Genitourinary manifestations of the acquired immunodeficiency syndrome

[Radiotherapy for HIV-infected patients]

Since the advent of highly active antiretroviral therapy, cancer incidence is still 2 to 3-fold higher in patients infected by human immunodeficiency virus (HIV) than in the general population, with an increased incidence of malignancies not associated with acquired immunodeficiency syndrome (AIDS). HIV-infected patients cancer treatment does not differ from that in the general population. However, the management of those patients have some particularities due to preexisting comorbid conditions, including metabolic, cardiovascular, renal or hepatic complications and the risk for potential drug - drug interactions in HIV-infected patients. In this review, we described efficacy and tolerance of radiotherapy with or without chemotherapy in this frail population treated for cancer. Utilization of modern radiotherapy techniques such as intensity-modulated radiotherapy may improve the treatment tolerance.

Posttransplant Lymphoproliferative Disorder Presenting as Testicular Lymphoma in a Kidney Transplant Recipient: A Case Report and Review of the Literature

Posttransplant lymphoproliferative disorder (PTLD) is a malignancy caused by the immunosuppression that occurs after transplantation. It is primarily a nodal lesion but frequently it involves extranodal masses. Treatment is usually by reducing immunosuppressive therapy. Testicular lymphoma as PTLD is notably rare in documented literature and there is limited evidence of definitive treatment guidelines. This manuscript describes a patient who developed diffuse large B-cell lymphoma of his right testis one year following kidney transplantation. A diagnosis of PTLD was made and treatment with rituximab, locoregional radiotherapy, and intrathecal methotrexate in addition to the standard reduction of immunosuppression resulted in complete remission until now. We submit this case along with literature review of similar cases in the past and a review of specific peculiarities of our case with emphasis on our treatment plan to further the understanding of this diversiform disease.

Radiotherapy in patients with HIV: current issues and review of the literature

Although the introduction of highly active antiretroviral therapy has radically improved the life expectancy of patients with HIV, HIV positivity is still considered a major barrier to oncological treatment for patients with cancer because of their worse prognosis and increased susceptibility to toxic effects compared with patients who are immunocompetent. The use of radiotherapy with or without chemotherapy, immunotherapy, or molecular targeted therapy is the standard of care for several cancers. These new drugs and substantial improvements in radiotherapy techniques, including intensity-modulated radiotherapy, image-guided radiotherapy, and stereotactic ablative radiotherapy, are optimising the feasibility of such anticancer treatments and are providing new opportunities for patients with cancer and HIV. In this Review, we discuss the role of radiotherapy, with or without chemotherapy or new drugs, in the treatment of cancer in patients with HIV, with a focus on the efficacy and tolerability of this approach on the basis of available evidence. Moreover, we analyse and discuss the biological basis of interactions between HIV and radiotherapy, evidence from preclinical studies, and immunomodulation by radiotherapy in the HIV setting.

Clinicopathological characteristics and management of prostate cancer in the human immunodeficiency virus (HIV)-positive population: experience in an Australian major HIV centre

OBJECTIVES

To characterise clinicopathological characteristics of prostate cancer among human immunodeficiency virus (HIV)-positive men and to evaluate the current practice patterns in the management of prostate cancer in these men.

PATIENTS AND METHODS

We retrospectively reviewed all patients with HIV in the State-wide HIV referral centre in Victoria, who were diagnosed with prostate cancer from 2000 onwards. In all, 12 patients were identified, and the medical records were reviewed to collect data on HIV parameters at the time of prostate cancer diagnosis, as well as prostate cancer clinicopathological characteristics, treatment details and outcomes.

RESULTS

At the time of prostate cancer diagnosis, eight patients had undetectable viral load, and the median cluster of differentiation 4 (CD4) count was 485 cells/μL. The average age at diagnosis of prostate cancer was 63 years and the median prostate-specific antigen (PSA) level of 11.1 ng/mL. Four patients had Gleason 6 prostate cancer, four Gleason 7, one Gleason 8 and three Gleason 9. Seven of the 12 patients had a positive family history for prostate cancer. Of the patients with clinically localised prostate cancer (10), most were treated with radiotherapy (RT): one permanent seed brachytherapy (BT), five external beam RT (EBRT), two open radical prostatectomies (RP), one active surveillance (AS), and one on watchful waiting (WW). For the two patients with metastatic disease, one had androgen-deprivation therapy and EBRT, while the other had a combination of EBRT and chemo-hormonal therapy with doxetacel. All patients were followed for a median of 46 months, with three deaths reported, none of which was a prostate cancer-specific death.

