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Hoang-Xuan K, Deckert M, Ferreri AJM, Furtner J, Gallego Perez-Larraya J, Henriksson R, Hottinger AF, Kasenda B, Lefranc F, Lossos A, McBain C, Preusser M, Roth P, Rudà R, Schlegel U, Soffietti R, Soussain C, Taphoorn MJB, Touitou V, Weller M, Bromberg JEC. European Association of Neuro-Oncology (EANO) guidelines for treatment of primary central nervous system lymphoma (PCNSL). Neuro Oncol 2023; 25:37-53. [PMID: 35953526 PMCID: PMC9825335 DOI: 10.1093/neuonc/noac196] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Indexed: 01/12/2023] Open
Abstract
The management of primary central nervous system (PCNSL) is one of the most controversial topics in neuro-oncology because of the complexity of the disease and the limited number of controlled studies available. In 2021, given recent advances and the publication of practice-changing randomized trials, the European Association of Neuro-Oncology (EANO) created a multidisciplinary task force to update the previously published evidence-based guidelines for immunocompetent adult patients with PCNSL and added a section on immunosuppressed patients. The guideline provides consensus considerations and recommendations for the treatment of PCNSL, including intraocular manifestations and specific management of the elderly. The main changes from the previous guideline include strengthened evidence for the consolidation with ASCT in first-line treatment, prospectively assessed chemotherapy combinations for both young and elderly patients, clarification of the role of rituximab even though the data remain inconclusive, of the role of new agents, and the incorporation of immunosuppressed patients and primary ocular lymphoma. The guideline should aid the clinicians in everyday practice and decision making and serve as a basis for future research in the field.
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Affiliation(s)
- Khê Hoang-Xuan
- APHP, Department of Neurology, Groupe Hospitalier Pitié-Salpêtrière; Sorbonne Université; IHU; ICM. Paris, France
| | - Martina Deckert
- Institute of Neuropathology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | | | - Julia Furtner
- Department of Biomedical and Imaging Image-guided Therapy Medical University of Vienna, Vienna, Austria
| | - Jaime Gallego Perez-Larraya
- Health Research Institute of Navarra (IdiSNA), Program in Solid Tumors, Foundation for the Applied Medical Research, Department of Neurology, Clinica Universidad de Navarra, Pamplona, Navarra, Spain
| | - Roger Henriksson
- Department of Radiation Sciences, Oncology, University of Umeå, S-901 85 Umea, Sweden
| | - Andreas F Hottinger
- Department of Oncology and Clinical Neurosciences, CHUV University Hospital Lausanne and University of Lausanne, LausanneSwitzerland
| | - Benjamin Kasenda
- Department of Hematology/Oncology and Palliative Care, Klinikum Stuttgart, Stuttgart, Germany
| | - Florence Lefranc
- Department of Neurosurgery, Hôpital Erasme, Université Libre de Bruxelles, Belgium
| | - Alexander Lossos
- Head, Leslie and Michael Gaffin Center for Neuro-Oncology; Department of Oncology and Neurology; Hadassah-Hebrew University Medical Center; Jerusalem, Israel
| | - Catherine McBain
- Department of Clinical Oncology, The Christie NHS FT; Manchester; United Kingdom
| | - Matthias Preusser
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna,Austria
| | - Patrick Roth
- Department of Neurology & Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Roberta Rudà
- Department of Neurology, Castelfranco Veneto/Treviso Hospital, Italy
- Division of Neuro-Oncology, Department of Neuroscience, University of Turin, and City of Health and Science University Hospital, Turin, Italy
| | - Uwe Schlegel
- Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Germany
| | - Riccardo Soffietti
- Division of Neuro-Oncology, Department of Neuroscience, University of Turin, and City of Health and Science University Hospital, Turin, Italy
| | - Carole Soussain
- Department of Hematology, Institut Curie, Site Saint-Cloud, France and INSERM U932 Institut Curie, PSL Research University, Paris, France
| | - Martin J B Taphoorn
- Department of Neurology, Leiden University Medical Center and Department of Neurology, Haaglanden Medical Center The Hague, The Netherlands
| | - Valérie Touitou
- APHP, Department of Ophtalmology, Groupe Hospitalier Pitié-Salpêtrière; Sorbonne Université. Paris, France
| | - Michael Weller
- Department of Neurology & Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Jacoline E C Bromberg
- Department of Neuro-Oncology, Erasmus MC University Medical Center Cancer Institute, Rotterdam. The Netherlands
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Neurosurgical Mimics. Neurol Clin 2022; 40:455-469. [DOI: 10.1016/j.ncl.2021.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Gijs PJ, Clerc O. Long-term remission of AIDS-related primary central nervous system lymphoma in a patient under antiretroviral therapy: a case report and review of the literature. AIDS Res Ther 2021; 18:76. [PMID: 34666791 PMCID: PMC8527804 DOI: 10.1186/s12981-021-00403-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 10/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AIDS-related primary central nervous system lymphoma (AR-PCNSL) is an AIDS-defining disease that usually occurs when the CD4 count is less than 50 cells/μl. The frequency of the disease has substantially decreased in the era of highly active antiretroviral therapy (HAART). Prognosis is poor with rapid progression leading to death within 2-3 months if left untreated. CASE DESCRIPTION A 65 years old male presented to medical attention with gait disturbance, weight loss and slight left-sided hemiparesis. Human immunodeficiency virus infection was diagnosed with an initial CD4 count of 116 cells/µl and a viral load of 260,000 copies/ml. Magnetic resonance imaging of the brain revealed three brain lesions involving the right frontal lobe and the left parietal lobe, which on biopsy led to a diagnosis of AR-PCNSL. HAART was initiated with whole-brain radiotherapy (WBRT), and the patient declined systemic chemotherapy. Due to poor performance status, he was transferred to palliative care. Under HAART, he slowly recovered with normalization of CD4 count and undetectable viral load. Medical imaging showed complete remission (CR) of the brain lesions. At 3-year follow-up, the patient remains in CR, but presented mild neurocognitive dysfunction possibly secondary to WBRT. CONCLUSION Nowadays, treatment paradigm parallels that of primary central nervous system lymphoma in the immunocompetent population based on systemic chemotherapy (primarily high-dose intravenous methotrexate and steroids) in association with HAART. The role of WBRT is questionable because of late neurotoxic effects.
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Affiliation(s)
- Pieter-Jan Gijs
- Service de Médecine Interne, Université de Lausanne et Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Olivier Clerc
- Service des Maladies Infectieuses, Réseau Hospitalier Neuchâtelois, Neuchâtel, Switzerland.
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Abstract
Purpose: To describe the epidemiology, clinical characteristics, diagnosis and treatment of human immunodeficiency virus (HIV)-related primary vitreoretinal lymphoma (PVRL).Methods: Narrative literature review.Results: HIV-related PVRL occurs in persons who are relatively young and generally have very low CD4+ T-cell counts. Vitritis with subretinal or sub-retinal pigment epithelial infiltrates is typical. Vitreous cytology remains the gold standard for diagnosis, supplemented by flow cytometry and genetic analyses of tumor cells, and measurement of aqueous or vitreous interleukin-10 levels. Concurrent brain involvement also may establish the diagnosis. Treatment includes antiretroviral therapy (ART), systemic chemotherapy (usually methotrexate-based) and local ocular treatment (intravitreal methotrexate, intravitreal rituximab, external beam radiotherapy). Systemic chemotherapy is of uncertain value for PVRL without other central nervous system involvement. Prognosis is poor, but has improved significantly compared to the pre-ART era.Conclusions: Ophthalmologists should consider the diagnosis of PVRL in HIV-positive individuals who present with intermediate or posterior uveitis.
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Affiliation(s)
- Jonel Steffen
- Division of Ophthalmology, University of Cape Town, Cape Town, South Africa
| | - Sarah E Coupland
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Liverpool Clinical Laboratories, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Justine R Smith
- Eye and Vision Health, Flinders University, Adelaide, Australia
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Shmakova A, Germini D, Vassetzky Y. HIV-1, HAART and cancer: A complex relationship. Int J Cancer 2020; 146:2666-2679. [PMID: 31603989 DOI: 10.1002/ijc.32730] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 09/30/2019] [Accepted: 10/02/2019] [Indexed: 12/14/2022]
Abstract
HIV infected people are at higher risk of developing cancer, although it is globally diminished in the era of highly active antiretroviral treatment (HAART). Recently, antioncogenic properties of some HAART drugs were discovered. We discuss the role of HAART in the prevention and improvement of treatment outcomes of cancers in HIV-infected people. We describe different trends in HAART-cancer relationships: cancer-predisposing as well as cancer-preventing. We cover the roles of particular drug regimens in cancer prevention. We also describe the causes of cancer treatment with HAART drugs in HIV-negative people, including ongoing clinical studies that may directly point to a possible independent anti-oncogenic activity of HAART drugs. We conclude that despite potent antioncogenic activities of every class of HAART drugs reported in preclinical models, the evidence to date indicates that their independent clinical impact in HIV-infected people is limited. Improved cancer prevention strategies besides HAART are needed to reduce HIV-cancer-related mortality.
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Affiliation(s)
- Anna Shmakova
- UMR 8126, CNRS, Univ. Paris-Sud, Institut Gustave Roussy, Université Paris Saclay, Édouard-Vaillant, Villejuif, France
- LIA 1066 LFR2O French-Russian Joint Cancer Research Laboratory, Édouard-Vaillant, Villejuif, France
- Laboratory of Gene and Cell Technologies, Faculty of Medicine, Lomonosov Moscow State University, Moscow, Russia
| | - Diego Germini
- UMR 8126, CNRS, Univ. Paris-Sud, Institut Gustave Roussy, Université Paris Saclay, Édouard-Vaillant, Villejuif, France
- LIA 1066 LFR2O French-Russian Joint Cancer Research Laboratory, Édouard-Vaillant, Villejuif, France
| | - Yegor Vassetzky
- UMR 8126, CNRS, Univ. Paris-Sud, Institut Gustave Roussy, Université Paris Saclay, Édouard-Vaillant, Villejuif, France
- LIA 1066 LFR2O French-Russian Joint Cancer Research Laboratory, Édouard-Vaillant, Villejuif, France
- Koltzov Institute of Developmental Biology, Moscow, Russia
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Chen Z, Wang N, Huang Y, Wang M. Clinical characteristics and cerebro-spinal fluid cytokine changes in patients with acquired immunodeficiency syndrome and central nervous system infection. Exp Ther Med 2019; 18:523-530. [PMID: 31258689 PMCID: PMC6566035 DOI: 10.3892/etm.2019.7587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 05/02/2019] [Indexed: 11/06/2022] Open
Abstract
Clinical characteristics and the cerebro-spinal fluid (CSF) cytokine changes in acquired immunodeficiency syndrome (AIDS) patients with tuberculous meningitis and cryptococcal meningitis in central nervous system (CNS) infections before and after treatment were investigated. The clinical records of 80 AIDS patients with CNS infections and 40 non-CNS infection patients hospitalized in the Infection Department of the First Hospital of Changsha from February 2013 to March 2016 were retrospectively analyzed. Forty-one cases of AIDS complicated with tuberculous meningitis were enrolled as group A, 39 cases of AIDS complicated with cryptococcal meningitis as group B, and 40 cases of non-CNS infection with lumbar puncture indication as group C. The general data, clinical symptoms, CSF examination and prognosis of the three groups of patients were collected. Of the 80 patients, 56 patients were discharged from hospital (improvement group) and 24 died (death group) after treatment. The concentrations of interferon-γ (IFN-γ), interleukin-6 (IL-6), interleukin-10 (IL-10) and tumor necrosis factor-α (TNF-α) in CSF were detected by enzyme-linked immunosorbent assay. There were significant differences in clinical manifestations, CSF pressure, CSF leucocyte count, CSF glucose, CSF chloride and CSF protein between group A, group B and group C (P<0.05). The concentrations of IFN-γ, IL-6, IL-10 and TNF-α in CSF of group A and group B increased significantly compared with group C (P<0.001). The IL-6, IL-10 and TNF-α levels in CSF in the improvement group were significantly lower than those in the death group (P<0.001), while the concentration of IFN-γ increased significantly (P<0.001). CSF biochemistry is characterized by increased pressure, leucocyte count and protein, and decreased chloride and glucose. IFN-γ, IL-6, IL-10 and TNF-α in CSF have certain predictive value for poor prognosis of AIDS patients with CNS infection.
