Lymphoma associated with human immunodeficiency virus infection

Opportunistic Neurologic Infections in Patients with Acquired Immunodeficiency Syndrome (AIDS)

Infections of the central nervous system (CNS) in individuals with human immunodeficiency virus (HIV) remain a substantial cause of morbidity and mortality despite the introduction of highly active antiretroviral therapy (HAART) especially in the resource-limited regions of the world. Diagnosis of these infections may be challenging because findings on cerebrospinal fluid (CSF) analysis and brain imaging are nonspecific. While brain biopsy provides a definitive diagnosis, it is an invasive procedure associated with a relatively low mortality rate, thus less invasive modalities have been studied in recent years. Diagnosis, therefore, can be established based on a combination of a compatible clinical syndrome, radiologic and CSF findings, and understanding of the role of HIV in these infections. The most common CNS opportunistic infections are AIDS-defining conditions; thus, treatment of these infections in combination with HAART has greatly improved survival.

Clinical Characteristics of Gastrointestinal Lymphomas Associated with AIDS (GI-ARL) and the Impact of HAART

PURPOSE

The gastrointestinal (GI) tract is the most common site of extranodal disease in patients with systemic non-Hodgkin's lymphoma (NHL). Patients with systemic NHL and GI involvement associated with AIDS (GI-ARL) have a significantly worse prognosis than those without AIDS. We studied whether the introduction of HAART is associated with improved survival in patients with GI-ARL.

PATIENTS AND METHOD

36 patients with GI-ARL were identified from the tumor registries of a large municipal hospital in New York City and a tertiary care facility in western New York State. Of these, 28 patients did not receive HAART and 8 were treated with HAART. The primary endpoint was survival, which was defined as time from date of diagnosis of NHL until death from any cause.

RESULTS

Patients were analyzed based on whether or not they were treated with HAART. Kaplan-Meier analysis showed significantly better survival in patients with GI-ARL who were concurrently treated with HAART (p =.014). Median survival was 5 months for the no-HAART group and 30 months for the HAART group.

CONCLUSION

In patients with GI-ARL who were treated with chemotherapy, concurrent therapy with HAART therapy was associated with improved survival.

FOLFOX-4 regimen with concomitant highly active antiretroviral therapy in metastatic colorectal cancer HIV-infected patients: a report of five cases and review of the literature

Colorectal cancers are rare in developing countries, but are the second most frequent malignancy in the affluent world. Data on colorectal cancer in HIV-positive patients are limited. Up to now, there are no published data on treatment patterns, response to therapy, or survival in this setting. Oxaliplatin is an antineoplastic agent currently indicated, concomitantly to fluorouracil and leucovorin, for the treatment of advanced colorectal cancer. The FOLFOX-4 regimen (oxaliplatin 85 mg/m(2) as a two-hour infusion on day 1; leucovorin 200 mg/m(2) as a two-hour infusion on days 1 and 2, fluorouracil as a bolus infusion on days 1 and 2, followed by a fluorouracil 22-hour infusion 600 mg/m(2) for two consecutive days every two weeks), with concomitant highly active antiretroviral therapy (HAART) is feasible and active, while the HIV infection is not a limiting factor for its use. Moreover, the concomitant use of HAART does not seem to increase the toxicity of the FOLFOX-4 regimen.

Primary gastrointestinal lymphoma: spectrum of imaging findings with pathologic correlation

Gastrointestinal lymphoma is an uncommon disease but is the most frequently occurring extranodal lymphoma and is almost exclusively of non-Hodgkin type. Primary gastrointestinal lymphoma most commonly involves the stomach but can involve any part of the gastrointestinal tract from the esophagus to the rectum. Risk factors for the development of gastrointestinal lymphoma include Helicobacter pylori infection, immunosuppression after solid organ transplantation, celiac disease, inflammatory bowel disease, and human immunodeficiency virus infection. Although gastrointestinal lymphoma has a wide variety of imaging appearances and definitive diagnosis relies on histopathologic analysis, certain findings (eg, a bulky mass or diffuse infiltration with preservation of fat planes and no obstruction, multiple site involvement, associated bulky lymphadenopathy) can strongly suggest the diagnosis. Imaging also plays an important role in the detection of complications such as perforation, obstruction, and fistulization. The most commonly used imaging modalities are barium examination and computed tomography (CT). These modalities are complementary, although CT provides a better overall assessment of the disease stage.