CONCLUSIONS

This is the first Australasian series on prostate cancer management in a HIV population. With the prolonged survival among HIV-positive men in the highly active anti-retroviral therapy era, PSA testing should be offered to this group of patients, especially those with a positive family history. HIV-positive men should also be offered all treatment options in the same manner as men in the general population.

Urologic aspects of HIV infection

Although lifespan has dramatically improved in the human immunodeficiency virus-positive (HIV+) population, HIV and its treatment continue to be a source of substantial morbidity in many organ systems, including the genitourinary tract. As the number of long-term survivors increases with advances in antiretroviral therapy, age-associated urologic symptoms are also becoming increasingly relevant considerations for people living with HIV. Primary care physicians have a major role to play in maintaining the genitourinary health of their HIV+ patients. This role is of great importance not just for the well-being of the individual patient but for the public health, as the genitourinary tract is a common vector for HIV transmission. In this article the authors review the management of the genitourinary system in patients with HIV infection. Particular consideration is given to urinary tract infections, lower urinary tract symptoms, renal insufficiency, sexual and fertility problems, and cancers of the genitourinary tract. Management algorithms are outlined and indications for referral to a urologist are emphasized.

Human immunodeficiency virus-associated prostate cancer: clinicopathological findings and outcome in a multi-institutional study

OBJECTIVE

To characterize the clinicopathological findings and the outcome of human immunodeficiency virus (HIV)-infected patients diagnosed and treated for prostate carcinoma, as HIV-positive men being treated with highly active antiretroviral therapy (HAART) are living longer and thus are more likely to develop cancers such as prostate cancer.

PATIENTS AND METHODS

We performed a retrospective, multi-institutional study involving HIV-positive men with concomitant prostate carcinoma. We collected data regarding patient demographics (age, race), HIV status (CD4(+) cell count, HIV viral load, HAART), PSA level (at cancer diagnosis), symptoms and signs, radiological findings, pathology (Gleason score, stage), cancer treatment (type, side-effects), and outcome (response, survival). Accrued data was analysed using descriptive statistics.

RESULTS

We identified 17 patients (mean age 59 years) with HIV-associated prostate adenocarcinoma. The mean CD4(+) count was 336 cells/mm(3) and the mean HIV viral load was 17 319 copies/mL. In all, 14 (82%) of these men were receiving HAART. Most patients were diagnosed with carcinoma after an abnormal screening PSA level. The mean PSA level was 30 ng/mL. Only six (35%) men had an abnormal prostate on examination. The mean Gleason score was 6.8, and in most cases, cancer was confined to the prostate gland. Most patients were amenable to curative treatment with hormonal therapy, radiation, and/or prostatectomy. There were no serious treatment related side-effects. One patient remained untreated. All treated patients had a complete response (undetectable PSA level). Most patients were long-term survivors. Documented death in five cases was unrelated to prostate cancer.

CONCLUSION

The management of HIV-positive men with prostate carcinoma in the HAART era is becoming increasingly important. Our data shows that in men receiving HAART, their age, PSA levels, clinical presentation, management, and outcome from treated prostate carcinoma does not appear to be significantly altered by HIV status. Therefore, we recommend that patients with prostate cancer and well-controlled HIV viraemia be managed similarly to their HIV-negative counterparts.

The management of chronic prostatitis in men with HIV

Prostatitis is a common urologic diagnosis. Although treatment algorithms are available for this poorly understood entity, several adaptations must be made in order to accommodate the therapeutic needs of HIV-positive patients. The most important consideration when treating HIV-infected patients for prostatitis is their current immune status, whether they are immunocompromised or not (non-progressive disease or reconstituted with highly active antiretroviral therapy). A treatment algorithm for those with chronic bacterial prostatitis (Category II), chronic nonbacterial prostatitis (Category IIIA), and prostatodynia (Category IIIB) is presented in this article. In the HIV-positive patient population, there is a greater likelihood for atypical pathogens including fungi, tuberculosis, anaerobes, and viruses. Because the HIV-infected patient is at increased risk for the development of prostatic abscess and urosepsis than the general population, increased monitoring and evaluation and longer-term appropriately directed antimicrobial therapy are required.

