Malignant melanoma in an HIV-infected man: a case report and literature review

Malignant Melanoma and Filariasis: A Coexistence or an Association?

Malignancy has been reported with chronic lymphedema, especially lymphangiosarcoma. The authors report on a patient with lymphedema due to filariasis, presenting with an ulcerated pigmented lesion that was malignant melanoma. A literature search revealed no previous report of such lesions existing together.

[Melanoma in HIV patients: 14 cases]

BACKGROUND

a clinical study of 14 patients presenting both malignant melanoma and HIV infection, and analysis of the literature to determine the frequency and specific features of this association.

PATIENTS AND METHODS

ten men and four women of median age 43 years were included. In 50% of cases, the primary melanoma consisted of spreading superficial melanoma with a mean Breslow thickness of 2.83 mm. In two cases, regional lymph node metastasis was discovered but with no primary melanoma being identified. HIV infection was already documented on diagnosis of melanoma in 11 cases, and it was discovered in three cases at the time of surgery for melanoma (treatment of the primary melanoma in two cases, and in one case, regional lymph node dissection two years after the initial diagnosis). Eight patients died within a mean period of 39 months, with melanoma being the cause of death in six cases. Following relapse of melanoma, the course of the disease was severe, with mean stage IV survival of 3.6 months. No response to chemotherapy was observed where such treatment was feasible.

DISCUSSION

the presence of HIV appears to be an aggravating factor for the outcome of metastatic melanoma.

CONCLUSION

our study suggests the importance of clinical examination of pigmented lesions in HIV patients in order to ensure early identification of melanoma.

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.

Cutaneous malignancy and human immunodeficiency virus disease

Certain skin cancers occur with increased frequency or altered course in patients infected with HIV. Malignant melanoma and squamous cell carcinoma are examples of cutaneous malignancies that have a more aggressive course in patients with HIV. Others, such as basal cell carcinoma, appear more frequently in this population but do not appear to be more aggressive. The incidence of HIV-associated Kapsosi's sarcoma has markedly decreased since the advent of HIV antiretroviral therapy. Our understanding of the pathogenesis of this malignancy and its unique management issues are fully reviewed. Cutaneous T-cell lymphoma (CTCL) is rare in this population. Other types of cutaneous lymphoma and HIV-associated pseudo-CTCL are discussed. This article addresses prevention, treatment, and follow-up strategies for this at-risk population.

LEARNING OBJECTIVE

At the completion of this learning activity, participants should be familiar with the unique epidemiology, clinical course, and management of cutaneous malignancy in patients infected with HIV.

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

Patients infected with human immunodeficiency virus (HIV) have an increased risk of developing skin cancers. These at-risk patients may have atypical presentations and/or altered clinical courses. This article will review and discuss management issues for the following malignancies: lymphomas, malignant melanoma, basal cell carcinoma, squamous cell carcinoma, and Kaposi's sarcoma.

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.

Non-AIDS-defining cancer in HIV-infected people

Since the advent of HAART, the natural history of HIV disease has been changing, with decreased risk of life-threatening opportunistic infections and prolonged survival. Concurrently, a variety of non-AIDS-defining cancers have been reported with increased incidence in HIV-infected adults, including anal cancer, Hodgkin's disease, head and neck cancer, testicular cancer, lung cancer, colon cancer, basal cell cancer, squamous cell cancer of the skin, and melanoma. It appears that these tumors may have a more aggressive clinical course in HIV-infected people. Available data, however, suggest that antitumor response and survival in HIV-infected people with malignancy are improved in people with higher CD4 counts. The possible mechanisms for the increased incidence and altered clinical course of these malignancies in HIV-infected people remain unclear.