Colorectal Malignancies in HIV-Positive Patients

Due to the development of more effective medications, those infected with HIV are living longer. Consequently, more tumors and infections have been added to the AIDS-defining criteria in the last decade. Our aim was to review the occurrence and clinical course of colorectal (CR) malignancies in HIV infected/AIDS patients from a single institution. A retrospective review of HIV/AIDS patients with colorectal malignant tumors was undertaken. We included adult patients, with ELISA and Western blot test positive for HIV, and primary malignant tumors located in the colon or rectum. Malignant neoplasms of the anus were excluded for the purposes of this study. Twelve patients (9 males and 3 females), mean age 41 years, were identified with the following neoplasm: 6 adenocarcinomas (ACA), 5 non-Hodgkin lymphomas (NHL), and 1 small-cell carcinoma. Intravenous drug abuse was the main risk factor for HIV. No patient had identified risk factors for colorectal neoplasm. Five out of six patients with ACA had metastatic disease at the time of diagnosis. One patient with stage II ACA developed early liver metastases after colonic resection. Seven out of 12 patients underwent surgery. Six (85.7%) of these sustained postoperative complications, primarily wound infection. The overall survival in our series was dismal, averaging 20 months. For NHL average survival was 29 months, and 12 months for CR-ACA. This is the largest series of cases of colorectal cancer in the HIV/AIDS patient population published in the English language and the largest number of colorectal ACA reported in this unique population. Early in our experience, tumors frequently found in immunoincompetent patients were detected (NHL). More recently, we have only treated patients with colorectal ACA; none of them had no risk factors for colorectal cancer (family history, IBD, FAP, HNPCC). These patients developed tumors at earlier ages and were diagnosed at an advanced stage. Therefore, these tumors may be associated with the grade of immunosuppression induced during the course of the HIV infection and with a tumorigenic effect of the HIV on the colonic epithelium. Consequently, a high index of suspicion when evaluating chronic abdominal complaints in such patients is warranted. The use of the new antiretroviral therapy regimens should be further evaluated to know its impact in the survival.

Effect of highly active antiretroviral therapy on survival among HIV-infected men with Kaposi sarcoma or non-Hodgkin lymphoma

The effect of highly active antiretroviral therapy (HAART) on survival in HIV-infected patients with Kaposi sarcoma (KS) or non-Hodgkin lymphoma (NHL) is unknown. Our study examines survival after HAART for these 2 malignancies. Analyses were performed using data from 387 HIV-infected men in the Multicenter AIDS Cohort Study (MACS) after a diagnosis of either KS or NHL in 1990-99. Potential prognostic factors, including HAART, were evaluated in univariate analyses using Kaplan-Meier survival curves and log-rank tests. Multivariate survival analyses were conducted using Cox's time-dependent proportional hazards models, adjusting for CD4(+) cell levels at the time of cancer diagnosis and other covariates. Forty-three of 287 KS patients (15%) and 13 of 100 NHL patients (13%) had been treated with HAART. HAART treatment was associated with improved survival for KS and NHL patients (log-rank p = 0.0001 for each group). In multivariate analyses, HAART was associated with an 81% reduced risk of death among KS patients [relative hazard (RH) 0.19, 95% confidence limits (CL) (0.08, 0.45)], compared to those not exposed to HAART and an 84% reduced risk [RH 0.16, 95% CL (0.04, 0.64)] among NHL patients. Relative hazards estimates were similar for those with HAART initiation before and after NHL diagnosis. The use of HAART prolongs overall survival among HIV-positive men diagnosed with KS and NHL. HAART appears to be effective in improving survival even when initiated after the diagnosis of NHL and KS.

