Acquired Immunodeficiency Syndrome and Cancer
Summary of Key Points
Incidence
• Non-Hodgkin lymphoma (NHL), Hodgkin lymphoma (HL), Kaposi sarcoma (KS), cervical cancer, and anal cancer all occur with increased incidence in patients infected with the human immunodeficiency virus (HIV). NHL, KS, and cervical cancer are acquired immunodeficiency syndrome (AIDS) defining.
• KS occurs in HIV-infected patients who also are infected with KS-associated herpesvirus. Outside of Africa and in some Mediterranean populations, KS occurs mainly in men who have sex with men.
• Lymphoma (non-Hodgkin and Hodgkin) occurs in all HIV risk groups. These neoplasms tend to be aggressive and extranodal and manifest at an advanced stage. Burkitt lymphoma and HL tend to occur in patients with higher CD4 counts (typically greater than 200 cells/µL), whereas primary central nervous system lymphoma tends to occur in patients with very low CD4 counts (typically less than 50/mm3).
Etiology and Pathogenesis
• KS is always associated with KS-associated herpesvirus; immunocompromise, inflammatory cytokines, and perhaps the HIV TaT protein contribute to pathogenesis.
• Lymphoma in HIV-infected patients is associated with Epstein-Barr virus (EBV) in approximately half of the cases; immunocompromise, chronic antigen stimulation, and perhaps inflammatory cytokines and chemokines contribute to pathogenesis.
• Cervical and anal cancer require the oncogenic strains of human papilloma virus. The pathogenesis of these two cancers is remarkably similar.
Kaposi Sarcoma
• A biopsy is indicated to confirm diagnosis.
• A computed tomography (CT) scan of the chest and abdomen is also indicated.
• Gastrointestinal endoscopy is performed if clinically indicated.
• Highly active antiretroviral therapy (HAART) and treatment of opportunistic infections sometimes are associated with regression of KS.
• If disease is symptomatic or rapidly progressive, or with visceral involvement, systemic therapy with liposomal anthracycline or paclitaxel is instituted; all patients should receive pneumocystis prophylaxis. Hematopoietic growth factors, antifungal treatment, and antiherpesvirus prophylaxis or treatment also are appropriate for most patients receiving cytotoxic chemotherapy.
• If disease is indolent and antiretroviral therapy has just been initiated or major changes have been made, observation may be appropriate.
• For a few lesions, topical therapy, injection of lesions, or radiation therapy may be adequate treatment.
• For persons with systemic disease, consider interferon, thalidomide, or experimental therapy.
Non-Hodgkin Lymphoma
• Signs and symptoms of tumor lysis.
• Extent of disease can be determined with use of CT and bone marrow biopsy in most cases.
• Extranodal and atypical presentations of lymphoma are common, as are constitutional symptoms (especially with HL).