Melacine: an allogeneic melanoma tumor cell lysate vaccine

Cancer vaccines have represented the holy grail of tumor immunology to many. In 2003, there are innumerable approaches to active specific immunotherapy for cancer. The identification of tumor antigens recognized by and able to activate human T-lymphocytes has heightened the enthusiasm for this approach. Melanoma is one of the diseases that has been primarily targeted by vaccine approaches. The identification of peptides and proteins associated with cancer has provided strategies to target specific components of the cancer cell. However, older vaccines utilizing products from whole cells may have a number of advantages. Melacine (Corixa Corp.) is an allogeneic melanoma tumor cell lysate combined with the adjuvant DETOX. Pioneered by Malcolm Mitchell, it has rare but confirmed antitumor activity in metastatic melanoma (5-10%). However, previous analysis of responses in advanced disease and a recent analysis in early-stage adjuvant trials suggest that Melacine may have its greatest benefit in a large subset of melanoma patients who express either the human leukocyte antigen (HLA) class I antigens A2 and/or HLA-C3. This finding must now be confirmed in a large perspective observation-controlled clinical trial to solidify the role of Melacine as an effective cancer vaccine in melanoma.

Mycosis fungoides associated with malignant melanoma and dysplastic nevus syndrome

BACKGROUND

The increased risk of second malignancies, including nonmelanoma skin cancers, in cutaneous T-cell lymphoma (CTCL) patients has been well documented. However, relatively few studies of malignant melanoma in CTCL patients have been reported.

METHODS

A database of 250 CTCL patients registered over a 3-year period was searched to identify patients with diagnoses of both mycosis fungoides (MF) and malignant melanoma.

RESULTS

We identified six cases of MF associated with malignant melanoma and one associated with dysplastic nevus syndrome, which is a marker of increased risk of melanoma. In four patients, melanoma was diagnosed along with or before MF. In the remaining two patients, MF was diagnosed prior to melanoma, although dysplastic nevi were noted at the time MF was diagnosed. These two patients received treatment for their MF (one with topical nitrogen mustard and another with radiation therapy and nitrogen mustard) prior to the histologic confirmation of melanoma. Six patients had early stages of MF (IA or IB), while one patient presented with simultaneous erythrodermic mycosis fungoides involving the lymph nodes as well as melanoma metastatic to the lymph nodes from an unknown primary.

CONCLUSION

There is an elevated prevalence of malignant melanoma in MF patients compared to the general US population (P < 0.00001) with a relative risk of 15.3 for observing malignant melanoma in MF patients (95% confidence interval 7.0-33.8). Possible pathologic links between the two diagnoses include effects of mycosis fungoides therapies, immunosuppression secondary to mycosis fungoides, and genetic alterations in the p16 tumor suppressor protein.

Multiple nevoid malignant melanomas in a patient with AIDS: the role of proliferating cell nuclear antigen in the diagnosis

The rapid growth of lesions clinically resembling compound nevi in patients with HIV/AIDS should alert physicians to the possibility of malignant melanomas. Immunohistochemistry for proliferating cell nuclear antigen can be helpful in the diagnosis of these tumors. A case of multiple primary nevoid melanomas in a patient with HIV/AIDS is reported.

AIDS and non-AIDS-related malignancies: a new vexing challenge in HIV-positive patients. Part II. Cervical and anal squamous epithelial lesions, lung cancer, testicular germ cell cancers, and skin cancers

As the AIDS epidemic progresses, more and more HIV-infected patients will develop malignancies. The natural history of a malignancy may change dramatically in the presence of HIV infection. Among the AIDS and non-AIDS malignancies, the most frequently reported solid tumors are cervical and anal cancer, testicular germ cell tumors, lung cancer, and skin cancer. Regardless of epidemiology and outcome, the natural history of the majority of non-AIDS-defining tumors changes in the setting of HIV infection. Physicians who treat patients with AIDS and non-AIDS-related cancers need to become familiar with antiretroviral agents, drug-drug interactions, and the prophylaxis and management of opportunistic infections.

Synchronous high-risk melanoma and lymphoid neoplasia

Large population-based studies have shown a significant association between melanoma and lymphoid neoplasia, particularly non-Hodgkin's lymphoma (NHL) and chronic lymphocytic leukaemia (CLL), that is independent of any treatment received for the initial tumour. This study examines the presentation, diagnosis, treatment and progress of three patients who developed advanced melanoma concurrently with a lymphoid neoplasm (one NHL, two CLLs), in order to illustrate their association, discuss common aetiological factors and examine possible therapeutic options. As it is the melanoma rather than the lymphoid neoplasm that represents the bigger threat to overall survival, initial treatment should be targeted towards this cancer. However, because of the interplay between the diseases and the possible side-effects of the various treatments, the choice of adjuvant therapy requires careful consideration. Immunosuppression associated with chemotherapy may permit a more aggressive course for the melanoma, while locoregional radiotherapy is contraindicated following lymph node dissections. As immunotherapy is of benefit in the treatment of melanoma and has also been recently shown to be effective in the management of lymphoid neoplasia, we instituted interferon-alpha as adjuvant therapy for these patients, thereby utilizing a single agent to treat the dual pathologies. The three patients have now been followed-up for 6 months without evidence of disease recurrence or progression.

