Cancers Common in Patients with HIV Infection

Incidence of non-Hodgkin lymphoma Non-Hodgkin Lymphomas Non-Hodgkin lymphomas are a heterogeneous group of disorders involving malignant monoclonal proliferation of lymphoid cells in lymphoreticular sites, including lymph nodes, bone marrow, the... read more is 50 to 200 times higher in patients infected with HIV. Most cases are B-cell, aggressive, high-grade histologic subtype lymphomas. At diagnosis, extranodal sites are usually involved; they include bone marrow, gastrointestinal tract, and other sites that are unusual in non–HIV-associated non-Hodgkin lymphoma, such as the central nervous system and body cavities (eg, pleural, pericardial, peritoneal).

Common presentations include rapidly enlarging lymph nodes or extranodal masses and systemic symptoms (eg, weight loss, night sweats, fevers).

Diagnosis of non-Hodgkin lymphoma is by biopsy with histopathologic and immunochemical analysis of tumor cells. Abnormal circulating lymphocytes or unexpected cytopenias suggest involvement of the bone marrow, mandating bone marrow biopsy. Tumor staging may require cerebrospinal fluid examination and CT or MRI of the chest, abdomen, and other areas where tumors are suspected.

Poor prognosis is predicted by the following:

Treatment of non-Hodgkin lymphoma is with various regimens of systemic, multidrug chemotherapy that includes cyclophosphamide, doxorubicin, vincristine, prednisone, and etoposide. These drugs are combined with IV rituximab and an anti-CD20 monoclonal antibody and supplemented with antiretroviral therapy (ART), prophylactic antibiotics and antifungals, and hematologic growth factors. Therapy may be limited by severe myelosuppression, particularly when combinations of myelosuppressive antitumor or antiretroviral drugs are used. Radiation therapy may debulk large tumors and control pain or bleeding.

Incidence of primary central nervous system lymphoma Primary Brain Lymphomas Primary brain lymphomas, a type of primary central nervous system lymphoma, originate in neural tissue and are usually B-cell tumors. Diagnosis requires neuroimaging and sometimes cerebrospinal... read more is markedly increased in patients infected with HIV with very low CD4 counts.

Primary central nervous system lymphomas consist of intermediate- or high-grade malignant B cells, originating in central nervous system tissue. These lymphomas do not spread systemically, but the prognosis is poor; median survival is < 6 months.

Presenting symptoms include headache, seizures, neurologic deficits (eg, cranial nerve palsies), and mental status changes.

Acute treatment of primary central nervous system lymphomas requires control of cerebral edema using corticosteroids. Although whole-brain radiation therapy and antitumor chemotherapy with high-dose methotrexate alone or combined with other chemotherapy drugs or rituximab are commonly used, none of these regimens has been rigorously evaluated. In observational studies of ART and in a single clinical trial of rituximab, survival appeared improved.

In women infected with HIV, prevalence of human papillomavirus (HPV) infection Human Papillomavirus (HPV) Infection Human papillomavirus (HPV) infects epithelial cells. Most of the > 100 subtypes infect cutaneous epithelium and cause skin warts; some types infect mucosal epithelium and cause anogenital warts... read more is increased, oncogenic subtypes (types 16, 18, 31, 33, 35, and 39) persist, the incidence of cervical intraepithelial dysplasia (CIN) is up to 60%, and the incidence of cervical cancer Cervical Cancer Cervical cancer is usually squamous cell carcinoma; adenocarcinoma is less common. The cause of most cervical cancers is human papillomavirus (HPV) infection. Cervical neoplasia is often asymptomatic... read more is increased (1 Reference AIDS-defining cancers in patients infected with HIV are Kaposi sarcoma Lymphoma, Burkitt (or equivalent term) Lymphoma, immunoblastic (or equivalent term) Lymphoma, primary, of central nervous system read more ). However, cervical cancers, if they occur, are more extensive, are more difficult to cure, and have higher recurrence rates after treatment.

Confirmed risk factors for cervical cancer in women infected with HIV include the following:

Management methods for CIN or cervical cancer is not changed by HIV infection. Frequent Papanicolaou tests are important to monitor for progression of CIN. ART may result in resolution of HPV infection and regression of CIN but has no clear effects on cancer.

Squamous cell carcinoma of the anus Anal Cancer Anal cancer accounts for an estimated 9760 cases and about 1870 deaths in the United States annually ( 1). The main symptom is bleeding with defecation. Diagnosis is by endoscopy. Treatment... read more and squamous cell carcinoma of the vulva Vulvar Cancer Vulvar cancer is usually a squamous cell cancer, most often occurring in older women. It usually manifests as a visible or palpable lesion. Diagnosis is by biopsy. Treatment typically includes... read more are caused by the same oncogenic types of HPV as cervical cancers and occur more commonly in patients infected with HIV. The increased incidence of anal intraepithelial neoplasia and cancers in these patients appears to be caused by both high-risk behaviors (eg, anal-receptive intercourse) and immunosupression by HIV; ART may decrease risk of progression.

Anal dysplasia is common, and squamous cell cancers can be very aggressive.

Treatments include surgical extirpation, radiation therapy, and combined chemotherapy with mitomycin or cisplatin and 5-fluorouracil.