Cancers in Children Infected With the Human Immunodeficiency Virus

A Challenging Knowledge Gap: Estimating Modes of HIV Acquisition Among Adolescents Entering HIV Care During Adolescence

Characterizing HIV acquisition modes among adolescents with HIV (AHIV) enrolling in care during adolescence is a challenging gap that impacts differential interventions. We explored whether primary data collection with targeted questionnaires may address this gap and improve understanding of risk factors and perceptions about adolescents’ HIV acquisition, in Kenyan AHIV entering care at ≥10 years, and their mothers with HIV (MHIV). Clinical data were derived through chart review. Among 1073 AHIV in care, only 26 (2%) met eligibility criteria of being ≥10 years at care enrollment, disclosed to, and with living MHIV. Among 18/26 AHIV-MHIV dyads enrolled (median age of AHIV 14 years), none had documented HIV acquisition modes. Data suggested perinatal infection in 17/18 AHIV, with 1 reported non-perinatal acquisition risk factor, and some discordance between adolescent-mother perceptions of HIV acquisition. In this difficult-to-enroll, vulnerable population of AHIV-MHIV dyads, primary data collection can enhance understanding of AHIV acquisition modes.

Biological Aging and Immune Senescence in Children with Perinatally Acquired HIV

Chronic HIV-infected children suffer from premature aging and aging-related diseases. Viral replication induces an ongoing inflammation process, with the release of pathogen-associated molecular patterns (PAMPs) and damage-associated molecular patterns (DAMPs), the activation of the immune system, and the production of proinflammatory cytokines. Although combined highly active antiretroviral therapy (ART) has significantly modified the natural course of HIV infection, normalization of T and B cell phenotype is not completely achievable; thus, many HIV-infected children display several phenotypical alterations, including higher percentages of activated cells, that favor an accelerated telomere attrition, and higher percentages of exhausted and senescent cells. All these features ultimately lead to the clinical manifestations related to premature aging and comorbidities typically observed in older general population, including non-AIDS-related malignancies. Therefore, even under effective treatment, the premature aging process of HIV-infected children negatively impacts their quality and length of life. This review examines the available data on the impact of HIV and ART on immune and biological senescence of HIV-infected children.

Human immunodeficiency virus-related cerebral white matter disease in children

The human immunodeficiency virus (HIV) epidemic seems largely controlled by anti-retroviral treatment with resultant large numbers of children growing up with the disease on long-term treatment, placing them at higher risk to develop HIV-related brain injury, ongoing cognitive impairment and treatment-related neurological complications. Cerebral white matter involvement is a common radiologic finding in HIV infection and the causes of this have overlapping appearances, ranging from diffuse widespread involvement to focal lesions. The varied pathophysiology is broadly grouped into primary effects of HIV, opportunistic infection, vascular disease and neoplasms. White matter changes in children can be different from those in adults. This review provides guidance to radiologists with the diagnostic dilemma of nonspecific cerebral white matter lesions in children with HIV. The authors discuss common causes of HIV-related cerebral white matter disease as well as the role of neuroimaging in the management of these children.

Malignancies in South African children with HIV

OBJECTIVES

In 2008 the South African Children's Cancer Study Group decided to review the epidemiology, management, and chemotherapy response of HIV-positive children with malignancy.

METHODS

This is a retrospective analysis of data collected from the records of HIV-positive children diagnosed with malignancy at 7 university-based pediatric oncology units serving 8 of the 9 provinces in South Africa.

RESULTS

Two hundred eighty-eight HIV-positive children were diagnosed with 289 malignancies between 1995 and 2009. Age at diagnosis ranged from 17 days to 18.64 years; median 5.79 years. Of the 220 HIV-associated malignancies, there were 97 Kaposi sarcomas, 61 Burkitt lymphomas, 47 other B-cell lymphomas including 2 primary central nervous system lymphomas, 12 Hodgkin lymphomas, and 3 leiomyosarcomas. Sixty-nine patients presented with non-AIDS-defining malignancies. More than 80% presented with advanced disease. Most patients (76.7%) were naive to antiretroviral therapy; 22.2% did not have access because it only became available in public hospitals in 2004. One hundred ninety-seven children were treated with curative intent; 91 received palliative care due to advanced malignancy and/or advanced HIV disease. Nearly one third had coexisting pathology, mostly tuberculosis. Overall survival for the whole group was 33.7%, but was 57.8% for those treated with antiretroviral therapy and chemotherapy.