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Affiliation(s)
- Zhong Chen
- Department of Acquired Immunodeficiency Syndrome, The First Hospital of Changsha, Changsha, Hunan 410005, P.R. China
| | - Ning Wang
- Department of Acquired Immunodeficiency Syndrome, The First Hospital of Changsha, Changsha, Hunan 410005, P.R. China
| | - Yaxiong Huang
- Department of Acquired Immunodeficiency Syndrome, The First Hospital of Changsha, Changsha, Hunan 410005, P.R. China
| | - Min Wang
- Department of Acquired Immunodeficiency Syndrome, The First Hospital of Changsha, Changsha, Hunan 410005, P.R. China
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Abstract
The epidemiology of spinal cord disease in human immunodeficiency virus (HIV) infection is largely unknown due to a paucity of data since combination antiretroviral therapy (cART). HIV mediates spinal cord injury indirectly, by immune modulation, degeneration, or associated infections and neoplasms. The pathologies vary and range from cytotoxic necrosis to demyelination and vasculitis. Control of HIV determines the differential for all neurologic presentations in infected individuals. Primary HIV-associated acute transverse myelitis, an acute inflammatory condition with pathologic similarities to HIV encephalitis, arises in early infection and at seroconversion. In contrast, HIV vacuolar myelopathy and opportunistic infections predominate in uncontrolled disease. There is systemic immune dysregulation as early as primary infection due to initial depletion of gut-associated lymphoid tissue CD4 cells and allowance of microbial translocation across the gut that never fully recovers throughout the course of HIV infection, regardless of how well controlled. The subsequent proinflammatory state may contribute to spinal cord diseases observed even after cART initiation. This chapter will highlight an array of spinal cord pathologies classified by stage of HIV infection and immune status.
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Affiliation(s)
- Seth N Levin
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States; Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Jennifer L Lyons
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
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Miralles P, Navarro JT, Berenguer J, Gómez Codina J, Kwon M, Serrano D, Díez-Martín JL, Villà S, Rubio R, Menárguez J, Ribera Santasusana JM. GESIDA/PETHEMA recommendations on the diagnosis and treatment of lymphomas in patients infected by the human immunodeficiency virus. Med Clin (Barc) 2018; 151:39.e1-39.e17. [PMID: 29357988 DOI: 10.1016/j.medcli.2017.11.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 10/21/2017] [Accepted: 11/02/2017] [Indexed: 01/20/2023]
Abstract
The incidence of non-Hodgkin's lymphoma and Hodgkin's lymphoma is higher in patients with HIV infection than in the general population. Following the introduction of combination antiretroviral therapy (cART), the prognostic significance of HIV-related variables has decreased, and lymphoma-related factors have become more pronounced. Currently, treatments for lymphomas in HIV-infected patients do not differ from those used in the general population. However, differentiating characteristics of seropositive patients, such as the need for cART and specific prophylaxis and treatment of certain opportunistic infections, should be considered. This document updates recommendations on the diagnosis and treatment of lymphomas in HIV infected patients published by GESIDA/PETHEMA in 2008.
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Affiliation(s)
- Pilar Miralles
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, España.
| | - José Tomás Navarro
- Institut Català d'Oncologia, Hospital Universitari Germans Trias i Pujol, Institut de Recerca Josep Carreras, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
| | - Juan Berenguer
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, España
| | | | - Mi Kwon
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, España
| | - David Serrano
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, España
| | - José Luis Díez-Martín
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, España
| | - Salvador Villà
- Institut Català d'Oncologia, Hospital Universitari Germans Trias i Pujol, Institut de Recerca Josep Carreras, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
| | | | - Javier Menárguez
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, España
| | - José-María Ribera Santasusana
- Institut Català d'Oncologia, Hospital Universitari Germans Trias i Pujol, Institut de Recerca Josep Carreras, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
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Abstract
Primary CNS lymphoma (PCNSL) has been designated an acquired immune deficiency syndrome (AIDS)-defining disease since 1983 and accounts for up to 15% of non-Hodgkin lymphomas in human immunodeficiency virus (HIV) patients. The majority of HIV patients are Epstein-Barr virus (EBV)-related. The most likely etiology is ineffective immunoregulation of EBV, inducing oncogenic protein expression, and subsequent loss of apoptosis and increased proliferation of lymphocytes. PCNSL generally presents with supratentorial, single or multiple, contrast-enhancing lesions. Neurologic symptoms can be headache, cognitive function disorders, focal neurologic, deficit and epilepsy. Differential diagnosis includes other oncologic or infectious causes, with cerebral toxoplasmosis being the most important. Magnetic resonance imaging characteristics, activity on 201thallium single-photon emission computed tomography, presence of EBV DNA in the cerebrospinal fluid, and toxoplasmosis serology can make either PCNSL or cerebral toxoplasmosis more or less likely. However, definitive diagnosis of PCNSL relies on histopathologic confirmation. First-choice treatment is combination antiretroviral therapy in combination with high-dose methotrexate(-based) chemotherapy in patients in whom this is feasible. Combination antiretroviral therapy combined with whole-brain radiotherapy may be an alternative. Treatment of EBV with antiviral agents such as ganciclovir or zidovudine may be beneficial, but this needs further study. Prognosis of HIV-related PCNSL is poor, with median survival varying from 2 to 4 months, but patients treated with chemotherapy do better (median survival 1.5 years).
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Affiliation(s)
- Dieta Brandsma
- Department of Neuro-Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Jacoline E C Bromberg
- Department of Neuro-Oncology, Erasmus MC University Medical Center Cancer Center Daniel den Hoed, Rotterdam, The Netherlands.
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Moulignier A, Lamirel C, Picard H, Lebrette MG, Amiel C, Hamidi M, Polivka M, Mikol J, Cochereau I, Pialoux G. Long-term AIDS-related PCNSL outcomes with HD-MTX and combined antiretroviral therapy. Neurology 2017; 89:796-804. [PMID: 28747447 DOI: 10.1212/wnl.0000000000004265] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 05/30/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess the characteristics and outcomes of patients with AIDS-related primary CNS lymphoma (AR-PCNSL) in the combined antiretroviral therapy (cART) era systematically treated with high-dose methotrexate (HD-MTX). METHODS We retrospectively analyzed (intention-to-treat analysis) 51 consecutive patients with AR-PCNSL (median age 39 years) who were diagnosed from 1996 to 2014 and treated with a median of 6 (range 1-15) infusions of HD-MTX (3 g/m2) combined with cART. RESULTS Median all-patients' and survivors' follow-up lasted 23 (range 0-186) and 76 (range 23-186) months, respectively. At PCNSL diagnosis, 83% of the patients were on cART, median plasma HIV load was 175,600 copies/mL, and median CD4+ T-cell count was 24/μL. Median Eastern Cooperative Oncology Group performance status was 2 (range 1-4). Median overall survival (OS) was 5.7 years, with 5- and 10-year rates of 48% and 41%. Median time to progression was not reached (69% at 10 months). PCNSL was the direct cause of 14 deaths, all observed within the 10 months after its diagnosis: 6 patients died before HD-MTX could be administered, 4 had refractory disease, and 4 relapsed. Multivariate analyses retained time interval between AIDS diagnosis and PCNSL diagnosis, age at AR-PCNSL diagnosis, and deep brain structure involvement as independent OS-predictive factors. To restore effective immune function, cART tailored to HIV genotypes was started and combined with HD-MTX; no interactions and no immune reconstitution inflammatory syndrome occurred. No patient died of acute treatment-related toxicity, and 21 of 51 (41%) patients experienced grade 3/4 toxicity. CONCLUSIONS Combined short-term HD-MTX monochemotherapy and optimal cART simply and effectively treat AR-PCNSL, achieving long-term survival with few relapses. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that short-term HD-MTX monochemotherapy improves long-term survival of patients with AIDS with primary CNS lymphoma receiving cARTs.
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Affiliation(s)
- Antoine Moulignier
- From the Department of Neurology (A.M.), Department of Ophthalmology (C.L., I.C.), and Clinical Research Unit (H.P.), Fondation Adolphe de Rothschild, Paris; Department of Infectious and Tropical Diseases (A.M., M.-G.L., M.H., G.P.) and Department of Virology (C.A.), Assistance Publique-Hôpitaux de Paris, Hôpital Tenon-Université Paris 6; and Department of Pathology (M.P., J.M.), Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière-Université Paris 7, France.