Focal neurological disease in patients with acquired immunodeficiency syndrome

Focal neurological disease in patients with acquired immunodeficiency syndrome may be caused by various opportunistic pathogens and malignancies, including Toxoplasma gondii, progressive multifocal leukoencephalopathy (PML), cytomegalovirus (CMV), and Epstein-Barr virus-related primary central nervous system (CNS) lymphoma. Diagnosis may be difficult, because the findings of lumbar puncture, computed tomography (CT), and magnetic resonance imaging are relatively nonspecific. Newer techniques have led to improved diagnostic accuracy of these conditions. Polymerase chain reaction (PCR) of cerebrospinal fluid specimens is useful for diagnosis of PML, CNS lymphoma, and CMV encephalitis. Recent studies have indicated the diagnostic utility of new neuroimaging techniques, such as single-photon emission CT and positron emission tomography. The combination of PCR and neuroimaging techniques may obviate the need for brain biopsy in selected cases. However, stereotactic brain biopsy, which is associated with relatively low morbidity rates, remains the reference standard for diagnosis. Highly active antiretroviral therapy has improved the prognosis of several focal CNS processes, most notably toxoplasmosis, PML, and CMV encephalitis.

Diagnosis and treatment of colonic disease in AIDS

The colon is a frequent site of gastrointestinal complications in patients with HIV infection, and these colonic disorders increase in frequency as immunodeficiency worsens. The most common clinical manifestations of colonic disease in AIDS are diarrhea, lower gastrointestinal bleeding, and abdominal pain. Toxic megacolon, intussuseption, typhlitis, idiopathic colonic ulcer, and pneumatosis intestinalis also have been described. In the HIV-infected patient with preserved immunity, the most common cause of colitis is bacterial, but as the degree of immunodeficiency worsens, opportunistic pathogens (CMV, protozoa, mycobacteria, fungi) and neoplasms become more frequent. The frequent use of antibiotics, chemotherapeutic agents, and frequent hospitalization increase the susceptibility to cf2Clostridium difficule cf1colitis. Endoscopy plays an integral role in the management of many colonic disorders in AIDS.

Primary esophageal lymphoma in AIDS

Primary esophageal lymphomas are extremely rare. We report a primary esophageal T cell lymphoma of the diffuse large cell type in a patient with AIDS and review other published data. Although rare, the diagnosis should be considered in patients with dysphagia, weight loss (with or without hematemesis), and endoscopic findings of masses, polyps, or ulcerations that are especially unresponsive to antifungal therapy or antiviral therapy or both. Repeat endoscopy with biopsy may be needed to establish the diagnosis properly.

Nasal mucosal cell alterations in HIV-infected patients

Patients with HIV infection often have nasopharyngeal symptoms related to inflammatory or infectious diseases of the upper respiratory tract. In this study, we examined specific nasal mucosal cytologic alterations in adult patients with HIV infection for associations with nasopharyngeal symptoms and other clinical parameters. Mucosal cytology was obtained in 62 patients from an urban HIV clinic using a plastic curettelike probe. The quantities of goblet cells, vacuolated cells, and leukocytes were determined and analyzed for associations with various clinical aspects of these patients and specifically with the presence or absence of prolonged (> 2-week duration) nasopharyngeal symptoms. Goblet cell, but not vacuolated cell, increases were observed in samples in which nasal eosinophilia was present and in samples obtained from April to October without specific associations with nasopharyngeal symptoms or histories of atopic disease. A history of allergic rhinitis or recent upper respiratory infection was significantly associated with increased proportions and total numbers of epithelial cells that showed vacuolization. In patients with prolonged nasopharyngeal symptoms, significantly higher numbers of nasal leukocytes were observed but higher proportions of vacuolated cells were not. Scores of tests for abnormal physical findings in the nose were higher for patients with prolonged nasopharyngeal symptoms than for those without. Peripheral blood CD4 concentrations, gender, nasal substance abuse history, and other comorbidities did not influence either vacuolated cell or goblet cell quantities. These data show that prolonged nasopharyngeal symptoms in HIV infection are associated with a certain nasal cellular pattern. It is conceivable that this pattern relates to recurrent or prolonged nasal inflammation secondary to upper respiratory infection.