CONCLUSIONS

The study shows more Kaposi sarcoma and fewer primary central nervous system lymphomas among HIV-positive children than that is reported in the developed world, but confirms a higher incidence of non-Burkitt B-cell lymphoma than in HIV-negative children. The high number of non-AIDS-defining malignancies underscores the prevalence of HIV-AIDS in South Africa. The overall survival should improve with universal access to antiretrovirals and earlier diagnosis.

Perinatally acquired HIV infection in adolescents from sub-Saharan Africa: a review of emerging challenges

Worldwide, more than three million children are infected with HIV, 90% of whom live in sub-Saharan Africa. As the HIV epidemic matures and antiretroviral treatment is scaled up, children with HIV are reaching adolescence in large numbers. The growing population of adolescents with perinatally acquired HIV infection living within this region presents not only unprecedented challenges but also opportunities to learn about the pathogenesis of HIV infection. In this Review, we discuss the changing epidemiology of paediatric HIV and the particular features of HIV infection in adolescents in sub-Saharan Africa. Longstanding HIV infection acquired when the immune system is not developed results in distinctive chronic clinical complications that cause severe morbidity. As well as dealing with chronic illness, HIV-infected adolescents have to confront psychosocial issues, maintain adherence to drugs, and learn to negotiate sexual relationships, while undergoing rapid physical and psychological development. Context-specific strategies for early identification of HIV infection in children and prompt linkage to care need to be developed. Clinical HIV care should integrate age-appropriate sexual and reproductive health and psychological, educational, and social services. Health-care workers will need to be trained to recognise and manage the needs of these young people so that the increasing numbers of children surviving to adolescence can access quality care beyond specialist services at low-level health-care facilities.

Successful outcome in a HIV infected child presenting with Pre-B Acute Lymphoblastic Leukemia

The present case is a 5 y old child with Pre-B Acute Lymphoblastic Leukemia (ALL), presenting with fever, pallor, purpuric spots, hepato-splenomegaly and lymphadenopathy of 20 d duration. During re-induction chemotherapy, he developed atypical skin lesions diagnosed as Varicella Zoster infection. He and his parents tested positive for anti HIV antibody. He entered complete remission and Anti-retroviral therapy (ART) along with maintenance chemotherapy has been initiated 3 mon ago. Acute leukemia is rare in HIV and probably this is the first case of Pre-B Acute Leukemia in association with perinatally transmitted HIV.

Pneumonia and malnutrition are highly predictive of mortality among African children hospitalized with human immunodeficiency virus infection or exposure in the era of antiretroviral therapy

OBJECTIVE

To identify clinical characteristics predicting death among inpatients who are infected with or exposed to human immunodeficiency virus (HIV) during a period of pediatric antiretroviral therapy scale-up in sub-Saharan Africa.

STUDY DESIGN

Retrospective review of medical records from every child with HIV infection (n = 834) or exposure (n = 351) identified by routine inpatient testing in Kamuzu Central Hospital, Lilongwe, Malawi, September 2007 through December 2008.

RESULTS

The inpatient mortality rate was high among children with HIV infection (16.6%) and exposure (13.4%). Clinically diagnosed Pneumocystis pneumonia or very severe pneumonia independently predicted death in inpatients with HIV infection (OR 14; 95% CI 8.2 to 23) or exposure (OR 21; CI 8.4 to 50). Severe acute malnutrition independently predicted death in children who are HIV infected (OR 2.2; CI 1.7 to 3.9) or exposed (OR 5.1; CI 2.3 to 11). Other independent predictors of death were septicemia, Kaposi sarcoma, meningitis, and esophageal candidiasis for children infected with HIV, and meningitis and severe anemia for inpatients exposed to HIV.

CONCLUSIONS

Severe respiratory tract infections and malnutrition are both highly prevalent and strongly associated with death among hospitalized children who are HIV infected or exposed. Novel programmatic and therapeutic strategies are urgently needed to reduce the high mortality rate among inpatients with HIV infection and HIV exposure in African pediatric hospitals.

Impact of infection with human immunodeficiency virus-1 (HIV) on the risk of cancer among children in Malawi - preliminary findings

BACKGROUND

The impact of infection with HIV on the risk of cancer in children is uncertain, particularly for those living in sub-Saharan Africa. In an ongoing study in a paediatric oncology centre in Malawi, children (aged

METHODS

Only children with a cancer diagnosis were included. Odds ratios (OR) for being HIV positive were estimated for each cancer type (with adjustment for age (<5 years, >/= 5 years) and sex) using children with other cancers and non-malignant conditions as a comparison group (excluding the known HIV-associated cancers, Kaposi sarcoma and lymphomas, as well as children with other haematological malignancies or with confirmed non-cancer diagnoses).