| | - Cédric Lamirel
- From the Department of Neurology (A.M.), Department of Ophthalmology (C.L., I.C.), and Clinical Research Unit (H.P.), Fondation Adolphe de Rothschild, Paris; Department of Infectious and Tropical Diseases (A.M., M.-G.L., M.H., G.P.) and Department of Virology (C.A.), Assistance Publique-Hôpitaux de Paris, Hôpital Tenon-Université Paris 6; and Department of Pathology (M.P., J.M.), Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière-Université Paris 7, France
| | - Hervé Picard
- From the Department of Neurology (A.M.), Department of Ophthalmology (C.L., I.C.), and Clinical Research Unit (H.P.), Fondation Adolphe de Rothschild, Paris; Department of Infectious and Tropical Diseases (A.M., M.-G.L., M.H., G.P.) and Department of Virology (C.A.), Assistance Publique-Hôpitaux de Paris, Hôpital Tenon-Université Paris 6; and Department of Pathology (M.P., J.M.), Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière-Université Paris 7, France
| | - Marie-Gisèle Lebrette
- From the Department of Neurology (A.M.), Department of Ophthalmology (C.L., I.C.), and Clinical Research Unit (H.P.), Fondation Adolphe de Rothschild, Paris; Department of Infectious and Tropical Diseases (A.M., M.-G.L., M.H., G.P.) and Department of Virology (C.A.), Assistance Publique-Hôpitaux de Paris, Hôpital Tenon-Université Paris 6; and Department of Pathology (M.P., J.M.), Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière-Université Paris 7, France
| | - Corinne Amiel
- From the Department of Neurology (A.M.), Department of Ophthalmology (C.L., I.C.), and Clinical Research Unit (H.P.), Fondation Adolphe de Rothschild, Paris; Department of Infectious and Tropical Diseases (A.M., M.-G.L., M.H., G.P.) and Department of Virology (C.A.), Assistance Publique-Hôpitaux de Paris, Hôpital Tenon-Université Paris 6; and Department of Pathology (M.P., J.M.), Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière-Université Paris 7, France
| | - Mohammed Hamidi
- From the Department of Neurology (A.M.), Department of Ophthalmology (C.L., I.C.), and Clinical Research Unit (H.P.), Fondation Adolphe de Rothschild, Paris; Department of Infectious and Tropical Diseases (A.M., M.-G.L., M.H., G.P.) and Department of Virology (C.A.), Assistance Publique-Hôpitaux de Paris, Hôpital Tenon-Université Paris 6; and Department of Pathology (M.P., J.M.), Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière-Université Paris 7, France
| | - Marc Polivka
- From the Department of Neurology (A.M.), Department of Ophthalmology (C.L., I.C.), and Clinical Research Unit (H.P.), Fondation Adolphe de Rothschild, Paris; Department of Infectious and Tropical Diseases (A.M., M.-G.L., M.H., G.P.) and Department of Virology (C.A.), Assistance Publique-Hôpitaux de Paris, Hôpital Tenon-Université Paris 6; and Department of Pathology (M.P., J.M.), Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière-Université Paris 7, France
| | - Jacqueline Mikol
- From the Department of Neurology (A.M.), Department of Ophthalmology (C.L., I.C.), and Clinical Research Unit (H.P.), Fondation Adolphe de Rothschild, Paris; Department of Infectious and Tropical Diseases (A.M., M.-G.L., M.H., G.P.) and Department of Virology (C.A.), Assistance Publique-Hôpitaux de Paris, Hôpital Tenon-Université Paris 6; and Department of Pathology (M.P., J.M.), Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière-Université Paris 7, France
| | - Isabelle Cochereau
- From the Department of Neurology (A.M.), Department of Ophthalmology (C.L., I.C.), and Clinical Research Unit (H.P.), Fondation Adolphe de Rothschild, Paris; Department of Infectious and Tropical Diseases (A.M., M.-G.L., M.H., G.P.) and Department of Virology (C.A.), Assistance Publique-Hôpitaux de Paris, Hôpital Tenon-Université Paris 6; and Department of Pathology (M.P., J.M.), Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière-Université Paris 7, France
| | - Gilles Pialoux
- From the Department of Neurology (A.M.), Department of Ophthalmology (C.L., I.C.), and Clinical Research Unit (H.P.), Fondation Adolphe de Rothschild, Paris; Department of Infectious and Tropical Diseases (A.M., M.-G.L., M.H., G.P.) and Department of Virology (C.A.), Assistance Publique-Hôpitaux de Paris, Hôpital Tenon-Université Paris 6; and Department of Pathology (M.P., J.M.), Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière-Université Paris 7, France
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Hoffmann C. Neoplastic Disease. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00097-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Zhang J, Liu X, Fu K, Xu C, Gong R, Liu L, Guo T, Zhou H, Zhao X, Chen J, Zhang J. Diagnostic Value and Safety of Stereotactic Biopsy in Acquired Immune Deficiency Syndrome Patients with Intracranial Lesions: Systematic Review and Meta-Analysis. World Neurosurg 2016; 98:790-799.e13. [PMID: 27965075 DOI: 10.1016/j.wneu.2016.11.151] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 11/28/2016] [Accepted: 11/29/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the diagnostic value and safety of stereotactic biopsy in acquired immune deficiency syndrome (AIDS) patients with intracranial lesions via meta-analysis. METHODS Relevant cohort studies were identified through a literature search in PubMed, Embase, and Ovid from 1985 to October 1, 2016. Appropriate studies were identified per search criteria. Systematic review and meta-analysis were used to assess the diagnostic success rate, changed management rate, clinical improvement rate, mortality rate, morbidity rate, hemorrhage rate, hemorrhage in morbidity rate, and final histologic diagnosis results. Study-specific outcomes were combined per a random effects model. Outcomes were compared between the pre-highly active antiretroviral therapy (HAART) and post-HAART groups. Correlations between outcomes were assessed via meta-regression analysis. RESULTS A total of 19 cohort studies with 820 patients were included in this meta-analysis. The weighted proportions per the random effects model were 92.2% (95% confidence interval [CI; 89.3%-94.5%]) for diagnostic success rate, 5.1% (95% CI [2.5%-8.3%]) for morbidity, and 0.7% (95% CI [0%-1.9%]) for mortality. The most common procedure-related morbidity was hemorrhage at 3.3% (95% CI [1.1%-6.3%]). Hemorrhage in morbidity was 78.0% (95% CI [51.4%-97.4%]). Management changed and clinical improvement were 60.4% (95% CI [49.4%-71.0%]) and 34.0% (95% CI [22.2%-46.8%]), respectively. The 4 most common diagnoses were primary central nervous system lymphoma (27.8%; 95% CI [20.2%-36.1%]), progressive multifocal leukoencephalopathy (PML) (21.0%; 95% CI [14.3%-28.4%]), toxoplasma encephalitis (TE) (20.3%; 95% CI [14.3%-27.0%]), and human immunodeficiency virus (HIV) encephalitis (4.1%; 95% CI [1.4%-7.6%]). Multiple diagnoses rate was 1.2% (95% CI [0.0%-3.6%]). HIV encephalitis rate was significantly higher in the post-HAART group than the pre-HAART group (17.9% vs. 3.2%, respectively; P = 0.0024). CONCLUSIONS Stereotactic biopsy is a safe and effective way of diagnosing intracranial lesions in patients with AIDS. It is helpful for the differential diagnosis and for choosing a suitable therapy. The 4 most common intracranial lesions in patients with AIDS are lymphoma, PML, TE, and HIV encephalitis.
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Affiliation(s)
- Jibo Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xuemeng Liu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Kai Fu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Chengshi Xu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Rui Gong
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Li Liu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Tao Guo
- Department of General Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Hui Zhou
- Intensive Care Unit, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xinyu Zhao
- Department of Ophthalmology, Peking Union Medical College Hospital, Beijing, China
| | - Jincao Chen
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jie Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China.
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Gupta NK, Nolan A, Omuro A, Reid EG, Wang CC, Mannis G, Jaglal M, Chavez JC, Rubinstein PG, Griffin A, Abrams DI, Hwang J, Kaplan LD, Luce JA, Volberding P, Treseler PA, Rubenstein JL. Long-term survival in AIDS-related primary central nervous system lymphoma. Neuro Oncol 2016; 19:99-108. [PMID: 27576871 DOI: 10.1093/neuonc/now155] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The optimal therapeutic approach for patients with AIDS-related primary central nervous system lymphoma (AR-PCNSL) remains undefined. While its incidence declined substantially with combination antiretroviral therapy (cART), AR-PCNSL remains a highly aggressive neoplasm for which whole brain radiotherapy (WBRT) is considered a standard first-line intervention. METHODS To identify therapy-related factors associated with favorable survival, we first retrospectively analyzed outcomes of AR-PCNSL patients treated at San Francisco General Hospital, a public hospital with a long history of dedicated care for patients with HIV and AIDS-related malignancies. Results were validated in a retrospective, multicenter analysis that evaluated all newly diagnosed patients with AR-PCNSL treated with cART plus high-dose methotrexate (HD-MTX). RESULTS We provide evidence that CD4+ reconstitution with cART administered during HD-MTX correlates with long-term survival among patients with CD4 <100. This was confirmed in a multicenter analysis which demonstrated that integration of cART regimens with HD-MTX was generally well tolerated and resulted in longer progression-free survival than other treatments. No profound differences in immunophenotype were identified in an analysis of AR-PCNSL tumors that arose in the pre- versus post-cART eras. However, we detected evidence for a demographic shift, as the proportion of minority patients with AR-PCNSL increased since advent of cART. CONCLUSION Long-term disease-free survival can be achieved in AR-PCNSL, even among those with histories of opportunistic infections, limited access to health care, and medical non-adherence. Given this, as well as the long-term toxicities of WBRT, we recommend that integration of cART plus first-line HD-MTX be considered for all patients with AR-PCNSL.
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Affiliation(s)
- Neel K Gupta
- Division of Hematology/Oncology, University of California, San Francisco (N.K.G., C.W., G.M., D.I.A., L.D.K., J.A.L., P.V., J.L.R.); Department of Pathology, University of California, San Francisco (A.N., P.A.T.); Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY (A.O.); Division of Hematology/Oncology, University of California, San Diego (E.G.R.); Division of Hematology/Oncology, San Francisco General Hospital (C.W., D.I.A., J.A.L.); Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL (M.J., J.C.C.); Department of Medicine, Section of Hematology/Oncology, John H. Stroger Jr. Hospital of Cook County, Ruth M. Rothstein CORE Center, Developmental Center for AIDS Research, Chicago, IL (P.G.R.); Department of Internal Medicine, Rush University Medical Center, Chicago, IL (P.G.R.); UCSF Cancer Registry, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (A.G.); Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (D.I.A., J.H., L.D.K., J.A.L., P.V., P.A.T., J.L.R.); Biostatistics and Computational Biology Core, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (J.H.); Center for AIDS Research; UCSF Gladstone Institute of Virology and Immunology (P.V.)
| | - Amber Nolan
- Division of Hematology/Oncology, University of California, San Francisco (N.K.G., C.W., G.M., D.I.A., L.D.K., J.A.L., P.V., J.L.R.); Department of Pathology, University of California, San Francisco (A.N., P.A.T.); Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY (A.O.); Division of Hematology/Oncology, University of California, San Diego (E.G.R.); Division of Hematology/Oncology, San Francisco General Hospital (C.W., D.I.A., J.A.L.); Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL (M.J., J.C.C.); Department of Medicine, Section of Hematology/Oncology, John H. Stroger Jr. Hospital of Cook County, Ruth M. Rothstein CORE Center, Developmental Center for AIDS Research, Chicago, IL (P.G.R.); Department of Internal Medicine, Rush University Medical Center, Chicago, IL (P.G.R.); UCSF Cancer Registry, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (A.G.); Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (D.I.A., J.H., L.D.K., J.A.L., P.V., P.A.T., J.L.R.); Biostatistics and Computational Biology Core, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (J.H.); Center for AIDS Research; UCSF Gladstone Institute of Virology and Immunology (P.V.)
| | - Antonio Omuro
- Division of Hematology/Oncology, University of California, San Francisco (N.K.G., C.W., G.M., D.I.A., L.D.K., J.A.L., P.V., J.L.R.); Department of Pathology, University of California, San Francisco (A.N., P.A.T.); Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY (A.O.); Division of Hematology/Oncology, University of California, San Diego (E.G.R.); Division of Hematology/Oncology, San Francisco General Hospital (C.W., D.I.A., J.A.L.); Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL (M.J., J.C.C.); Department of Medicine, Section of Hematology/Oncology, John H. Stroger Jr. Hospital of Cook County, Ruth M. Rothstein CORE Center, Developmental Center for AIDS Research, Chicago, IL (P.G.R.); Department of Internal Medicine, Rush University Medical Center, Chicago, IL (P.G.R.); UCSF Cancer Registry, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (A.G.); Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (D.I.A., J.H., L.D.K., J.A.L., P.V., P.A.T., J.L.R.); Biostatistics and Computational Biology Core, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (J.H.); Center for AIDS Research; UCSF Gladstone Institute of Virology and Immunology (P.V.)
| | - Erin G Reid
- Division of Hematology/Oncology, University of California, San Francisco (N.K.G., C.W., G.M., D.I.A., L.D.K., J.A.L., P.V., J.L.R.); Department of Pathology, University of California, San Francisco (A.N., P.A.T.); Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY (A.O.); Division of Hematology/Oncology, University of California, San Diego (E.G.R.); Division of Hematology/Oncology, San Francisco General Hospital (C.W., D.I.A., J.A.L.); Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL (M.J., J.C.C.); Department of Medicine, Section of Hematology/Oncology, John H. Stroger Jr. Hospital of Cook County, Ruth M. Rothstein CORE Center, Developmental Center for AIDS Research, Chicago, IL (P.G.R.); Department of Internal Medicine, Rush University Medical Center, Chicago, IL (P.G.R.); UCSF Cancer Registry, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (A.G.); Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (D.I.A., J.H., L.D.K., J.A.L., P.V., P.A.T., J.L.R.); Biostatistics and Computational Biology Core, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (J.H.); Center for AIDS Research; UCSF Gladstone Institute of Virology and Immunology (P.V.)
