Malignant tumours in patients with HIV infection

Acute lymphocitic leukaemia and AIDS

Patients with AIDS have become more and more prevalent. Therefore, the onset of diseases that coexist with this condition must be studied in order to establish proper diagnosis and treatment. We report a case of a patient who reported with loss of strength in the lower limbs and a progressive worsening in his clinical picture. He was diagnosed with acute lymphocytic leukaemia, an unusual form of association with the AIDS condition. Despite the diagnosis, he evolved into pulmonary sepsis and so staging and chemotherapy treatment could not be performed.

Immune surveillance and lymphoid malignancy in immunocompromised host

Immune surveillance is a dynamic process that involves an intact immune system to identify and protect the host against tumor development. The increased understanding of the genetics, infections and hematological malignancies in congenital immune deficiency states supports the concept that impaired T cells and Natural-killer/T cells leads to B-cell lymphoma. Furthermore, severe combined immunodeficient mice are prone to spontaneous tumor development and therefore serve as experimental models. Here we discuss the acquired conditions and mechanisms involved in dysregulation of the immune system that lead to lymphoma. Preemptive strategies to improve immune regulation and response and restore a competent immune system may lead to a decrease in lymphoid malignancies.

Spectrum of HIV lymphoma 2009

PURPOSE OF REVIEW

HIV-infected individuals remain at an increased risk for developing malignancies despite the use of combined antiretroviral therapy. Lymphomas comprise a large proportion of the malignancies that affect the HIV-infected population in developed countries. This review summarizes the recent progress made in HIV lymphoma research published in 2009 through January 2010.

RECENT FINDINGS

The majority of investigation in this field has been in diffuse large B-cell lymphoma, with infusional therapy remaining promising. Rituximab likely improves complete response and possibly overall survival, but may be associated with increased infections in a subset of patients with very low CD4 cell counts. Risk factors associated with the development of lymphoma include low CD4 cell count and likely cumulative HIV viremia. Biologic insights have been realized regarding pathogenesis.

SUMMARY

Overall, the outcome for HIV lymphoma continues to improve as insights into the pathophysiology and treatment advance.

An hsr on chromosome 7 was shown to be an insertion of four copies of the 11q23 MLL gene region in an HIV-related lymphoma

A 45-year-old male with AIDS presented with a cecal diffuse large B-cell lymphoma. Cytogenetic and flourescence in situ hybridization (FISH) studies revealed a complex karyotype with multiple aberrations that included a translocation, t(8;14) involving MYC on chromosome 14. This is specific to B-cell lymphomas. There were also frequently observed secondary changes such as chromosome 1 rearrangement leading to trisomy of 1q and loss of tp53 from the deleted chromosome 17. A unique secondary abnormality was an hsr on chromosome 7, which by FISH and SKY investigations was shown to originate from chromosome 11 involving 4 copies of the MLL gene region.

Changing incidence and survival in patients with aids-related non-Hodgkin's lymphomas in the era of highly active antiretroviral therapy (HAART)

To determine role of highly active antiretroviral therapy (HAART) and additional factors in incidence and outcome of patients with AIDS-related non-Hodgkin's lymphomas (NHL) we retrospectively analyzed 257 cases of AIDS-related NHL (24 low-grade, 168 high-grade B-cell, 6 high-grade T-cell, and 59 primary CNS lymphomas (PCNSL) among 2004 patients with HIV-infection treated at the University Hospital of Frankfurt, Germany from January 1983 to May 1999. Data were evaluated by univariate and multivariate analyses, using overall survival as end point. Patients received CHOP-like therapy as standard treatment. Until May 1999 incidence of all diagnosed cases of NHL was decreasing (1991-94: 14.2% versus 1995-5/99: 12.8%). Mainly, the incidence of low-grade NHL and PCNSL clearly decreased whereas the incidence of high-grade B-cell NHL increased compared to all diagnosed cases of NHL (1983-86: 53.3% versus 1995-5/99: 78.6%). One-year survival probability of all screened patients with AIDS related NHL was 54%, while 5-year survival rate remained 5%. We found age <25 years, development of NHL in the years before 1990, IVDU, CD4 counts <150/microl, PCNSL as well as NHL as the AIDS index disease, to be highly significant independent predictors of poor survival, including increased hazard ratios. In the era of HAART incidence of NHL is decreasing, mainly the incidence of low-grade NHL and PCNSL. Overall survival of patients has been prolonged with HAART. This development is mainly due to improvement of antiretroviral therapy, rather than to any fundamental changes in the chemotherapeutic treatment of NHL. Therefore, new treatment approaches for AIDS-related NHL should focus on more efficient antiretroviral therapy in association with combination chemotherapy.

