AIDS-Related Non-Hodgkin's Lymphoma in the Era of Highly Active Antiretroviral Therapy

Prevalence and trend of AIDS-defining cancers and non-AIDS-defining cancers and their association with antiretroviral therapy among people living with HIV in South Carolina: a population-based cohort study

ABSTRACTMonitoring cancer trends and risk is critical as cancer remains a growing problem in persons living with HIV (PLWH). Recent population-based data are limited regarding the cancer trends among PLWH. Our study examined the prevalence and trends in the rate of AIDS-defining cancers (ADC) and non-AIDS-defining cancers (NADC) and their risk factors in PLWH in South Carolina. Utilizing linked population-based HIV data (2005-2020), time-dependent proportional hazards model was used to identify associated risk predictors of developing cancer in PLWH. Among 11,238 PLWH, 250 individuals developed ADC and 454 developed NADC. The median time from HIV diagnosis to cancer diagnosis was 1.9 years for ADC and 3.8 years for NADC. Individuals who developed ADC or NADC were more likely to be older, male, use substances, have hepatitis infection, hypothyroidism, hypertension, and renal disease. Individuals with viral load >100,000 copies/ml were more likely to develop ADC while those with CD4 count >350 cells/mm3 were less likely to develop ADC or NADC. Our findings suggest that long-term viral suppression may contribute to risk reduction for cancer in PLWH. Early HIV diagnosis along with viral load suppression should be a part of ongoing cancer prevention efforts.

Chest CT Findings in Patients with HIV Presenting to the Emergency Department: A Single Institute Experience

PURPOSE

The aim of this study was to analyze chest CT imaging findings and relevant clinical factors in patients with HIV presenting to the emergency department (ED).

MATERIALS AND METHODS

A retrospective review was performed to identify patients with HIV who received chest CT imaging evaluation in the acute ED setting. Analyzed patients included adults with a known diagnosis of HIV who presented to the ED at a single tertiary care center between 2004 and 2020 and received chest CT imaging. Chest CT findings were assessed by 2 radiologist readers, and relevant clinical data were gathered. Statistical analysis was performed to determine if imaging and clinical factors demonstrate significant associations with CD4 count, viral load, and antiretroviral therapy status.

RESULTS

A total of 113 patients with HIV were identified who presented to the ED and underwent chest CT imaging evaluation (mean age 47 ± 11 years). Frequently detected chest CT findings included infectious pneumonia (24%), malignancy (11%), pleural effusion (17%), pericardial effusion (13%), and pulmonary embolism (4%). CD4 count, viral load, and active retroviral therapy demonstrated statistically significant associations with a number of key imaging and clinical factors, including presence of pneumonia, malignancy, average length of hospital admission, and survival.

CONCLUSION

Patients with HIV present with a wide range of imaging findings when presenting in the acute ED setting. CD4 count, viral load, and active retroviral therapy status demonstrate statistically significant associations with multiple key imaging findings and clinical factors. Chest CT plays an integral role in the clinical management of this unique patient population.

National, regional, and global causes of mortality in 5-19-year-olds from 2000 to 2019: a systematic analysis

BACKGROUND

Investments in the survival of older children and adolescents (aged 5-19 years) bring triple dividends for now, their future, and the next generation. However, 1·5 million deaths occurred in this age group globally in 2019, nearly all from preventable causes. To better focus the attention of the global community on improving survival of children and adolescents and to guide effective policy and programmes, sound and timely cause of death data are crucial, but often scarce.

METHODS

In this systematic analysis, we provide updated time-series for 2000-19 of national, regional, and global cause of death estimates for 5-19-year-olds with age-sex disaggregation. We estimated separately for countries with high versus low mortality, by data availability, and for four age-sex groups (5-9-year-olds [both sexes], 10-14-year-olds [both sexes], 15-19-year-old females, and 15-19-year-old males). Only studies reporting at least two causes of death were included in our analysis. We obtained empirical cause of death data through systematic review, known investigator tracing, and acquisition of known national and subnational cause of death studies. We adapted the Bayesian Least Absolute Shrinkage and Selection Operator approach to address data scarcity, enhance covariate selection, produce more robust estimates, offer increased flexibility, allow country random effects, propagate coherent uncertainty, and improve model stability. We harmonised all-cause mortality estimates with the UN Inter-agency Group for Child Mortality Estimation and systematically integrated single cause estimates as needed from WHO and UNAIDS.