| | - Chia-Ching Wang
- Division of Hematology/Oncology, University of California, San Francisco (N.K.G., C.W., G.M., D.I.A., L.D.K., J.A.L., P.V., J.L.R.); Department of Pathology, University of California, San Francisco (A.N., P.A.T.); Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY (A.O.); Division of Hematology/Oncology, University of California, San Diego (E.G.R.); Division of Hematology/Oncology, San Francisco General Hospital (C.W., D.I.A., J.A.L.); Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL (M.J., J.C.C.); Department of Medicine, Section of Hematology/Oncology, John H. Stroger Jr. Hospital of Cook County, Ruth M. Rothstein CORE Center, Developmental Center for AIDS Research, Chicago, IL (P.G.R.); Department of Internal Medicine, Rush University Medical Center, Chicago, IL (P.G.R.); UCSF Cancer Registry, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (A.G.); Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (D.I.A., J.H., L.D.K., J.A.L., P.V., P.A.T., J.L.R.); Biostatistics and Computational Biology Core, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (J.H.); Center for AIDS Research; UCSF Gladstone Institute of Virology and Immunology (P.V.)
| | - Gabriel Mannis
- Division of Hematology/Oncology, University of California, San Francisco (N.K.G., C.W., G.M., D.I.A., L.D.K., J.A.L., P.V., J.L.R.); Department of Pathology, University of California, San Francisco (A.N., P.A.T.); Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY (A.O.); Division of Hematology/Oncology, University of California, San Diego (E.G.R.); Division of Hematology/Oncology, San Francisco General Hospital (C.W., D.I.A., J.A.L.); Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL (M.J., J.C.C.); Department of Medicine, Section of Hematology/Oncology, John H. Stroger Jr. Hospital of Cook County, Ruth M. Rothstein CORE Center, Developmental Center for AIDS Research, Chicago, IL (P.G.R.); Department of Internal Medicine, Rush University Medical Center, Chicago, IL (P.G.R.); UCSF Cancer Registry, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (A.G.); Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (D.I.A., J.H., L.D.K., J.A.L., P.V., P.A.T., J.L.R.); Biostatistics and Computational Biology Core, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (J.H.); Center for AIDS Research; UCSF Gladstone Institute of Virology and Immunology (P.V.)
| | - Michael Jaglal
- Division of Hematology/Oncology, University of California, San Francisco (N.K.G., C.W., G.M., D.I.A., L.D.K., J.A.L., P.V., J.L.R.); Department of Pathology, University of California, San Francisco (A.N., P.A.T.); Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY (A.O.); Division of Hematology/Oncology, University of California, San Diego (E.G.R.); Division of Hematology/Oncology, San Francisco General Hospital (C.W., D.I.A., J.A.L.); Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL (M.J., J.C.C.); Department of Medicine, Section of Hematology/Oncology, John H. Stroger Jr. Hospital of Cook County, Ruth M. Rothstein CORE Center, Developmental Center for AIDS Research, Chicago, IL (P.G.R.); Department of Internal Medicine, Rush University Medical Center, Chicago, IL (P.G.R.); UCSF Cancer Registry, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (A.G.); Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (D.I.A., J.H., L.D.K., J.A.L., P.V., P.A.T., J.L.R.); Biostatistics and Computational Biology Core, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (J.H.); Center for AIDS Research; UCSF Gladstone Institute of Virology and Immunology (P.V.)
| | - Julio C Chavez
- Division of Hematology/Oncology, University of California, San Francisco (N.K.G., C.W., G.M., D.I.A., L.D.K., J.A.L., P.V., J.L.R.); Department of Pathology, University of California, San Francisco (A.N., P.A.T.); Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY (A.O.); Division of Hematology/Oncology, University of California, San Diego (E.G.R.); Division of Hematology/Oncology, San Francisco General Hospital (C.W., D.I.A., J.A.L.); Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL (M.J., J.C.C.); Department of Medicine, Section of Hematology/Oncology, John H. Stroger Jr. Hospital of Cook County, Ruth M. Rothstein CORE Center, Developmental Center for AIDS Research, Chicago, IL (P.G.R.); Department of Internal Medicine, Rush University Medical Center, Chicago, IL (P.G.R.); UCSF Cancer Registry, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (A.G.); Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (D.I.A., J.H., L.D.K., J.A.L., P.V., P.A.T., J.L.R.); Biostatistics and Computational Biology Core, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (J.H.); Center for AIDS Research; UCSF Gladstone Institute of Virology and Immunology (P.V.)
| | - Paul G Rubinstein
- Division of Hematology/Oncology, University of California, San Francisco (N.K.G., C.W., G.M., D.I.A., L.D.K., J.A.L., P.V., J.L.R.); Department of Pathology, University of California, San Francisco (A.N., P.A.T.); Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY (A.O.); Division of Hematology/Oncology, University of California, San Diego (E.G.R.); Division of Hematology/Oncology, San Francisco General Hospital (C.W., D.I.A., J.A.L.); Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL (M.J., J.C.C.); Department of Medicine, Section of Hematology/Oncology, John H. Stroger Jr. Hospital of Cook County, Ruth M. Rothstein CORE Center, Developmental Center for AIDS Research, Chicago, IL (P.G.R.); Department of Internal Medicine, Rush University Medical Center, Chicago, IL (P.G.R.); UCSF Cancer Registry, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (A.G.); Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (D.I.A., J.H., L.D.K., J.A.L., P.V., P.A.T., J.L.R.); Biostatistics and Computational Biology Core, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (J.H.); Center for AIDS Research; UCSF Gladstone Institute of Virology and Immunology (P.V.)
| | - Ann Griffin
- Division of Hematology/Oncology, University of California, San Francisco (N.K.G., C.W., G.M., D.I.A., L.D.K., J.A.L., P.V., J.L.R.); Department of Pathology, University of California, San Francisco (A.N., P.A.T.); Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY (A.O.); Division of Hematology/Oncology, University of California, San Diego (E.G.R.); Division of Hematology/Oncology, San Francisco General Hospital (C.W., D.I.A., J.A.L.); Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL (M.J., J.C.C.); Department of Medicine, Section of Hematology/Oncology, John H. Stroger Jr. Hospital of Cook County, Ruth M. Rothstein CORE Center, Developmental Center for AIDS Research, Chicago, IL (P.G.R.); Department of Internal Medicine, Rush University Medical Center, Chicago, IL (P.G.R.); UCSF Cancer Registry, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (A.G.); Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (D.I.A., J.H., L.D.K., J.A.L., P.V., P.A.T., J.L.R.); Biostatistics and Computational Biology Core, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (J.H.); Center for AIDS Research; UCSF Gladstone Institute of Virology and Immunology (P.V.)
| | - Donald I Abrams
- Division of Hematology/Oncology, University of California, San Francisco (N.K.G., C.W., G.M., D.I.A., L.D.K., J.A.L., P.V., J.L.R.); Department of Pathology, University of California, San Francisco (A.N., P.A.T.); Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY (A.O.); Division of Hematology/Oncology, University of California, San Diego (E.G.R.); Division of Hematology/Oncology, San Francisco General Hospital (C.W., D.I.A., J.A.L.); Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL (M.J., J.C.C.); Department of Medicine, Section of Hematology/Oncology, John H. Stroger Jr. Hospital of Cook County, Ruth M. Rothstein CORE Center, Developmental Center for AIDS Research, Chicago, IL (P.G.R.); Department of Internal Medicine, Rush University Medical Center, Chicago, IL (P.G.R.); UCSF Cancer Registry, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (A.G.); Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (D.I.A., J.H., L.D.K., J.A.L., P.V., P.A.T., J.L.R.); Biostatistics and Computational Biology Core, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (J.H.); Center for AIDS Research; UCSF Gladstone Institute of Virology and Immunology (P.V.)
| | - Jimmy Hwang
- Division of Hematology/Oncology, University of California, San Francisco (N.K.G., C.W., G.M., D.I.A., L.D.K., J.A.L., P.V., J.L.R.); Department of Pathology, University of California, San Francisco (A.N., P.A.T.); Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY (A.O.); Division of Hematology/Oncology, University of California, San Diego (E.G.R.); Division of Hematology/Oncology, San Francisco General Hospital (C.W., D.I.A., J.A.L.); Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL (M.J., J.C.C.); Department of Medicine, Section of Hematology/Oncology, John H. Stroger Jr. Hospital of Cook County, Ruth M. Rothstein CORE Center, Developmental Center for AIDS Research, Chicago, IL (P.G.R.); Department of Internal Medicine, Rush University Medical Center, Chicago, IL (P.G.R.); UCSF Cancer Registry, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (A.G.); Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (D.I.A., J.H., L.D.K., J.A.L., P.V., P.A.T., J.L.R.); Biostatistics and Computational Biology Core, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (J.H.); Center for AIDS Research; UCSF Gladstone Institute of Virology and Immunology (P.V.)
| | - Lawrence D Kaplan
- Division of Hematology/Oncology, University of California, San Francisco (N.K.G., C.W., G.M., D.I.A., L.D.K., J.A.L., P.V., J.L.R.); Department of Pathology, University of California, San Francisco (A.N., P.A.T.); Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY (A.O.); Division of Hematology/Oncology, University of California, San Diego (E.G.R.); Division of Hematology/Oncology, San Francisco General Hospital (C.W., D.I.A., J.A.L.); Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL (M.J., J.C.C.); Department of Medicine, Section of Hematology/Oncology, John H. Stroger Jr. Hospital of Cook County, Ruth M. Rothstein CORE Center, Developmental Center for AIDS Research, Chicago, IL (P.G.R.); Department of Internal Medicine, Rush University Medical Center, Chicago, IL (P.G.R.); UCSF Cancer Registry, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (A.G.); Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (D.I.A., J.H., L.D.K., J.A.L., P.V., P.A.T., J.L.R.); Biostatistics and Computational Biology Core, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (J.H.); Center for AIDS Research; UCSF Gladstone Institute of Virology and Immunology (P.V.)
| | - Judith A Luce
- Division of Hematology/Oncology, University of California, San Francisco (N.K.G., C.W., G.M., D.I.A., L.D.K., J.A.L., P.V., J.L.R.); Department of Pathology, University of California, San Francisco (A.N., P.A.T.); Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY (A.O.); Division of Hematology/Oncology, University of California, San Diego (E.G.R.); Division of Hematology/Oncology, San Francisco General Hospital (C.W., D.I.A., J.A.L.); Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL (M.J., J.C.C.); Department of Medicine, Section of Hematology/Oncology, John H. Stroger Jr. Hospital of Cook County, Ruth M. Rothstein CORE Center, Developmental Center for AIDS Research, Chicago, IL (P.G.R.); Department of Internal Medicine, Rush University Medical Center, Chicago, IL (P.G.R.); UCSF Cancer Registry, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (A.G.); Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (D.I.A., J.H., L.D.K., J.A.L., P.V., P.A.T., J.L.R.); Biostatistics and Computational Biology Core, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (J.H.); Center for AIDS Research; UCSF Gladstone Institute of Virology and Immunology (P.V.)
| | - Paul Volberding
- Division of Hematology/Oncology, University of California, San Francisco (N.K.G., C.W., G.M., D.I.A., L.D.K., J.A.L., P.V., J.L.R.); Department of Pathology, University of California, San Francisco (A.N., P.A.T.); Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY (A.O.); Division of Hematology/Oncology, University of California, San Diego (E.G.R.); Division of Hematology/Oncology, San Francisco General Hospital (C.W., D.I.A., J.A.L.); Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL (M.J., J.C.C.); Department of Medicine, Section of Hematology/Oncology, John H. Stroger Jr. Hospital of Cook County, Ruth M. Rothstein CORE Center, Developmental Center for AIDS Research, Chicago, IL (P.G.R.); Department of Internal Medicine, Rush University Medical Center, Chicago, IL (P.G.R.); UCSF Cancer Registry, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (A.G.); Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (D.I.A., J.H., L.D.K., J.A.L., P.V., P.A.T., J.L.R.); Biostatistics and Computational Biology Core, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (J.H.); Center for AIDS Research; UCSF Gladstone Institute of Virology and Immunology (P.V.)