Approach to management of clinically localized prostate cancer in patients with human immunodeficiency virus

OBJECTIVES

To evaluate the approach to management of localized prostate cancer (PCa) in patients with human immunodeficiency virus (HIV) in the highly active antiretroviral therapy era.

METHODS

A retrospective analysis was performed on 10 HIV-positive patients who recently presented with elevated prostate-specific antigen levels and clinically localized PCa.

RESULTS

At the diagnosis of PCa, the average patient was 54.0 years old, had been HIV positive for 8.75 years, had a CD4 count of 417, a prostate-specific antigen level of 9.2 ng/mL, and a Gleason score of 6. Eight of the patients had risk factors for PCa--either African-American descent (n = 6) or a positive family history (n = 2). The treatment was laparoscopic radical prostatectomy in 1, potency-preserving androgen deprivation in 1, cryosurgery in 1, brachytherapy in 2, observation in 2, and external beam radiotherapy in 3.

CONCLUSIONS

Screening of all HIV-positive men should be initiated at age 40 if they have either a positive family history of prostate cancer or are of African-American descent. Asymptomatic HIV-positive patients should be offered all therapeutic PCa treatment options.

The urological management of the patient with acquired immunodeficiency syndrome

In people infected with the human immunodeficiency virus (HIV) both the CD4 T-cell count and the viral load are used to monitor disease progression to acquired immunodeficiency syndrome (AIDS). CD4 counts of <500/mm(3) are associated with opportunistic infections and certain malignancies, so-called 'AIDS-defining' conditions. Highly active antiretroviral therapy, using combinations of reverse transcriptase inhibitors and/or protease inhibitors, can improve considerably the prognosis of people who are HIV-positive, but such therapy is not yet widely available in many developing countries. People with AIDS are predisposed to urinary tract infection (UTI) by uncommon bacteria and pathogens, e.g. fungi, parasites and viruses, which may affect any urogenital organ; treatment should be culture-specific and long-term, because there is a tendency to recurrence, infection with multiple organisms and resistant isolates. Voiding dysfunction in patients with AIDS is usually a result of neurological complications caused by opportunistic infections, and has a poor prognosis. Of patients with AIDS, 30-50% develop a cancer, especially Kaposi's sarcoma (KS) and non-Hodgkin's lymphoma (NHL). KS may involve any urogenital organ, but is usually part of systemic disease. Small lesions on the external genitalia can be treated with laser, cryotherapy or surgical excision, larger lesions with radiotherapy, and disseminated or visceral KS with multidrug chemotherapy. NHL may involve the kidneys, testes and retroperitoneal lymph nodes, thus obstructing the ureters, which may require ureteric stenting or percutaneous nephrostomy. NHL can be treated with radiotherapy and combination chemotherapy. Urolithiasis in patients with AIDS may be caused by indinavir, a protease inhibitor, but the more common types of stones may also occur. Fluid-electrolyte and acid-base disturbances are common in patients with advanced AIDS, secondary to vomiting, diarrhoea, malnutrition or septicaemia. HIV-associated nephropathy occurs in 10-30% of patients, and often leads to renal failure. Testicular atrophy is common, leading to infertility, erectile dysfunction (ED) and decreased libido. Treatment for ED must include counselling about strategies to reduce the transmission of HIV. The risk of HIV transmission after parenteral exposure to blood from an HIV-positive patient is relatively low (0.2-0.4%); the urologist can reduce the risk of transmission during surgery by adopting certain precautions. After occupational exposure to HIV, chemoprophylaxis with antiretroviral medication can significantly reduce the probability of HIV transmission.

Epididymocutaneous fistula in a patient with the acquired immunodeficiency syndrome and Marfan's syndrome

Epididymocutaneous fistula is a rare entity. A recent case in a patient with the acquired immunodeficiency syndrome and Marfan's syndrome led to this review. The patient's immunocompromised status as well as his past medical history necessitated special considerations in the diagnosis and management of his epididymocutaneous fistula.