies. It has been estimated that the incidence of melanoma in HIV-infected people is 2.6-fold higher than in uninfected ones. In this group of patients, melanoma shows a more aggressive phenotype and poorer survival rates compared to HIV-negative people. Standard guidelines of diagnosis and care do not exist yet. Studies suggest high index of suspicion and a low threshold for biopsy in HIV-positive patients regardless of their CD4⁺ count and the use of standard surgical margins for re-excision procedures. In case of diagnosis of melanoma in HIV-positive patients, a thorough search for metastatic disease is recommended because of the more aggressive course of this cancer in HIV-positive patients. Moreover, to rapidly find out any recurrence or metastatic disease after treatment, these patients need a close follow-up, every 3 months, for the first 2 years and at least twice yearly thereafter. Although surgery remains the main therapeutic option, application of immune checkpoint-based immunotherapy is being studied and seems to be promising. The aim of this review is to present the current knowledge and future options for melanoma diagnosis and treatment in people living with HIV.

HIV-Related Skin Disease in the Era of Antiretroviral Therapy: Recognition and Management

Antiretroviral therapy (ART) has revolutionized the treatment and prognosis of people living with HIV (PLHIV). With increased survival and improved overall health, PLHIV are experiencing dermatologic issues both specific to HIV and common to the general population. In this new era of ART, it is crucial for dermatologists to have a strong understanding of the broad range of cutaneous disease and treatment options in this unique population. In this review, we outline the most common skin diseases in PLHIV, including HIV-associated malignancies, inflammatory conditions, and infections, and focus on the role of ART in altering epidemiology, clinical features, diagnosis, and treatment of cutaneous conditions.

Immunosuppression Impact on Head and Neck Cutaneous Squamous Cell Carcinoma: A Systematic Review with Meta-analysis

Objective

The primary objective was to define and quantify the relationship between immunosuppression and prognosis in patients with cutaneous squamous cell carcinoma of the head and neck.

Data Sources

Ovid/Medline, PubMed, Embase, and Scopus were searched from inception through June 5, 2017, with cross-referenced subject headings of squamous cell carcinoma, skin neoplasms, head and neck neoplasms, and prognosis. Additional gray literature was queried.

Review Methods

All prospective, retrospective, and cohort studies in the English literature investigating prognosis in patients with head and neck cutaneous squamous cell carcinoma were eligible for inclusion. Meta-analysis data were pooled using the fixed-effects model. The main outcome measures were hazard ratios detailing subgroup analysis between immunosuppressed and immunocompetent patients.

Results

Seventeen studies were eligible for inclusion; 317 of the 2886 patients were immunosuppressed. Meta-analysis with pooled hazard ratios was performed for all outcome variables with at least 3 reported hazard ratios. Immunosuppression portended a worse prognosis across all outcome variables of interest: locoregional recurrence (2.20; 95% confidence interval [CI], 1.45-3.36), disease-free survival (2.69; 95% CI, 1.60-4.51), disease-specific survival (3.61; 95% CI, 2.63-4.95), and overall survival (2.09; 95% CI, 1.64-2.67).

Conclusion

This is the largest investigation into the impact of immunosuppression on head and neck cutaneous squamous cell carcinoma. Immunosuppressed patients experience worse recurrence and survival outcomes compared to immunocompetent counterparts. The data support formal inclusion of immunosuppression in head and neck cutaneous squamous cell carcinoma staging systems.

A unique cutaneous presentation of Burkitt lymphoma

Few reports of cutaneous Burkitt lymphoma exist in the literature. Here, the authors describe the case of a human immunodeficiency virus-positive individual with the rare diagnosis of cutaneous Burkitt lymphoma. Three weeks before the development of his cutaneous lesions, the patient experienced bilateral lower extremity paralysis, and an epidural mass was found. Bone marrow biopsy findings and serum protein electrophoresis seemed consistent with multiple myeloma. The visible appearance of the skin lesions raised concern for cutaneous involvement by myeloma; however, the skin biopsy showed morphological and immunohistochemical features of Burkitt lymphoma. In this case report, the authors discuss the histopathologic findings of the cutaneous lesions in consideration with the bone marrow biopsy findings.

Perianal Bowen disease in a child with human immunodeficiency virus

Individuals infected with the human immunodeficiency virus (HIV) are at increased risk for human papillomavirus (HPV)-related cancers of the anogenital region. A majority of these cancers have been reported in adult patients; few reports are available regarding anogenital HPV-associated carcinomas developing in children. We report a case of perianal Bowen disease in an HIV-positive child. An 8-year-old HIV-positive boy with a history of perianal verrucous lesions presented to a clinic in Lesotho because his caregiver noted his lesions were changing in color, texture, and extent. Histologic sections revealed squamous cell carcinoma in situ. Several cases of anogenital condyloma in HIV-positive children have been reported, but very few cases of HPV-associated cancer. Children with vertically transmitted HIV may be uniquely susceptible to persistent infection with strains of HPV acquired perinatally. While the introduction of highly active antiretroviral therapy has resulted in immune restoration, decreased opportunistic infection, and increased life expectancy for children and adults with HIV, it has not affected the incidence of HPV-related cancers in these patients. The increased life expectancy of children with HIV may actually put them at risk for developing an HPV-related anogenital cancer.

HIV and skin cancer

AIDS produces profound alterations in normal immunity. Impaired cellular immunity permits new tumor formation as evidenced by the solid-organ transplant literature. The weakened cellular immune system of HIV-infected patients resembles in some ways the iatrogenic immunosuppression in solid-organ transplant recipients. This article summarizes what is known about skin cancer in the solid-organ transplant population and compares the immunodysregulation of HIV infection with the iatrogenic immunosuppression following solid-organ transplantation.