Malignancies in HIV infection
Rabindran1, Gedam DS2
1Dr. Rabindran, Consultant Neonatologist, Billroth
Hospital, Chennai, 2Dr D Sharad Gedam, Professor of
Pediatrics, L N Medical collegw, Bhopal, MP, India.
Address for
correspondence: Dr Rabindran, E mail:
rabindranindia@yahoo.co.in
Abstract
HIV is associated with malignancies. AIDS defining malignancies are
Kaposi’s Sarcoma, B cell non- Hodgkin’s lymphoma,
Primary CNS lymphoma & cervical cancer
Key words:
Malignancies, HIV infection, Kaposi sarcoma
People with HIV have more than twofold increased risk of malignancy;
about 30% to 40% of them will develop malignancy[1]. The relationship
between HIV &cancer became evident early during the HIV/AIDS
epidemic in 1981.AIDS defining malignancies are Kaposi’s
Sarcoma, B cell non- Hodgkin’s lymphoma, Primary CNS lymphoma
& cervical cancer. Non AIDS defining malignancies are anal
cancer, lung cancer, Hodgkin lymphoma & liver cancer [2].
Although the incidence of AIDS-defining cancers has decreased with the
use of antiretroviral therapy, non-AIDS-defining cancers have
increased. Among HIV patients increased risk is 3 times for lung
cancer, 29 times for anal cancer, 3 times for liver cancer & 13
times for haematological cancer. Reasons for the increase of
malignancies among HIV patients are increasing HIV/AIDS population,
people living longer & not dying from opportunistic
infections&increase in smoking.
Pathogenesis of Cancer in HIVis manifold [3]. Many are virally-induced
cancers, some due to immune dysregulation, decreased immune
surveillance, increased susceptibility to carcinogens and
endothelial/epithelial cell abnormalities. HIV activates
proto-oncogenes, inhibits tumor suppressor genes & induces
genetic instability. In vitrostudies have shown that the tat
(transactivator of transcription) gene product from HIV increases the
expression of the proto-oncogenes c-myc, c-fos & c-jun and
downregulate the tumor suppression gene p53 in adenocarcinoma cell
lines[4].
Kaposi sarcoma is the most common tumour in people with HIV infection.
Non- Hodgkin’s lymphoma is the second most common tumour in
individuals with HIV; though studies show a decline in
incidence since the introduction ofhighly active antiretroviral therapy
(HAART) [5], AIDS-related lymphomas (ARLs) have increased as a
percentage of first AIDS Defining Illness. The two commonest
subtypes are diffuse large B-cell lymphoma (DLBCL) & Burkitt
lymphoma/leukaemia (BL). The developmentof ARL has been shown to be
related to older age,low CD4 cell count & no prior treatment
with HAART. Median survival in the post-HAART era is approachingthose
in the HIV- negative population & depends critically on
histological subtype & stage of the disease.
Primary central nervous system lymphoma (PCNSL) isdefined as a
non-Hodgkin lymphoma (NHL) confined to thecranio-spinal axis without
systemic involvement. AIDS-related PCNSL is characteristically
high-grade diffuse large B-cell or immunoblastic NHL. Primary effusion
lymphoma (PEL) is an unusual rare form(approximately 3%) of
HIV-associated non-Hodgkin lymphoma.Patients with PEL are usually
HIV-positive menpresenting as growth in a liquidphase in serous body
cavities such as thepleura, peritoneum & pericardial cavities
without identifiabletumour masses or lymphadenopathy.
Women with HIV infection are more likely to have infectionwith HPV 16
or 18 than women who are HIV negative. They also have a higher
prevalence& incidence of CIN than HIV-negativewomen [6]. The
incidence of anal cancer in people living with HIV isup to 40 times
higher compared with the general population & it occurs at a
much younger age. The highest risk is in HIV-positive men who have sex
withmen (MSM) who have an incidence of 70–100 per 100
000person years (PY) compared with 35 per 100 000 PY in HIV-negative
MSM [7].
Hodgkin lymphoma (HL) has a 10 to 20 fold increased incidence in HIV
patients in comparison with the HIV-negative population.It tends to
present more frequently in advanced stage at diagnosis, with extra
nodal involvement,especially bone marrow infiltration & with a
higher proportion presenting with B symptoms and poor
performance status than in the general population. The outcome of HIV
patients with HL has dramatically improved after the introduction of
HAART. HIV-positive patients have a two-to five-fold risk of developing
a non melanoma skin cancer. Actinic keratoses are very
common.
Among Testicular germ cell cancers, seminoma (as opposed to
nonseminomagerm cell tumours) occurs more frequently inHIV. Penis
cancer is five-to-six times commoner in HIV despite antiretroviral
treatments . The uncircumcised state, poor hygiene, smoking, lichen
sclerosis and HPV are the principal risk factors. Patients with
HIV-related non-small cell lung cancer present at a youngerage
& with more advanced disease than their
HIVnegativecounterparts. Regarding Hepatocellular carcinomas (HCC), HIV
affects the natural history of HCV infection in two important ways:
first, it increases the likelihood of chronic infection following the
acute episode and second, it hastens the development of cirrhosis once
chronic infection is established posing important implications for the
subsequent development of HCC. HIV positive patients with colorectal
adenocarcinoma are significantly younger, have more advanced
disease with anincreased prevalence of right-sided tumours.
More studies are needed to assess the risk, associated factors for
prompt management of malignancies in AIDS. The role of more aggressive
chemotherapy regimens & earlier starting HAART therapy in
patients whohave non-AIDS-defining cancers needs to be clarified.
Whether the same chemotherapy regimens could be applied with success in
HIV-infected populations is still debatable. Finally periodic screening
and proper monitoring for the various malignancies in at risk
population is mandatory to reduce the mortality and improve the quality
of life among HIV patients.
Kiran VH et al noticed malignancy in 62 % of their study
population, out of this 62 % were males and 38% were females,
95% were receiving ART, Predominantly the patients were in STAGE 4 and
NHL was the most common malignancy in our study. CD4 count has no
correlation with the incidence of malignancy [8].
Funding:
Nil, Conflict of
interest: None initiated.
Permission
from IRB:
Yes
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How to cite this article?
Rabindran, Gedam DS. Malignancies in HIV infection. Int J Med Res Rev
2015;3(6):538-539. doi: 10.17511/ijmrr.2015.i6.130.