| | - Patrick A Treseler
- Division of Hematology/Oncology, University of California, San Francisco (N.K.G., C.W., G.M., D.I.A., L.D.K., J.A.L., P.V., J.L.R.); Department of Pathology, University of California, San Francisco (A.N., P.A.T.); Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY (A.O.); Division of Hematology/Oncology, University of California, San Diego (E.G.R.); Division of Hematology/Oncology, San Francisco General Hospital (C.W., D.I.A., J.A.L.); Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL (M.J., J.C.C.); Department of Medicine, Section of Hematology/Oncology, John H. Stroger Jr. Hospital of Cook County, Ruth M. Rothstein CORE Center, Developmental Center for AIDS Research, Chicago, IL (P.G.R.); Department of Internal Medicine, Rush University Medical Center, Chicago, IL (P.G.R.); UCSF Cancer Registry, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (A.G.); Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (D.I.A., J.H., L.D.K., J.A.L., P.V., P.A.T., J.L.R.); Biostatistics and Computational Biology Core, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (J.H.); Center for AIDS Research; UCSF Gladstone Institute of Virology and Immunology (P.V.)
| | - James L Rubenstein
- Division of Hematology/Oncology, University of California, San Francisco (N.K.G., C.W., G.M., D.I.A., L.D.K., J.A.L., P.V., J.L.R.); Department of Pathology, University of California, San Francisco (A.N., P.A.T.); Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY (A.O.); Division of Hematology/Oncology, University of California, San Diego (E.G.R.); Division of Hematology/Oncology, San Francisco General Hospital (C.W., D.I.A., J.A.L.); Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL (M.J., J.C.C.); Department of Medicine, Section of Hematology/Oncology, John H. Stroger Jr. Hospital of Cook County, Ruth M. Rothstein CORE Center, Developmental Center for AIDS Research, Chicago, IL (P.G.R.); Department of Internal Medicine, Rush University Medical Center, Chicago, IL (P.G.R.); UCSF Cancer Registry, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (A.G.); Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (D.I.A., J.H., L.D.K., J.A.L., P.V., P.A.T., J.L.R.); Biostatistics and Computational Biology Core, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (J.H.); Center for AIDS Research; UCSF Gladstone Institute of Virology and Immunology (P.V.)
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14
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Lee AM, Bai HX, Zou Y, Qiu D, Zhou J, Martinez-Lage Alvarez M, Zhang P, Tao Y, Tang X, Xiao B, Yang L. Safety and diagnostic value of brain biopsy in HIV patients: a case series and meta-analysis of 1209 patients. J Neurol Neurosurg Psychiatry 2016; 87:722-33. [PMID: 26758989 DOI: 10.1136/jnnp-2015-312037] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Accepted: 12/02/2015] [Indexed: 12/23/2022]
Abstract
Early brain biopsy may be indicated in HIV patients with focal brain lesion. This study aimed to evaluate and compare the safety and diagnostic value of brain biopsy in HIV patients in the pre-highly active antiretroviral therapy (HAART) versus post-HAART era via meta-analysis. Appropriate studies were identified per search criteria. The local database was retrospectively reviewed to select a similar patient cohort. Patient demographics, brain biopsy technique, histopathology and patient outcomes were extracted from each study. Study-specific outcomes were combined per random-effects model. Outcomes were compared between the pre-HAART and post-HAART era. Correlations between outcomes and baseline characteristics were assessed via meta-regression analysis. The proportions of histopathological diagnosis were tabulated and compared between the pre- and post-HAART era. Survival analysis was performed for patients in the post-HAART era. A total of 26 studies (including the local database) with 1209 patients were included in this meta-analysis. The most common indications for brain biopsy were diagnosis unlikely to be toxoplasmosis (n=8, 42.1%), focal brain lesion (n=5, 26.3%) or both (n=3, 15.8%). The weighted proportions for diagnostic success were 92% (95% CI 90.0% to 93.8%), change in management 57.7% (45.9% to 69.1%) and clinical improvement 36.6% (26.3% to 47.5%). Morbidity and mortality were 5.7% (3.6% to 8.3%) and 0.9% (0.3% to 1.9%), respectively. Diagnostic success rate was significantly higher in the post-HAART than the pre-HAART era (97.5% vs 91.9%, p=0.047). The odds ratio (OR) for diagnostic success in patients with contrast-enhanced lesions was 2.54 ((1.25 to 5.15), p<0.01). The median survival for HIV patients who underwent biopsy in the post-HAART era was 225 days (90-2446). Brain biopsy in HIV patients is safe with high diagnostic yield. Early brain biopsy should be considered in patients without classic presentation of toxoplasmosis encephalitis.
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Affiliation(s)
- Ashley M Lee
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Harrison X Bai
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yingjie Zou
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Dongxu Qiu
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Jianhua Zhou
- Department of Pathology, The First Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | | | - Paul Zhang
- Department of Pathology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yongguang Tao
- Cancer Research Institute of Xiangya School of Medicine, Central South University, Changsha, Hunan, People's Republic of China
| | - Xiangqi Tang
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bo Xiao
- Department of Neurology, The First Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Li Yang
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
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15
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Evzelman MA, Snimschikova IA, Koroleva LY, Kamchatnov PR. [Neurological disorders associated with HIV-infection]. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:89-93. [PMID: 26171483 DOI: 10.17116/jnevro20151153189-93] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
HIV-infection is a common intractable disease which is often concomitant with nervous system lesions. We considered the main mechanisms of nervous tissue lesions in AIDS, in particular, those caused by opportunistic infections. The current data about the problem of neurological disorders in patients with HIV-infection, pathogenesis characteristics, HIV-infection complications, diagnosis and treatment strategy were analyzed. Neurologic complications of HIV-infection is a valid reason for a decision to start a highly active antiretroviral treatment.
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Affiliation(s)
| | | | | | - P R Kamchatnov
- Pirogov Russian National Research Medical University, Moscow
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16
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Kaur A, Thomas A. Diffuse Large B-Cell Lymphoma Presenting with Diabetes Insipidus: A Case Report. AACE Clin Case Rep 2015. [DOI: 10.4158/ep14295.cr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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17
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Rituximab plus liposomal doxorubicin in HIV-infected patients with KSHV-associated multicentric Castleman disease. Blood 2014; 124:3544-52. [PMID: 25331113 DOI: 10.1182/blood-2014-07-586800] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Kaposi sarcoma (KS) herpesvirus-associated multicentric Castleman disease (KSHV-MCD) is a lymphoproliferative disorder, most commonly seen in HIV-infected patients, that has a high mortality if untreated. Concurrent KS is common. Although rituximab has reported activity in KSHV-MCD, its use is often associated with KS progression. Within a natural history study of KSHV-MCD, we prospectively evaluated rituximab 375 mg/m(2) combined with liposomal doxorubicin 20 mg/m(2) (R-Dox) every 3 weeks in 17 patients. Patients received a median of 4 cycles (range 3-9). All received antiretroviral therapy, 11 received consolidation interferon-α, and 6 received consolidation high-dose zidovudine with valganciclovir. Using NCI KSHV-MCD response criteria, major clinical and biochemical responses were attained in 94% and 88% of patients, respectively. With a median 58 months' potential follow-up, 3-year event-free survival was 69% and 3-year overall survival was 81%. During R-Dox therapy, cutaneous KS developed in 1 patient, whereas 5 of 6 patients with it had clinical improvement. R-Dox was associated with significant improvement in anemia and hypoalbuminemia. KSHV viral load, KSHV viral interleukin-6, C-reactive protein, human interleukin-6, and serum immunoglobulin free light chains decreased with therapy. R-Dox is effective in symptomatic KSHV-MCD and may be useful in patients with concurrent KS. This trial was registered at www.clinicaltrials.gov as #NCT00092222.
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18
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Hentrich M, Hoffmann C, Mosthaf F, Müller M, Siehl J, Wyen C, Hensel M. Therapy of HIV-associated lymphoma—recommendations of the oncology working group of the German Study Group of Physicians in Private Practice Treating HIV-Infected Patients (DAGNÄ), in cooperation with the German AIDS Society (DAIG). Ann Hematol 2014; 93:913-21. [DOI: 10.1007/s00277-014-2058-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 03/15/2014] [Indexed: 11/24/2022]
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19
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Factors associated with survival among patients with AIDS-related primary central nervous system lymphoma. AIDS 2014; 28:397-405. [PMID: 24076659 DOI: 10.1097/qad.0000000000000030] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE AIDS-related primary central nervous system lymphoma (AR-PCNSL) has a poor prognosis. Improved understanding of specific patient, infectious, diagnostic, and treatment-related factors that affect overall survival (OS) is required to improve outcomes. DESIGN Population-based registry linkage study. METHODS Adult cases from the San Francisco AIDS registry (1990-2000) were matched with the California Cancer Registry (1985-2002) to ascertain AR-PCNSL data. Survival time was assessed through 31 December 2007. Risk factors and temporal trends for death were measured using two-sided Kaplan-Meier and Cox analyses. RESULTS Two hundred and seven AR-PCNSL patients were identified: 68% were white, 20% Hispanic, 10% African-American, and 2% Asian. Nineteen percent of patients had central nervous system (CNS) opportunistic infections diagnosed prior to AR-PCNSL. Fifty-seven percent of patients received radiation and/or chemotherapy and 12% used HAART prior to or within 30 days of AR-PCNSL diagnosis. One hundred and ninety-nine patients died (34 deaths/100 person-years). In adjusted analysis, prior CNS opportunistic infection diagnosis increased risk of death (hazard ratio 1.9, P = 0.0006) whereas radiation and/or chemotherapy decreased risk (hazard ratio 0.6, P < 0.0001). AR-PCNSL diagnosis 1999-2002 had a lower mortality risk (hazard ratio = 0.4, P = 0.02) compared to 1990-1995. African-Americans had an increased risk of death compared to whites or Asians (hazard ratio = 2.0, P = 0.007). CONCLUSION OS among AR-PCNSL patients improved over time but remains poor, especially among African-Americans. Prospective evaluation of curative therapy in AR-PCNSL is urgently needed. Accurate diagnosis of CNS mass lesions in patients with AIDS is required and for those with AR-PCNSL, antiretroviral therapy with concomitant AR-PCNSL therapy, and antimicrobial supportive care may improve OS.
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20
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Wolf T, Kiderlen T, Atta J, Stephan C, Kann G, Brodt HR, Brandts C. Successful treatment of AIDS-associated, primary CNS lymphoma with rituximab- and methotrexate-based chemotherapy and autologous stem cell transplantation. Infection 2014; 42:445-7. [PMID: 24442720 DOI: 10.1007/s15010-013-0579-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 12/23/2013] [Indexed: 11/29/2022]
Affiliation(s)
- T Wolf
- Department of Medicine II-Infectious Diseases, HIV Center, Hospital of the J. W. Goethe University, Theodor Stern Kai 7, 60596, Frankfurt, Germany,
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21
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Salvage therapy for refractory AIDS-related primary central nervous system lymphoma. Case Rep Oncol Med 2012; 2012:343491. [PMID: 23029628 PMCID: PMC3458413 DOI: 10.1155/2012/343491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2012] [Accepted: 08/26/2012] [Indexed: 11/23/2022] Open
Abstract
A 27-year-old male patient presented with speech disorders and multiple brain masses on MRI evaluation. He tested positive for HIV. A sterotactic biopsy diagnosed primary central nervous system lymphoma (diffuse large B-cell lymphoma). After two cycles of high-dose metotrexate (HD-MTX-)-based chemotherapy, the tumor progressed. He underwent whole brain radiotherapy achieving complete response. Six cycles of consolidating immunochemotherapy with rituximab-temozolomide were administered after radiation. Forty-three months after remission, he has not recurred and his neurological status is optimal. Younger HIV patients with refractory PCNSL and preserved immune function can face salvage therapy successfully achieving long term remissions with no remarkable neurotoxicity.