Anaplastic large cell lymphoma (CD 30+), T-phenotype, in the heart of an HIV-positive man

Non-Hodgkin's lymphomas described in patients with HIV-infection are most often high-grade B-cell lymphomas. Anaplastic large cell lymphoma (CD 30+) has been described in a minority of immunocompromised patients. Although sporadic reports of T-cell lymphomas associated with HIV infection are found in the literature, they have not been described to occur in the myocardium. We present a case of anaplastic large cell lymphoma (CD 30+), T-phenotype involving the heart in a 42-year-old HIV-positive patient.

AIDS-related primary pulmonary lymphoma

We describe 12 cases of AIDS-related primary pulmonary lymphoma occurring between 1986 and 1996 in a large French cohort of HIV-infected patients. Diagnostic criteria were: (1) histologically proven lymphomatous pulmonary involvement; (2) absence of mediastinal and/or hilar adenopathy on chest radiography; (3) absence of extrathoracic lymphoma extension. All patients were severely immunodeficient at the time of diagnosis. All but one patient presented with B and/or nonspecific respiratory symptoms. Chest radiography showed one or more marginated nodule(s) or large mass. CT scan showed a cavitary lesion in five patients. No lymph node enlargement or specific pleural effusion was detected. Transthoracic needle biopsies were performed in 10 patients and avoided open-lung biopsy for the diagnosis of lymphoma in five patients. All but one of the primary pulmonary lymphoma were high-grade B-cell non-Hodgkin's lymphomas. Using antilatent membrane protein-1 antibodies and an Epstein-Barr-Virus-encoded RNA transcript-specific probe, latent EBV infection of tumor cells was demonstrated in every case. All but one of the patients received chemotherapy. The median survival time was 4 mo, and no patient was still alive at the cut-off date for this analysis. Progessive pulmonary lymphoma was the main cause of death, but infections were also frequent.

Overview: Kaposi's sarcoma, oral neoplasms

Since the last international workshop on the oral manifestations of HIV in 1993 there has been extremely rapid progress in our knowledge of the possible aetiology of Kaposi's sarcoma (KS) and this is reflected in this section which concentrates mainly on the epidemiology and molecular aspects of KS. Research continues in assessing potential links of oral neoplasms and especially in non-Hodgkin's lymphomas in patients with HIV/AIDS.

Chemotherapy of AIDS--related Kaposi's sarcoma

Kaposi's sarcoma (KS) is the most common tumor associated with AIDS. A growing number of patients with this tumor are presenting at later stages of HIV with more rapidly progressive, extensive, or symptomatic KS or with tumors involving visceral organs. Chemotherapy treatment is effective in inducing tumor regression, reducing edema, and ameliorating symptoms caused by these tumors. Side effects and toxicities from these agents, however, can be quite pronounced, especially in patients with advanced AIDS Antiretroviral therapy, prophylaxis for opportunistic infections, and the use of hematopoietic growth factors should be routinely included in the management of these patients. Newer chemotherapeutic agents and combination regimens may be more effective or less toxic than previously evaluated regimens.

Morphologic patterns and molecular pathways of AIDS-related head and neck and other systemic lymphomas

Head and neck manifestations of human immunodeficiency virus (HIV) infection include lymph nodal and extranodal localization of non-Hodgkin's lymphoma (NHL). A histopathologic characteristic common to head and neck NHLs and to all the other systemic lymphomas in HIV patients is the frequent occurrence of cases displaying pleomorphic features and some overlap between established histologic subtypes. This article highlights the difficulties in defining HIV-related NHLs correctly, and proposes a specific pathologic categorization of these disorders accounting for their pathogenic aspects as gathered from molecular data.

Kaposi's sarcoma: advances and perspectives

Kaposi's sarcoma (KS) is an unusual neoplasm that has proved to be an enigma in many ways since its original description by Kaposi in 1872. Its epidemiology has stimulated tremendous interest, amplified markedly in 1981 when it became known as an original defining part of the complex of immune disorders now known as AIDS. The cell of origin, etiology, and therapy for both AIDS-associated and AIDS-unassociated KS continue as matters of intense investigation. In fact, whether it is a reactive hyperplasia or a true malignancy is still a matter of debate, as is the concept of multicentricity versus metastases. Epidemiologic studies suggest that a separate agent apart from HIV-1 may cause KS. A newly postulated KS-associated herpes virus may be linked. The role of the HIV-1 tat gene product, basic fibroblast growth factor, scatter factor, oncostatin M, and other factors that regulate the growth of KS cells are discussed, as well as therapeutic options.

Dysphagia in an HIV-positive man

An HIV-positive man whose dysphagia was due to non-Hodgkin's lymphoma. The differential diagnosis of this symptom in the context of HIV infection is summarised in box 3.