FINDINGS

In 2019, the global leading specific causes of death were road traffic injuries (115 843 [95% uncertainty interval 110 672-125 054] deaths; 7·8% [7·5-8·1]); neoplasms (95 401 [90 744-104 812]; 6·4% [6·1-6·8]); malaria (81 516 [72 150-94 477]; 5·5% [4·9-6·2]); drowning (77 460 [72 474-85 952]; 5·2% [4·9-5·5]); and diarrhoea (72 679 [66 599-82 002], 4·9% [4·5-5·3]). The leading causes varied substantially across regions. The contribution of communicable, maternal, perinatal, and nutritional conditions declined with age, whereas the number of deaths associated with injuries increased. The leading causes of death were diarrhoea (51 630 [47 206-56 235] deaths; 10·0% [9·5-10·5]) in 5-9-year-olds; malaria (31 587 [23 940-43 116]; 8·6% [6·6-10·4]) in 10-14-year-olds; self-harm (32 646 [29 530-36 416]; 13·4% [12·6-14·3]) in 15-19-year-old females; and road traffic injuries (48 757 [45 692-52 625]; 13·9% [13·3-14·3]) in 15-19-year-old males. Widespread declines in cause-specific mortality were estimated across age-sex groups and geographies in 2000-19, with few exceptions like collective violence.

INTERPRETATION

Child and adolescent survival needs focused attention. To translate the vision into actions, more investments in the health information infrastructure for cause of death and in the related life-saving interventions are needed.

FUNDING

Bill & Melinda Gates Foundation and WHO.

Spectrum of imaging findings in AIDS-related diffuse large B cell lymphoma

Lymphoma in HIV-infected patients is AIDS defining. This is the second most common AIDS defining malignancy after Kaposi's sarcoma. Development of lymphoma in HIV patients is related to immunosuppression and high viral load. Co-infection with other lymphotrophic viruses especially EBV is also strongly associated with development of lymphoma in HIV patients. Despite advances in HAART therapy, incidence of diffuse large B cell lymphoma in HIV-infected patients remains significantly higher than in the general population.Early diagnosis is challenging due to presence of opportunistic infections and atypical presentation of the lymphoma in this subset of patients. Atypical imaging findings are not unusual, and the diagnosis of lymphoma on imaging is on many occasions unexpected as the patient would ideally be initially investigated for presumed opportunistic infection.Lymphoma treatment approaches in HIV patients are complicated by comorbidity with opportunistic infections and performance status of the patients. Treatment failure and early relapse are also common in AIDS-related lymphoma. This review article highlights the common and unusual multimodality imaging findings in HIV-associated lymphoma.

Common oral opportunistic infections in Human Immunodeficiency Virus infection/Acquired Immunodeficiency Syndrome: Changing epidemiology; diagnostic criteria and methods; management protocols

There were 36.9 million in the world living with human immunodeficiency virus (HIV) infection/acquired immunodeficiency syndrome (AIDS) as of 2017, and new infections have seen a reduction by 18% since 2010. But this rate of decline is not sufficient for the goal of eradication of AIDS by 2030. Only 21.7  million people infected with HIV have accesses to antiretroviral therapy, with the rest at risk of the potential complications of HIV infection. It has been shown that oral lesions are diagnostic and prognostic of HIV infection, and many oral opportunistic infections continue to be a major problem, particularly in developing countries. It is therefore important that dental surgeons be aware and updated to recognize and manage the oral effects of HIV infection/AIDS. This chapter describes the classification, diagnosis, and management of oral lesions in these patients, based on our current understanding of the infection. This review also discusses the standardization of diagnosis of oral lesions in HIV infection/AIDS patients, immune reconstitution inflammatory syndrome case definition, and the research priorities formulated at the 7th World Workshop on Oral Health and Disease in AIDS.

Epstein-Barr Virus in Gliomas: Cause, Association, or Artifact?

Gliomas are the most common malignant brain tumors and account for around 60% of all primary central nervous system cancers. Glioblastoma multiforme (GBM) is a grade IV glioma associated with a poor outcome despite recent advances in chemotherapy. The etiology of gliomas is unknown, but neurotropic viruses including the Epstein–Barr virus (EBV) that is transmitted via salivary and genital fluids have been implicated recently. EBV is a member of the gamma herpes simplex family of DNA viruses that is known to cause infectious mononucleosis (glandular fever) and is strongly linked with the oncogenesis of several cancers, including B-cell lymphomas, nasopharyngeal, and gastric carcinomas. The fact that EBV is thought to be the causative agent for primary central nervous system (CNS) lymphomas in immune-deficient patients has led to its investigations in other brain tumors including gliomas. Here, we provide a review of the clinical literature pertaining to EBV in gliomas and discuss the possibilities of this virus being simply associative, causative, or even an experimental artifact. We searched the PubMed/MEDLINE databases using the following key words such as: glioma(s), glioblastoma multiforme, brain tumors/cancers, EBV, and neurotropic viruses. Our literature analysis indicates conflicting results on the presence and role of EBV in gliomas. Further comprehensive studies are needed to fully implicate EBV in gliomagenesis and oncomodulation. Understanding the role of EBV and other oncoviruses in the etiology of gliomas, would likely open up new avenues for the treatment and management of these, often fatal, CNS tumors.