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Uldrick TS, Polizzotto MN, Yarchoan R. Recent advances in Kaposi sarcoma herpesvirus-associated multicentric Castleman disease. Curr Opin Oncol 2012; 24:495-505. [PMID: 22729151 PMCID: PMC6322210 DOI: 10.1097/cco.0b013e328355e0f3] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE OF REVIEW The discovery of Kaposi sarcoma herpesvirus (KSHV) led to recognition of KSHV-associated multicentric Castleman disease (MCD) as a distinct lymphoproliferative disorder. The pathogenesis of KSHV-MCD is attributed to proliferation of KSHV-infected B cells, production of KSHV-encoded viral interleukin 6 by these cells, and dysregulation of human interleukin 6 and interleukin 10. This article reviews advances in the field of disease pathogenesis and targeted therapies. RECENT FINDINGS Our understanding of the pathogenesis of KSHV-MCD has increased in recent years and improved therapies have been developed. Recent studies demonstrate that the anti-CD20 monoclonal antibody, rituximab, as well as virus-activated cytotoxic therapy using high-dose zidovudine and valganciclovir, can control symptoms and decrease adenopathy. With treatment, 1-year survival now exceeds 85%. Interestingly, even in the absence of pathologic findings of MCD, KSHV-infected patients may have inflammatory symptoms, excess cytokine production, and elevated KSHV viral load similar to KSHV-associated MCD. The term KSHV-associated inflammatory cytokine syndrome has been proposed to describe such patients. SUMMARY Recent advances in targeted therapy have improved outcomes in KSHV-MCD, and decreased need for cytotoxic chemotherapy. Improved understanding of the pathogenesis of KSHV-MCD and KSHV-associated inflammatory cytokine syndrome is needed, and will likely lead to additional advances in therapy for these disorders.
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Affiliation(s)
- Thomas S Uldrick
- HIV and AIDS Malignancy Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA.
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23
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Travi G, Ferreri AJ, Cinque P, Gerevini S, Ponzoni M, Terreni MR, Lazzarin A, Crippa F. Long-Term Remission of HIV-Associated Primary CNS Lymphoma Achieved With Highly Active Antiretroviral Therapy Alone. J Clin Oncol 2012; 30:e119-21. [DOI: 10.1200/jco.2011.39.9642] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | | | - Adriano Lazzarin
- San Raffaele Scientific Institute; and Università Vita-Salute San Raffaele, Milan, Italy
| | - Fulvio Crippa
- San Raffaele Scientific Institute; and Azienda Ospedaliera San Paolo Polo Universitario, Milan, Italy
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24
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Abstract
Over the past 10 years, significant progress has been made in understanding HIV-associated lymphomas and improving the prognosis of these diseases. With the advent of combination antiretroviral therapy and the development of novel therapeutic strategies, most patients with HIV-associated lymphomas are cured. The outcome for the majority of patients with HIV-associated diffuse large B-cell lymphoma and Burkitt lymphoma in particular, is excellent, with recent studies supporting the role of rituximab in these diseases. Indeed, in the combination antiretroviral therapy era, the curability of many patients with HIV-associated lymphoma is similar to their HIV-negative counterparts. New treatment frontiers need to focus on improving the outcome for patients with advanced immune suppression and for those with adverse tumor biology, such as the activated B-cell type of diffuse large B-cell lymphoma and the virally driven lymphomas. Future clinical trials need to investigate novel targeted agents alone and in combination with chemotherapy.
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25
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The management of primary central nervous system lymphoma related to AIDS in the HAART era. Curr Opin Oncol 2011; 23:648-53. [DOI: 10.1097/cco.0b013e32834b6adc] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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26
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Abstract
Primary CNS Lymphoma (PCNSL) accounts for 3% of all primary brain tumors with a median age at onset of about 62 years. In the vast majority of cases, PCNSL presents as unifocal or multifocal enhancing lesions on MRI, frequently adjacent to the ventricles. Stereotactic biopsy is the diagnostic procedure of choice revealing high-grade malignant non-Hodgkin's B-cell lymphoma in more than 90% of cases. Therapy is not evidence based. When eligible, patients should be included in clinical trials. In patients younger than 60 years cure is the aim. Polychemotherapy based on high-dose methotrexate (MTX) or alternatively high-dose chemotherapy with autologous stem cell rescue should be offered to patients eligible for this regimens. For patients over 60 years of age no curative regimen with acceptable toxicity has yet been established. An MTX-based chemotherapy, for example, in combination with temozolomide, is recommended. The role of radiotherapy as part of the initial treatment is not established; however, the combination of radiotherapy with MTX-based chemotherapy potentially leads to severe long-term neurotoxic sequelae. Therefore, radiotherapy as part of the initial therapy is not recommended by the author outside clinical trials. At relapse or in cases of refractory disease, patients will frequently benefit of salvage therapy, which depends on the initial treatment.
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Affiliation(s)
- Uwe Schlegel
- Knappschaftskrankenhaus, Bochum-Langendreer, Ruhr-University Bochum, Germany
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27
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Marretta L, Stocker H, Drauz D, Mueller M, Masuhr A, Dieckmann S, Wong V, Koch A, Grueneisen A, Arastéh K, Weiss R. Treatment of HIV-related primary central nervous system lymphoma with AZT high dose, HAART, interleukin-2 and foscarnet in three patients. Eur J Med Res 2011; 16:197-205. [PMID: 21719392 PMCID: PMC3352191 DOI: 10.1186/2047-783x-16-5-197] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Accepted: 01/12/2011] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Combined immunomodulatory and antiviral treatment was administered to three patients with newly diagnosed HIV-associated primary central nervous system lymphoma (PCNSL) in an attempt to improve outcomes. PATIENTS AND METHODS Three patients from our institution who were recently diagnosed with HIV-associated PCNSL received intravenous azidothymidine (AZT) 1.6 gr. bid for two weeks, followed by oral AZT 250mg bid from day 15. In addition, complementary highly active antiretroviral therapy (HAART) with a second nucleoside reverse transcriptase inhibitor (NRTI) plus one protease inhibitor (PI) and interleukin 2 (IL-2) subcutaneously 2 million units twice daily (bid) plus foscarnet 90mg/kg bid were administered on days 1-14. One patient received anti-Epstein-Barr virus (EBV)-maintenance therapy with ganciclovir, followed by cidofovir. RESULTS All patients experienced progressive disease while on induction therapy, and switched early to whole-brain radiation therapy (WBRT) as second line-treatment. No grade 3 or 4 toxicities were observed. Two patients died on days 50 and 166 respectively due to progressive disease. The third patient with histo?logically proven lymphoproliferation and only suspected PCNSL remained alive at 53 months. He was on HAART and remained clinically and neurologically stable. CONCLUSION Although IL-2, HAART, high-dose AZT and foscarnet are used for other HIV-related conditions, they did not demonstrate benefit in lymphoma remission for 2 HIV- associated PCNSL patients. The third patient went into delayed remission after additional radiotherapy and was in good clinical and neurological health status over 53 months after diagnosis.
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Affiliation(s)
- Lore Marretta
- DRK-Kliniken Köpenick, Berlin, II. Innere Abteilung, Hämato-Onkologie, Salvador-Allende-Allee 2-8, 12559 Berlin, Germany.
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28
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Thomaidis L, Bertou G, Critselis E, Spoulou V, Kafetzis DA, Theodoridou M. Cognitive and psychosocial development of HIV pediatric patients receiving highly active anti-retroviral therapy: a case-control study. BMC Pediatr 2010; 10:99. [PMID: 21184692 PMCID: PMC3022796 DOI: 10.1186/1471-2431-10-99] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Accepted: 12/27/2010] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The psychosocial development of pediatric HIV patients has not been extensively evaluated. The study objectives were to evaluate whether emotional and social functions are differentially associated with HIV-related complications. METHODS A matched case-control study design was conducted. The case group (n = 20) consisted of vertically infected children with HIV (aged 3-18 years) receiving HAART in Greece. Each case was matched with two randomly selected healthy controls from a school-based population. CNS imaging and clinical findings were used to identify patients with HIV-related neuroimaging abnormalities. The Wechsler Intelligence Scale III and Griffiths Mental Abilities Scales were applied to assess cognitive abilities. The age specific Strengths and Difficulties Questionnaire was used to evaluate emotional adjustment and social skills. The Fisher's exact test, student's t-test, and Wilcoxon rank sum test were used to compare categorical, continuous, and ordinal scores, respectively, of the above scales between groups. RESULTS HIV patients without neuroimaging abnormalities did not differ from patients with neuroimaging abnormalities with respect to either age at HAART initiation (p = 0.306) or months of HAART treatment (p = 0.964). While HIV patients without neuroimaging abnormalities had similar cognitive development with their healthy peers, patients with neuroimaging abnormalities had lower mean General (p = 0.027) and Practical (p = 0.042) Intelligence Quotient scores. HIV patients without neuroimaging abnormalities had an increased likelihood of both Abnormal Emotional Symptoms (p = 0.047) and Hyperactivity scores (p = 0.0009). In contrast, HIV patients with neuroimaging abnormalities had an increased likelihood of presenting with Abnormal Peer Problems (p = 0.033). CONCLUSIONS HIV patients without neuroimaging abnormalities are more likely to experience maladjustment with respect to their emotional and activity spheres, while HIV patients with neuroimaging abnormalities are more likely to present with compromised social skills. Due to the limited sample size and age distribution of the study population, further studies should investigate the psychosocial development of pediatric HIV patients following the disclosure of their condition.
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Affiliation(s)
- Loretta Thomaidis
- Developmental Assessment Unit, Second Department of Pediatrics, "P. & A. Kyriakou" Children's Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Georgia Bertou
- Developmental Assessment Unit, Second Department of Pediatrics, "P. & A. Kyriakou" Children's Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Elena Critselis
- Second Department of Pediatrics, "P. & A. Kyriakou" Children's Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Vassiliki Spoulou
- First Department of Pediatrics, "Aghia Sophia" Children's Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Dimitrios A Kafetzis
- Second Department of Pediatrics, "P. & A. Kyriakou" Children's Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Maria Theodoridou
- First Department of Pediatrics, "Aghia Sophia" Children's Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
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Abstract
There is no class I evidence for any therapeutic option in primary central nervous system lymphoma (PCNSL). When possible, patients should be included in clinical trials. The role of surgery is restricted to stereotactic biopsy in order to gain material for histopathologic diagnosis. Radiotherapy alone is associated with a median survival of no more than 1.5 years; cure is exceptional. However, in patients aged younger than 60 years, cure is the therapeutic aim. Polychemotherapy based on high-dose methotrexate with deferred radiation results in long-term survival in most of these patients and possibly cure in a substantial fraction of these patients. With regard to chemotherapy in PCNSL, the following must be considered: 1) the most efficient drug in PCNSL is methotrexate at a dosage of at least 1.5 g/m(2) per single dose; 2) methotrexate alone will lead to complete remission in only some patients, whereas the combination of methotrexate with other drugs is more efficient; and 3) the value of additional intraventricular chemotherapy and the necessity of "consolidation" radiotherapy after response to chemotherapy are not yet defined. For patients aged older than 60 years, no curative regimen with acceptable toxicity has yet been established. The combination of radiotherapy with methotrexate-based chemotherapy leads to severe long-term neurotoxic sequelae, ie, cognitive dysfunction, in most older patients and in some patients aged younger than 60 years.