RESULTS

Of the 586 children recruited, 541 (92%) met the inclusion criteria and 525 (97%) were tested for HIV. Overall HIV seroprevalence was 10%. Infection with HIV was associated with Kaposi sarcoma (29 cases; OR = 93.5, 95% CI 26.9 to 324.4) and with non-Burkitt, non-Hodgkin lymphoma (33 cases; OR = 4.4, 95% CI 1.1 to 17.9) but not with Burkitt lymphoma (269 cases; OR = 2.2, 95% CI 0.8 to 6.4).

CONCLUSIONS

In this study, only Kaposi sarcoma and non-Burkitt, non-Hodgkin lymphoma were associated with HIV infection. The endemic form of Burkitt lymphoma, which is relatively frequent in Malawi, was not significantly associated with HIV. While the relatively small numbers of children with other cancers, together with possible limitations of diagnostic testing may limit our conclusions, the findings may suggest differences in the pathogenesis of HIV-related malignancies in different parts of the world.

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Affiliation(s)

Nora Mutalima Epidemiology and Genetics Unit, Department of Health Sciences, Seebohm Rowntree Building, Area 3, University of York, York YO10 5DD, UK
Elizabeth M Molyneux Department of Paediatrics, University of Malawi, College of Medicine, P/Bag 360 Chichiri, Blantyre 3, Malawi
William T Johnston Epidemiology and Genetics Unit, Department of Health Sciences, Seebohm Rowntree Building, Area 3, University of York, York YO10 5DD, UK
Harold W Jaffe Department of Public Health, University of Oxford, Rosemary Rue Building, Old Road Campus, Roosevelt Drive, Headington, Oxford OX3 7LF, UK
Steve Kamiza Department of Histopathology, University of Malawi, College of Medicine, P/Bag 360 Chichiri, Blantyre 3, Malawi
Eric Borgstein Department of Surgery, University of Malawi, College of Medicine, P/Bag 360 Chichiri, Blantyre 3, Malawi
Nyengo Mkandawire Department of Surgery, University of Malawi, College of Medicine, P/Bag 360 Chichiri, Blantyre 3, Malawi
George N Liomba Department of Histopathology, University of Malawi, College of Medicine, P/Bag 360 Chichiri, Blantyre 3, Malawi
Mkume Batumba Department of Ophthalmology, University of Malawi, College of Medicine, P/Bag 360 Chichiri, Blantyre 3, Malawi
Lucy M Carpenter Department of Public Health, University of Oxford, Rosemary Rue Building, Old Road Campus, Roosevelt Drive, Headington, Oxford OX3 7LF, UK
Robert Newton Epidemiology and Genetics Unit, Department of Health Sciences, Seebohm Rowntree Building, Area 3, University of York, York YO10 5DD, UK

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Clinical characteristics and outcome of children with Burkitt lymphoma in Uganda according to HIV infection

BACKGROUND

Characteristics of children with Burkitt lymphoma (BL) and HIV infection have not been described in Uganda before.

PROCEDURE

We reviewed records at Uganda Cancer Institute (UCI) for years 1994-2004, to compare clinical features and outcome of BL in children who are HIV positive and negative (HIV+, HIV-). As statistical methods we used Student's t-test, Chi-square and Kaplan-Meier's to compare both groups.

RESULTS

Of 1,462 records of children retrieved, 228 met the eligibility criteria and were reviewed (158 HIV-, 70 HIV+). There were 139 (61%) males and 89 (39%) females. The mean age was 6.9 years (HIV+ 6.7, HIV- 7.1). One hundred seventy-one cases (75%) had facial tumor (HIV+ 71.4%, HIV- 76.6%). HIV positive children presented significantly with extrafacial disease (lymphadenopathy 67%, hepatic masses 51%, and thoracic masses 10%). Presentation with advanced stage disease occurred more frequently in HIV positive patients compared to HIV negative patients. Treatment response rates to chemotherapy were similar irrespective of HIV status. However, overall survival was poorer in HIV positive patients with a median survival of 11.79 months (P-value < 0.000, 95% CI 8.65-14.92).

CONCLUSIONS

BL in Uganda presents frequently with facial disease irrespective of HIV status. However HIV+ BL also presents commonly with extra facial sites, mainly lymphadenopathy. There is no difference in response to treatment with chemotherapy, but HIV+ BL patients have poorer survival. There is need for further characterization of BL in Uganda to understand the role of HIV in disease process and outcome.