The pattern of secondary cancers in patients with Kaposi sarcoma in the United States

PURPOSE

In the U.S., Kaposi sarcoma (KS) occurs mostly in HIV-infected patients, who are also at increased risk of developing secondary cancers. The trends in secondary cancer risk are unclear in the HAART era.

METHODS

We extracted data from the SEER database on patients diagnosed with KS between 1981 and 2013, stratified into the pre-HAART (1981-1995) and HAART (1996-2013) eras. We compared the risk of secondary cancer in KS patients and the general population, and estimated the absolute risk.

RESULTS

We followed 13,535 KS patients for 49,813 person-years, during which 1,041 secondary cancers were diagnosed: 774 in the pre-HAART and 267 in the HAART era. In the pre-HAART era, non-Hodgkin's lymphoma (NHL) and anal carcinomas were the most common secondary cancers. The standard incidence ratio of secondary cancers decreased from 3.44 (pre-HAART era) to 1.94 (HAART era) in patients aged <70 years. The absolute excess risk decreased from 178 to 68 cases per 10,000 person-years. The risk of NHL decreased, while the risk of anal carcinoma did not change significantly. The risk of lung cancer was lower in KS patients than in the general population. The absolute risk of non-AIDS-defining cancers increased fourfold in the HAART era.

CONCLUSIONS

The absolute risk of non-AIDS-defining secondary cancers has increased in KS patients in the HAART era. However, the overall relative risk of secondary cancers has decreased, mainly due to a significant decrease in the risk of NHL.

Stage IV advanced diffuse large B-cell lymphoma in human immunodeficiency virus infection with achieving cure by using highly active antiretroviral therapy alone: a case report

After the introduction of highly active antiretroviral therapy (HAART), there has been a decrease in the incidence of lymphoma among the HIV-infected population and also significantly improved survival rates. We describe a remarkable case of an HIV-infected patient with advanced stage IV diffuse large B-cell lymphoma (DLBCL), completely regressed with the use of HAART alone. He remained disease-free for 6 years and he achieved cure without chemotherapy. Although several cases of low-grade lymphoma with complete regression were reported, we could not find any case of stage IV high-grade malignant lymphoma with HAART alone in complete remission for over 5 years from our review of the literature. This unique case shows the importance of HAART in improving survival and achieving cure in HIV-high-grade malignant lymphoma.

Infectious and Non-infectious Etiologies of Cardiovascular Disease in Human Immunodeficiency Virus Infection

Background:

Increasing rates of HIV have been observed in women, African Americans, and Hispanics, particularly those residing in rural areas of the United States. Although cardiovascular (CV) complications in patients infected with human immunodeficiency virus (HIV) have significantly decreased following the introduction of antiretroviral therapy on a global scale, in many rural areas, residents face geographic, social, and cultural barriers that result in decreased access to care. Despite the advancements to combat the disease, many patients in these medically underserved areas are not linked to care, and fewer than half achieve viral suppression.

Methods:

Databases were systematically searched for peer-reviewed publications reporting infectious and non-infectious etiologies of cardiovascular disease in HIV-infected patients. Relevant articles cited in the retrieved publications were also reviewed for inclusion.

Results:

A variety of outcomes studies and literature reviews were included in the analysis. Relevant literature discussed the manifestations, diagnosis, treatment, and outcomes of infectious and non-infectious etiologies of cardiovascular disease in HIV-infected patients.

Conclusion:

In these medically underserved areas, it is vital that clinicians are knowledgeable in the manifestations, diagnosis, and treatment of CV complications in patients with untreated HIV. This review summarizes the epidemiology and causes of CV complications associated with untreated HIV and provide recommendations for management of these complications.

Comparison of cancer survival trends in the United States of adolescents and young adults with those in children and older adults

BACKGROUND

With prior reports indicating a lack of progress in survival improvement in older adolescents and young adults (AYAs) aged 15 to 39 years with cancer compared with both younger and older patients with cancer, the current analysis provides an update of survival trends of cancers among AYAs, children, and older adults.

METHODS

Data from the National Cancer Institute Surveillance, Epidemiology, and End Results database for 13 regions were used to ascertain survival trends of the 34 most frequent cancers diagnosed in AYAs compared with children and older adults.

RESULTS

As of 2002 through 2006, the 5-year relative survival rate for all invasive cancers in AYAs was 82.5% (standard error, 0.2%). In AYAs, 14 cancers demonstrated evidence of a statistically significant improvement in their 5-year relative survival since 1992. Survival improved less in AYAs than in children for acute myeloid leukemia and medulloblastoma. Fourteen cancers had survival improvements that were found to be less in AYAs compared with older adults, including hepatic carcinoma, acute myeloid leukemia, high-grade astrocytoma, acute lymphocytic leukemia, pancreatic carcinoma, low-grade astrocytoma, gastric carcinoma, renal carcinoma, cancer of the oral cavity and pharynx, Hodgkin lymphoma, ovarian cancer, fibromatous sarcoma, other soft tissue sarcoma, and thyroid carcinoma.