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Affiliation(s)
- Hendrik Pels
- Department of Neurology, Ruhr-University Bochum, Knappschaftskrankenhaus, In der Schornau 23-25, D-44892 Bochum, Germany
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31
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Bayraktar S, Bayraktar UD, Ramos JC, Stefanovic A, Lossos IS. Primary CNS lymphoma in HIV positive and negative patients: comparison of clinical characteristics, outcome and prognostic factors. J Neurooncol 2010; 101:257-65. [DOI: 10.1007/s11060-010-0252-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Accepted: 05/20/2010] [Indexed: 10/19/2022]
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Nagai H, Odawara T, Ajisawa A, Hagiwara S, Watanabe T, Uehira T, Uchiumi H, Yotsumoto M, Miyakawa T, Watanabe A, Kambe T, Konishi M, Saito S, Takahama S, Tateyama M, Okada S. Whole brain radiation alone produces favourable outcomes for AIDS-related primary central nervous system lymphoma in the HAART era. Eur J Haematol 2010; 84:499-505. [DOI: 10.1111/j.1600-0609.2010.01424.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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33
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Current Management of Primary Central Nervous System Lymphoma. Int J Radiat Oncol Biol Phys 2010; 76:666-78. [DOI: 10.1016/j.ijrobp.2009.10.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Revised: 09/22/2009] [Accepted: 10/21/2009] [Indexed: 11/18/2022]
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Bibas M, Antinori A. EBV and HIV-Related Lymphoma. Mediterr J Hematol Infect Dis 2009; 1:e2009032. [PMID: 21416008 PMCID: PMC3033170 DOI: 10.4084/mjhid.2009.032] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2009] [Accepted: 12/27/2009] [Indexed: 11/18/2022] Open
Abstract
HIV-associated lymphoproliferative disorders represent a heterogeneous group of diseases, arising in the presence of HIV-associated immunodeficiency. The overall prevalence of HIV-associated lymphoma is significantly higher compared to that of the general population and it continues to be relevant even after the wide availability of highly active antiretroviral therapy (HAART) (1). Moreover, they still represent one of the most frequent cause of death in HIV-infected patients. Epstein-Barr virus (EBV), a γ-Herpesviruses, is involved in human lymphomagenesis, particularly in HIV immunocompromised patients. It has been largely implicated in the development of B-cell lymphoproliferative disorders as Burkitt lymphoma (BL), Hodgkin disease (HD), systemic non Hodgkin lymphoma (NHL), primary central nervous system lymphoma (PCNSL), nasopharyngeal carcinoma (NC). Virus-associated lymphomas are becoming of significant concern for the mortality of long-lived HIV immunocompromised patients, and therefore, research of advanced strategies for AIDS-related lymphomas is an important field in cancer chemotherapy. Detailed understanding of the EBV lifecycle and related cancers at the molecular level is required for novel strategies of molecular-targeted cancer chemotherapy The linkage of HIV-related lymphoma with EBV infection of the tumor clone has several pathogenetic, prognostic and possibly therapeutic implications which are reviewed herein.
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Affiliation(s)
- Michele Bibas
- Clinical Department, National Institute for Infectious Diseases “Lazzaro Spallanzani”, IRCCS, Rome, Italy
| | - Andrea Antinori
- Clinical Department, National Institute for Infectious Diseases “Lazzaro Spallanzani”, IRCCS, Rome, Italy
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Rothschild S, Dolder M, Seifert B, Lütolf UM, Ciernik IF. Radiation therapy for HIV-associated diffuse large cell non-Hodgkin lymphoma. ACTA ACUST UNITED AC 2009; 8:239-48. [PMID: 19589920 DOI: 10.1177/1545109709340439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To report the clinical experience with external beam radiotherapy (RT) for AIDS-related lymphoma (ARL) with or without the involvement of the central nervous system (CNS) in HIV-infected patients. PATIENTS AND METHODS Clinical outcome of 24 HIV-seropositive patients with ARL treated with RT from 1995 to 2004 was reviewed, testing factors associated with outcome. RESULTS After 1 and 5 years, the overall survival was 65% and 35%, respectively. The mean RT dose was 31 Gy after normalization to fractions of daily 2 Gy (range, 7.8-47.2 Gy). Radiotherapy dose was associated with survival in univariate (P = .04) and multivariate analysis (P = .01). Other factors in univariate analysis associated with outcome were viral load (VL), highly active antiretroviral therapy (HAART), ARL stage, and CNS involvement. Patients with CNS involvement achieved complete response in 46% and improved clinical performance was seen in 73%. CONCLUSIONS After chemotherapy, RT in combination with HAART is highly active, and RT should be encouraged especially after suboptimal responses to induction treatment.
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Affiliation(s)
- Sacha Rothschild
- Radiation Oncology, Zurich University Hospital, University of Zurich, Zurich, Switzerland.
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Dou H, Grotepas CB, McMillan JM, Destache CJ, Chaubal M, Werling J, Kipp J, Rabinow B, Gendelman HE. Macrophage delivery of nanoformulated antiretroviral drug to the brain in a murine model of neuroAIDS. THE JOURNAL OF IMMUNOLOGY 2009; 183:661-9. [PMID: 19535632 DOI: 10.4049/jimmunol.0900274] [Citation(s) in RCA: 176] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Antiretroviral therapy (ART) shows variable blood-brain barrier penetration. This may affect the development of neurological complications of HIV infection. In attempts to attenuate viral growth for the nervous system, cell-based nanoformulations were developed with the focus on improving drug pharmacokinetics. We reasoned that ART carriage could be facilitated within blood-borne macrophages traveling across the blood-brain barrier. To test this idea, an HIV-1 encephalitis (HIVE) rodent model was used where HIV-1-infected human monocyte-derived macrophages were stereotactically injected into the subcortex of severe combined immunodeficient mice. ART was prepared using indinavir (IDV) nanoparticles (NP, nanoART) loaded into murine bone marrow macrophages (BMM, IDV-NP-BMM) after ex vivo cultivation. IDV-NP-BMM was administered i.v. to mice resulting in continuous IDV release for 14 days. Rhodamine-labeled IDV-NP was readily observed in areas of HIVE and specifically in brain subregions with active astrogliosis, microgliosis, and neuronal loss. IDV-NP-BMM treatment led to robust IDV levels and reduced HIV-1 replication in HIVE brain regions. We conclude that nanoART targeting to diseased brain through macrophage carriage is possible and can be considered in developmental therapeutics for HIV-associated neurological disease.
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Affiliation(s)
- Huanyu Dou
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, 68198, USA
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Tran H, Nourse J, Hall S, Green M, Griffiths L, Gandhi MK. Immunodeficiency-associated lymphomas. Blood Rev 2008; 22:261-81. [DOI: 10.1016/j.blre.2008.03.009] [Citation(s) in RCA: 124] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Spano JP, Costagliola D, Katlama C, Mounier N, Oksenhendler E, Khayat D. AIDS-related malignancies: state of the art and therapeutic challenges. J Clin Oncol 2008; 26:4834-42. [PMID: 18591544 DOI: 10.1200/jco.2008.16.8252] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Despite the impact of combination antiretroviral therapy (cART) on HIV-related mortality, malignancy remains an important cause of death in the current era. Although the advent of cART has resulted in reductions in the incidence of Kaposi's sarcoma and non-Hodgkin's lymphoma, non-AIDS-defining malignancies present an increased risk for HIV-infected patients, characterized by some common clinical features, generally with a more aggressive behavior and a more advanced disease at diagnosis, which is responsible for poorer patient outcomes. Specific therapeutic recommendations are lacking for these new nonopportunistic malignancies, such as Hodgkin's lymphoma, anal cancer, lung cancer, hepatocarcinoma, and many others. Antiretroviral agents have a propensity for causing drug interactions as a result of their ability to either inhibit or induce the cytochrome P450 (CYP) enzyme system. Because many antineoplastic drugs are also metabolized by the CYP system, coadministration with cART could result in either drug accumulation with increased toxicity, or decreased efficacy of one or both classes of drugs. Further research delineating the combined safety and pharmacokinetics of antiretrovirals and antineoplastic therapy is necessary. Special considerations of these AIDS-related and non-AIDS-related malignancies and their clinical and therapeutic aspects constitute the subject of this review.
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Affiliation(s)
- Jean-Philippe Spano
- Pitié-Salpêtrière Hospital, Department of Medical Oncology, 47 Blvd de l'Hôpital, 75013 Paris, France.
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Miralles P, Berenguer J, Ribera Santasusana JM, Calvo F, Díaz Mediavilla J, Díez-Martín JL, Gomez Codina J, López Aldeguer J, Rubio R, Santos J, Valencia E. Recomendaciones de GESIDA/PETHEMA sobre el diagnóstico y el tratamiento de los linfomas en pacientes infectados por el virus de la inmunodeficiencia humana. Med Clin (Barc) 2008; 130:300-11. [PMID: 18358123 DOI: 10.1157/13116574] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Pilar Miralles
- Servicio de Enfermedades Infecciosas/VIH, Hospital General Gregorio Marañón, Madrid, España.
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Angeletti PC, Zhang L, Wood C. The viral etiology of AIDS-associated malignancies. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2008; 56:509-57. [PMID: 18086422 DOI: 10.1016/s1054-3589(07)56016-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Peter C Angeletti
- Nebraska Center for Virology, School of Biological Sciences, University of Nebraska-Lincoln, Lincoln, Nebraska 68588, USA
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Aboulafia DM, Puswella AL. Highly active antiretroviral therapy as the sole treatment for AIDS-related primary central nervous system lymphoma: a case report with implications for treatment. AIDS Patient Care STDS 2007; 21:900-7. [PMID: 18154487 DOI: 10.1089/apc.2007.0009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A 40-year-old male presented to medical attention with Pneumocystis jiroveci pneumonia and HIV infection. His CD4+ count was 18 cells per microliter and his HIV viral load (VL) was more than 400,000 copies milliliter. After 3 weeks of antibiotic therapy, he continued to have global cognitive deficits. A brain imaging study showed a right temporal mass, which on biopsy proved to be primary central nervous system lymphoma (PCNSL). He began highly active antiretroviral therapy (HAART) but declined palliative whole-brain radiotherapy (WBRT). Four months later, his CD4+ count had improved to 153 cells per microliter and his HIV VL was less than 75 copies per milliliter. At 36 months follow-up, he remained in complete remission (CR). Through a literature review, we identified 4 additional PCNSL patients who achieved prolonged remission after the initiation of HAART. One patient required WBRT and ventriculo-peritoneal shunting for signs and symptoms of obstructive hydrocephalus. The other 3 patients presented with stable neurologic findings and were treated with HAART alone. The median initial CD4+ count for these patients was 50 cells per microliter (range, 2 to 220 cells per microliter). All 5 remained in CR with a median follow-up of 23.5 (range, 13 to 36) months. For patients who present with PCNSL as their initial AIDS-defining event, stable neurologic findings, and effective HAART options, initial treatment with HAART alone may be possible, reserving WBRT and corticosteroids for those who show signs of impending neurologic demise. Chemotherapy and other novel approaches could also be considered for selected patients with lesser degrees of immune suppression and high baseline functional status.