High-dose therapy and autologous stem cell transplantation for children with HIV-associated non-Hodgkin lymphoma

In contrast to adults, autologous stem cell transplantation (ASCT) as part of the salvage strategy after high-dose chemo/radiotherapy in human immunodeficiency virus (HIV) related Non-Hodgkin lymphoma (NHL) is not yet established for children. We report on a 13-year patient with congenital HIV infection and refractory Burkitt lymphoma, who was successfully treated by high-dose therapy (HDT) including rituximab followed by ASCT. After 26 months follow-up the patient remains in complete remission and his HIV parameters have normalized with continued highly active antiretroviral therapy (HAART). HIV infection may no longer exclude children from ASCT as part of salvage therapy.

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.

Update on non-acquired immunodeficiency syndrome-defining malignancies

PURPOSE OF REVIEW

Since the introduction of highly active antiretroviral therapy (HAART), the natural history of human immunodeficiency virus (HIV) infection has changed. Early in the acquired immunodeficiency syndrome (AIDS) epidemic, epidemiologic studies showed that HIV-infected patients were at higher risk for developing specific AIDS-defining malignancies. More recent studies linking HIV/AIDS databases to cancer registries have shown that HIV-infected patients are also at higher risk of developing non-AIDS-defining malignancies. We review the most recent data regarding clinical presentation, pathology, and treatment outcomes for these non-AIDS-defining malignancies.

RECENT FINDINGS

Recent large cohort studies linking HIV/AIDS databases to cancer registries have shown that HIV-infected patients are also at higher risk of developing non-AIDS-defining malignancies. Besides anal cancer and Hodgkin disease, the cohort studies have identified other malignancies that appear to occur at a higher rate in the HIV-infected population as compared with the general population. These malignancies include lung cancer, skin cancer, germ cell tumors, leiomyosarcomas, cancers of the head and neck, conjunctival cancer, multiple myeloma, and leukemias.

SUMMARY

As the epidemiology of non-AIDS-defining malignancies continues to evolve, it is unclear whether the appropriate treatments and outcomes for these or other malignancies are changed for HIV-infected patients treated with HAART.

Immunotherapy for Epstein-Barr virus-associated cancers in children

Latent Epstein-Barr virus (EBV) infection is associated with several malignancies, including Burkitt's lymphoma, Hodgkin's disease, nasopharyngeal carcinoma, and post-transplant lymphoproliferative disease (LPD). The presence of EBV antigens in these tumors provides a target for immunotherapy approaches, and immunotherapy with EBV-specific cytotoxic T cells (CTLs) has proved effective in post-transplant LPDs, which are highly immunogenic tumors expressing type III latency. The malignant cells in Hodgkin's disease and nasopharyngeal carcinoma express type II latency and hence a more restricted pattern of EBV antigens. Trials with autologous EBV-specific CTL responses are under way in both of these diseases, and while some activity has been seen, no patient has yet been cured. This reduced CTL efficacy may reflect either downregulation of immunodominant EBV proteins, which are major CTL targets, or the ability of these tumors to evade the immune response by secreting inhibitory cytokines. Further improvement of EBV-specific CTL therapy for these type II latency tumors will require improved methods to activate and expand CTLs specific for the subdominant EBV genes expressed and to genetically modify the expanded CTLs to render them resistant to inhibitory cytokines. If these strategies to improve the therapeutic potential of immunotherapy for EBV-associated tumors prove successful, this type of treatment may be adapted to other tumors expressing known (viral) antigens.

Epidemiology of non-Hodgkin lymphomas and other haemolymphopoietic neoplasms in people with AIDS

HIV-infected individuals have a high risk of developing non-Hodgkin lymphoma (NHL). In Europe, the prevalence of AIDS with a concurrent NHL diagnosis increased from 3.6% to 5.4% between 1994 and 2000. In population-based record linkages between cancer registries and AIDS registries in the USA, Italy, and Australia, the relative risks of NHL in people with AIDS ranged between 15 for low-grade and T-cell NHL and 400 for high-grade NHL. The corresponding relative risk of Hodgkin's disease was about 10, whereas the risks for multiple myeloma and leukaemias were in the range 2 to 5. Since the introduction of highly active antiretroviral therapy in the more developed countries (1996), most studies have suggested a decline in the incidence of some types of NHL, most notably the primary brain form. In studies from Africa, the risk of HIV-associated NHL is about ten times less than that in the more developed countries, but underascertainment and earlier death from other AIDS-related illnesses may explain the relative lack of HIV-associated lymphomas.