Fine-needle aspiration diagnosis of unusual cutaneous neoplasms of the scalp in HIV-infected patients: a report of two cases and review of the literature

We report on two unusual, non-AIDS-defining scalp neoplasms, Merkel-cell carcinoma (MCC) and malignant melanoma, in 2 men with acquired immunodeficiency syndrome (AIDS). In the first patient, metastatic MCC was initially diagnosed by fine-needle aspiration (FNA) of a posterior cervical lymph node, based on the cytomorphology and the characteristic immunohistochemical and ultrastructural features. No skin lesion was initially apparent, but a 0.3-mm scalp primary was found during the ensuing neck dissection. In the second patient, recurrent and metastatic malignant melanoma from a Breslow 1.3-mm scalp primary was diagnosed by FNA. Both patients developed generalized disease in a relatively short time, despite their small primaries. These cases illustrate the occurrence of Merkel-cell carcinoma and melanoma in AIDS patients, and stress the need to consider these unusual cutaneous neoplasms when evaluating lymph node FNA samples from HIV-positive patients, especially since both may present as metastases from clinically occult primaries.

Evidence for an association between cutaneous melanoma and non-Hodgkin lymphoma

BACKGROUND

Over the past 2 decades both cutaneous melanoma (CM) and non-Hodgkin lymphoma (NHL) incidence rates have increased substantially. One approach to better understanding the etiologic basis for these increases is to examine the risk of NHL in CM survivors and the risk of CM in NHL survivors.

METHODS

To explore the possible association between CM and NHL, the authors followed cohorts of CM and NHL patients registered through the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program between 1973 and 1996 and identified patients who developed CM after NHL and NHL after CM. The number of observed cases then were compared with the number of expected cases to see if CM survivors were at an increased risk of NHL or if NHL survivors were at an increased risk of CM.

RESULTS

Between 1973 and 1996, 54,803 CM patients and 62,597 NHL patients who met the authors' inclusion criteria were identified through SEER. The authors found statistically significant elevated risks of NHL among CM survivors (standardized incidence ratio [SIR], 1.42; 95% confidence interval [CI], 1.23-1.63) and CM among NHL survivors (SIR, 1.75; 95% CI, 1.48-2.07).

CONCLUSIONS

These results support an association between CM and NHL. Although detection bias and posttherapy effects may explain part of this association, shared genetic or etiologic factors, such as sunlight exposure, also may play a role.

Pathogenesis of non-AIDS-defining cancers: a review

As the AIDS epidemic advances, the number of HIV-infected subjects developing AIDS-related neoplasms is rapidly increasing, and the spectrum of malignancies encountered is expanding. Several non-AIDS-defining cancers are being reported at an increasing incidence in HIV-infected individuals, including anal, skin, oral mucosa, head and neck and lung carcinomas, testicular tumors, and pediatric soft-tissue sarcoma. There appears to be an emerging role for various concurrent viral infections in the HIV-infected host that are likely implicated in the pathogenesis of some nondefining-AIDS neoplasms. Our recent findings in HIV-associated lung cancers and in the precursor lesions of cervical carcinoma suggest that wide-spread genomic instability, as manifested by the development of increased numbers of microsatellite alterations (MAs), may occur frequently in HIV-associated tumors and they may play an important role in the pathogenesis of those neoplasms. Although the mechanism underlying the development of increased MAs is unknown, it may play a crucial role in the development of many HIV-associated tumors. It will be important to track the epidemiological and biological features of non-AIDS-defining cancers in HIV-infected patients, and compare them to those tumors in the general population. It is likely that further clues about malignant transformation and oncogenesis unraveled in the HIV setting will have broad clinical implications.