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Affiliation(s)
- David M. Aboulafia
- Division of Hematology and Oncology, Virginia Mason Medical Center, Seattle, Washington
- Division of Hematology, University of Washington, Seattle, Washington
| | - Amal L. Puswella
- Department of Internal Medicine, Virginia Mason Medical Center, Seattle, Washington
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Rosenow JM, Hirschfeld A. Utility of brain biopsy in patients with acquired immunodeficiency syndrome before and after introduction of highly active antiretroviral therapy. Neurosurgery 2007; 61:130-40; discussion 140-1. [PMID: 17621028 DOI: 10.1227/01.neu.0000279733.28768.ff] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE This study investigates the changing indications, results, and practice patterns of brain biopsy in patients with acquired immunodeficiency syndrome (AIDS) as treatment evolved with the development of highly active antiretroviral therapy (HAART). METHODS We collected data on 246 patients with AIDS who were undergoing brain biopsy of intracranial lesions. Patients were managed in accordance with a uniform protocol. Patients were divided into two groups of those biopsied in the era before (1992-1996) or after (1997-2001) the use of HAART. RESULTS The introduction of HAART led to a steep decrease in the number of biopsies performed annually. The protocol functioned well. Diagnoses were obtained for 92.3% of patients. Lymphoma was the most frequent diagnosis (52.9% of patients), followed by progressive multifocal leukoencephalopathy (18.9% of patients) and toxoplasmosis (8.1% of patients). No patient who underwent lesion biopsy for reasons of negative toxoplasmosis titers or atypical radiology evaluation was diagnosed with toxoplasmosis. Nineteen patients who experienced failed toxoplasmosis treatment were diagnosed with toxoplasmosis. Toxoplasmosis titers had a high specificity and a negative predictive value. Patients with progressive multifocal leukoencephalopathy or nondiagnostic biopsies were more likely to have solitary lesions. The average Karnofsky performance score at the time of biopsy was 72.4, which is still within the range of independent functioning. Significant intracerebral hemorrhages were only observed in patients with lymphoma who also had low platelet counts. CONCLUSION Although the number of patients with AIDS who require brain biopsy has decreased, the procedure still has merits. The paradigm we developed was useful for selecting patients for early biopsy. Patients with AIDS who also have intracerebral lesions should have toxoplasmosis titers performed, and those whose titers are negative for toxoplasmosis should undergo early brain biopsy.
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Affiliation(s)
- Joshua M Rosenow
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA.
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AIDS defining lymphomas in the era of highly active antiretroviral therapy (HAART) – An African perspective. Transfus Apher Sci 2007; 37:63-70. [DOI: 10.1016/j.transci.2007.04.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2007] [Accepted: 04/24/2007] [Indexed: 11/15/2022]
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Scaravilli F, Bazille C, Gray F. Neuropathologic contributions to understanding AIDS and the central nervous system. Brain Pathol 2007; 17:197-208. [PMID: 17388950 PMCID: PMC8095617 DOI: 10.1111/j.1750-3639.2007.00047.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
This historical review describes the evolution of the pathogenetic concepts associated with infection by the Human Immunodeficiency Virus (HIV), with emphasis on the pathology of the nervous system. Although the first descriptions of damage to the nervous system in the acquired immunodeficiency syndrome (AIDS) only appeared in 1982, the dramatic diffusion of the epidemic worldwide and the invariably rapidly fatal outcome of the disease, before the introduction of efficient treatment, generated from the beginning an enormous amount of research with rethinking on a number of pathogenetic concepts. Less than 25 years after the first autopsy series of AIDS patients were published and the virus responsible for AIDS was identified, satisfactory definition and classification of a number of neuropathological complications of HIV infection have been established, leading to accurate clinical radiological and biological diagnosis of the main neurological complications of the disease, which remain a major cause of disability and death in AIDS patients. Clinical and experimental studies have provided essential insight into the pathogenesis of CNS lesions and natural history of the disease. The relatively recent introduction of highly active antiretroviral therapy (HAART) in 1995-1996 has dramatically improved the course and prognosis of HIV disease. However, there remain a number of unsolved pathogenetic issues, the most puzzling of which remains the precise mechanism of neuronal damage underlying the specific HIV-related cognitive disorders (HIV dementia). In addition, although HAART has changed the course of neurological complications of HIV infection, new issues have emerged such as the lack of improvement or even paradoxical deterioration of the neurological status in treated patients. Interpretation of these latter data remains largely speculative partly because of the small number of neuropathological studies related to the beneficial consequence of this treatment.
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Affiliation(s)
| | - Céline Bazille
- Service Central d’Anatomie et de Cytologie Pathologiques, AP‐HP, Hôpital Lariboisière—Université Paris VII, France
| | - Françoise Gray
- Service Central d’Anatomie et de Cytologie Pathologiques, AP‐HP, Hôpital Lariboisière—Université Paris VII, France
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Gasser O, Bihl FK, Wolbers M, Loggi E, Steffen I, Hirsch HH, Günthard HF, Walker BD, Brander C, Battegay M, Hess C. HIV patients developing primary CNS lymphoma lack EBV-specific CD4+ T cell function irrespective of absolute CD4+ T cell counts. PLoS Med 2007; 4:e96. [PMID: 17388662 PMCID: PMC1831733 DOI: 10.1371/journal.pmed.0040096] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2006] [Accepted: 01/18/2007] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND In chronic HIV infection, antiretroviral therapy-induced normalization of CD4(+) T cell counts (immune reconstitution [IR]) is associated with a decreased incidence of opportunistic diseases. However, some individuals remain at risk for opportunistic diseases despite prolonged normalization of CD4(+) T cell counts. Deficient Epstein-Barr virus (EBV)-specific CD4(+) T cell function may explain the occurrence of EBV-associated opportunistic malignancy-such as primary central nervous system (PCNS) lymphoma-despite recovery of absolute CD4(+) T cell counts. METHODS AND FINDINGS Absolute CD4(+) T cell counts and EBV-specific CD4(+) T cell-dependent interferon-gamma production were assessed in six HIV-positive individuals prior to development of PCNS lymphoma ("cases"), and these values were compared with those in 16 HIV-infected matched participants with no sign of EBV-associated pathology ("matched controls") and 11 nonmatched HIV-negative blood donors. Half of the PCNS lymphoma patients fulfilled IR criteria (defined here as CD4(+) T cell counts >or=500/microl blood). EBV-specific CD4(+) T cells were assessed 0.5-4.7 y prior to diagnosis of lymphoma. In 0/6 cases versus 13/16 matched controls an EBV-specific CD4(+) T cell response was detected (p = 0.007; confidence interval for odds ratio [0-0.40]). PCNS lymphoma patients also differed with regards to this response significantly from HIV-negative blood donors (p < 0.001, confidence interval for odds ratio [0-0.14]), but there was no evidence for a difference between HIV-negative participants and the HIV-positive matched controls (p = 0.47). CONCLUSIONS Irrespective of absolute CD4(+) T cell counts, HIV-positive patients who subsequently developed PCNS lymphoma lacked EBV-specific CD4(+) T cell function. Larger, ideally prospective studies are needed to confirm these preliminary data, and clarify the impact of pathogen-specific versus surrogate marker-based assessment of IR on clinical outcome.
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Affiliation(s)
- Olivier Gasser
- Immunobiology Laboratory, Department of Research, University Hospital Basel, Basel, Switzerland
| | - Florian K Bihl
- Partners AIDS Research Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Marcel Wolbers
- Institute for Clinical Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Elisabetta Loggi
- Partners AIDS Research Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Ingrid Steffen
- Institute for Medical Microbiology, University of Basel, Basel, Switzerland
| | - Hans H Hirsch
- Institute for Medical Microbiology, University of Basel, Basel, Switzerland
| | - Huldrych F Günthard
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, Zürich, Switzerland
| | - Bruce D Walker
- Partners AIDS Research Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Christian Brander
- Partners AIDS Research Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Manuel Battegay
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Christoph Hess
- Immunobiology Laboratory, Department of Research, University Hospital Basel, Basel, Switzerland
- * To whom correspondence should be addressed. E-mail:
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Primary central nervous system lymphoma. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/s0072-9752(07)85015-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Abstract
Among individuals with HIV-infection, coinfection with oncogenic viruses including EBV, HHV-8, and HPV cause significant cancer-related morbidity and mortality. It is clear that these viruses interact with HIV in unique ways that predispose HIV-infected individuals to malignant diseases. In general, treatment directed specifically against these viruses does not appear to change the natural history of the malignant disease, and once the malignancy develops, if their health permits, HIV-infected patients should be treated using similar treatment protocols to HIV-negative patients. However, for the less frequent HIV-related malignancies, such as PEL, or MCD, optimal treatments are still emerging. For certain AIDS-defining malignancies, it is clear that the widespread access to HAART has significantly decreased the incidence, and improved outcomes. However, for other cancers, such as the HPV-related tumors, the role of HAART is much less clear. Further research into prevention and treatment of these oncogenic virally mediated AIDS-related malignancies is necessary.
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Affiliation(s)
- Anita Arora
- Center for Clinical Studies, Houston, TX, USA
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Boffito M, Pillay D, Wilkins E. Management of advanced HIV disease: resistance, antiretroviral brain penetration and malignancies. Int J Clin Pract 2006; 60:1098-106. [PMID: 16939552 DOI: 10.1111/j.1742-1241.2006.01073.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Data from Italy, Spain and the USA all highlight the worrying fact that presentation with advanced HIV disease - defined as a cluster of differentiation 4 (CD4) count <50 cells/mm(3) or the presence of an acquired immunodeficiency syndrome-defining illness - is increasingly common. A review from 2003 showed that 31% of patients in the UK and Ireland presented late (<200 CD4 cells/mm(3)). Early diagnosis is vital to ensure that patients benefit from antiretroviral therapy, and when patients present late, they do not obtain the benefits of early treatment. The risk of death is lower when antiretroviral therapy is initiated at CD4 counts of 201-350 cells/mm(3) than at lower CD4 cell counts. In addition, the risk of unintentional infection of others is increased, which is particularly troubling in light of evidence that transmission of resistance can occur even in the absence of antiretroviral therapy. The management of patients with advanced disease and no complications is complex, but issues of transmitted resistance and comorbid conditions further confuse management decisions in the treatment of patients with higher CD4 counts. This article reviews recent evidence on transmitted resistance, the pharmacokinetics of antiretroviral drugs in patients with central nervous system disease and the management issues in patients with comorbid malignancies to offer practical advice on therapeutic options for treatment-naïve patients who present with advanced HIV disease.
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Affiliation(s)
- M Boffito
- Pharmacokinetic Research Unit, Chelsea and Westminster Hospital, London, UK.
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Gray F, Keohane C. The neuropathology of HIV infection in the era of Highly Active AntiRetroviral Therapy (HAART). Brain Pathol 2006; 13:79-83. [PMID: 12580547 PMCID: PMC8095826 DOI: 10.1111/j.1750-3639.2003.tb00008.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Françoise Gray
- Laboratoire Universitaire de Neuropathologie, Hôpital Raymond Poincaré-Faculté de Médecine Paris-Ile de France Ouest, Garches, France.
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Bower M, Palmieri C, Dhillon T. AIDS-related malignancies: changing epidemiology and the impact of highly active antiretroviral therapy. Curr Opin Infect Dis 2006; 19:14-9. [PMID: 16374212 DOI: 10.1097/01.qco.0000200295.30285.13] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Three cancers in people with HIV denote an AIDS diagnosis: Kaposi's sarcoma, high-grade B-cell non-Hodgkin's lymphoma and invasive cervical cancer. In addition a number of other cancers occur at increased frequency in this population group but are not AIDS-defining illnesses. This review discusses the impact of highly active antiretroviral therapy on the epidemiology and outcome of AIDS-defining cancers. RECENT FINDINGS The incidence of both Kaposi's sarcoma and non-Hodgkin's lymphoma has declined in the era of highly active antiretroviral therapy and the outcome of both tumours has improved. Moreover, highly active antiretroviral therapy alone produces a response in a majority of antiretroviral-naïve patients with Kaposi's sarcoma. In contrast, highly active antiretroviral therapy has had little impact on the incidence of human papilloma virus-associated tumours (cervical and anal cancer) in people with HIV, although it may improve survival by reducing opportunistic infection deaths. As people with HIV live longer with highly active antiretroviral therapy, an increased incidence of other non AIDS-defining cancers that have no known association with oncogenic infections is becoming apparent. SUMMARY For those with access to highly active antiretroviral therapy, the good news from the AIDS-defining cancers - particularly Kaposi's sarcoma and non-Hodgkin's lymphoma - may be balanced by the increasing numbers of non AIDS-defining cancers.
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Affiliation(s)
- Mark Bower
- Department of Oncology, Chelsea and Westminster Hospital, London, UK.
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