How radiosensitive are the developing embryo and fetus?

In its 1990 recommendations, the ICRP considered the radiation risks after exposure during prenatal development. This report is a critical review of new experimental animal data on biological effects and evaluations of human studies after prenatal radiation published since the 1990 recommendations.

Thus, the report discusses the effects after radiation exposure during pre-implantation, organogenesis, and fetogenesis. The aetiology of long-term effects on brain development is discussed, as well as evidence from studies in man on the effects of in-utero radiation exposure on neurological and mental processes. Animal studies of carcinogenic risk from in-utero radiation and the epidemiology of childhood cancer are discussed, and the carcinogenic risk to man from in-utero radiation is assessed. Open questions and needs for future research are elaborated.

The report reiterates that the mammalian embryo and fetus are highly radiosensitive. The nature and sensitivity of induced biological effects depend upon dose and developmental stage at irradiation. The various effects, as studied in experimental systems and in man, are discussed in detail. It is concluded that the findings in the report strengthen and supplement the 1990 recommendations of the ICRP.

Epstein Barr virus-associated lymphoma in HIV-infected children

The relationship between Epstein Barr Virus (EBV) and the human host is commonly benign, whereas the development of malignancy is most likely due to imbalance between the virus and host's immune system. The aim of this study was to analyze the association of EBV with pediatric lymphomas in human immunodeficiency virus (HIV) patients. Four consecutive patients with a histological and clinical diagnosis of lymphomas among 351 pediatric HIV-infected children prospectively followed up at our hospital since 1991 were studied. The cases included one diffuse fibrosis lymphocyte depletion subtype Hodgkin's lymphoma, 2 Burkitt's lymphomas, and one primary diffuse large B-cell lymphoma of the central nervous system. We assessed EBV presence by LMP-1 protein labeling by immunohistochemistry and in situ hybridization for EBERs in formalin-fixed and paraffin-embedded biopsies from all four cases. All HIV-associated lymphomas studied were found to be associated with EBV. The lymphoproliferative action of EBV may induce oncogenesis by increasing the probability of genetic alterations and/or by expanding an already malignant clone. As an oncogenic protein, LMP-1 expression by tumor cells supports the involvement of EBV in disease pathogenesis.

Proliferative and neoplastic disorders in children with acquired immunodeficiency syndrome

Acquired immunodeficiency syndrome (AIDS) is a multisystem disease and, besides infections, various proliferative and neoplastic disorders are seen in cytology, biopsy, and autopsy specimens from infected children. These lesions can be classified into four types: systemic lymphoproliferation, smooth muscle tumors, Kaposi sarcoma (KS), and human papilloma (HPV)-related genital lesions. In addition, isolated cases of multiple miscellaneous tumors have been reported. Proliferative and neoplastic disorders are categorized as lesions of undetermined pathogenesis; however, there are certain factors that are suggested to be related to their pathogenesis. The symptoms related to them may be atypical or difficult to appreciate, and proliferative and neoplastic disorders may clinically mimic an opportunistic infection. The type and site of proliferative and neoplastic disorder also tends to be atypical as compared with those seen in non HIV-infected children. This is a brief but detailed review of these disorders in children with AIDS.

Epidemiology of AIDS-related tumours in developed and developing countries

AIDS-associated illnesses include Kaposi's sarcoma (KS), non-Hodgkin's lymphoma (NHL), and, since 1993, invasive cervical cancer (ICC). Between 1988 and 1998, among AIDS cases reported in western Europe, 9.6% had KS and 3.9% had NHL as AIDS-defining illnesses. Between 1988 and 1998, the frequency of KS decreased from 13.4 to 6.4%, while NHL increased from 3.8 to 5.3%. Estimates of the relative risk (RR) of neoplasms in HIV-seropositive populations came from population-based cancer and AIDS registries linkage studies conducted in the United States, Italy and Australia and from a few cohort and case-control studies. In adults with HIV/AIDS, the RR was over 1000 for KS and ranged between 14 for low-grade NHL and over 300 for high-grade NHL. For Hodgkin's disease (HD), a consistent 10-fold higher RR was observed. For cervical and other anogenital tumours associated with human papilloma virus, risk increases were 2- and 12-fold, depending upon location. In Africa, the AIDS epidemic led to KS becoming the most common cancer type in men in several areas. The RR of AIDS-associated tumours were lower in Africa than those reported in western countries.