CONCLUSIONS

Improvements in the survival of several cancer types that occur frequently in AYAs are encouraging. However, survival does not appear to be improving to the same extent in AYAs as in children or older adults for several cancers. Further investment in exploring the distinct biology of tumors in this age group, and of their hosts, must be a priority in AYA oncology.

Hematopoietic stem cell transplantation for HIV cure

The apparent cure of an HIV-infected person following hematopoietic stem cell transplantation (HSCT) from an allogeneic donor homozygous for the ccr5Δ32 mutation has stimulated the search for strategies to eradicate HIV or to induce long-term remission without requiring ongoing antiretroviral therapy. A variety of approaches, including allogeneic HSCT from CCR5-deficient donors and autologous transplantation of genetically modified hematopoietic stem cells, are currently under investigation. This Review covers the experience with HSCT in HIV infection to date and provides a survey of ongoing work in the field. The challenges of developing HSCT for HIV cure in the context of safe, effective, and convenient once-daily antiretroviral therapy are also discussed.

HIV-infection impact on clinical-biological features and outcome of diffuse large B-cell lymphoma treated with R-CHOP in the combination antiretroviral therapy era

OBJECTIVE

Since the introduction of combination antiretroviral therapy (cART) patients with HIV-related diffuse large B-cell lymphoma (DLBCL) show better control of immunosuppression, which may have an impact on the characteristics and prognosis of the disease. We aimed to compare the clinical presentation and prognosis of patients with HIV-related and HIV-unrelated DLBCL treated with rituximab, cyclophosphamide, adriamycin, vincristine, and prednisone (R-CHOP) in the cART era.

METHODS AND DESIGN

Eighty-one HIV-infected patients included in a Spanish multicentre trial were compared with 84 HIV-uninfected patients diagnosed in a Spanish institution in the same period all treated with R-CHOP.

RESULTS

HIV-infected patients had a worse performance status, more frequent B-symptoms, and higher Ann-Arbor stages than HIV-uninfected patients, with similar frequency of extranodal involvement. The complete response (CR) rate of patients with high tumor burden was not different in HIV-infected and HIV-uninfected patients. Patients with HIV-related DLBCL showed a worse overall survival (OS) (5-year OS: 56 vs. 74%) but a similar disease-free survival (DFS) (5-year DFS: 84 vs. 73%). In the subgroup of patients with high tumor, the results regarding survival were similar to the whole series. Previous AIDS-defining illness was the strongest negative prognostic factor for OS in HIV-infected patients.

CONCLUSION

In the cART era, HIV-related DLBCL still presents more aggressive features than HIV-unrelated DLBCL, and has a worse OS despite having a similar DFS. Prevention of HIV-related complications is essential to achieve outcomes comparable with HIV-uninfected patients with DLBCL.

Recent cancer incidence trends in an observational clinical cohort of HIV-infected patients in the US, 2000 to 2011

Background

In HIV-infected populations in developed countries, the most recent published cancer incidence trend analyses are only updated through 2008. We assessed changes in the distribution of cancer types and incidence trends among HIV-infected patients in North Carolina up until 2011.

Methods

We linked the University of North Carolina Center for AIDS Research HIV Clinical Cohort, an observational clinical cohort of 3141 HIV-infected patients, with the North Carolina Cancer registry. Cancer incidence rates were estimated across calendar years from 2000 to 2011. The distribution of cancer types was described. Incidence trends were assessed with linear regression.

Results

Across 15,022 person-years of follow-up, 202 cancers were identified (incidence rate per 100,000 person-years [IR]: 1345; 95% confidence interval [CI]: 1166, 1544). The majority of cancers were virus-related (61%), including Kaposi sarcoma (N = 32) (IR: 213; 95%CI: 146, 301), non-Hodgkin lymphoma (N = 34) (IR: 226; 95%CI: 157, 316), and anal cancer (N = 16) (IR: 107; 95%CI: 61, 173). Non-Hodgkin lymphoma was observed to decrease from 2000 to 2011 (decline of 15 cases per 100,000 person-years per calendar year, 95%CI: -27, -3). No other changes in incidence or changes in incidence trends were observed for other cancers (all P > 0.20).

Conclusions

We observed a substantial burden of a variety of cancers in this population in the last decade. Kaposi sarcoma and non-Hodgkin lymphoma were consistently two of the greatest contributors to cancer burden across calendar time. Cancer rates appeared stable across calendar years, except for non-Hodgkin lymphoma, which appeared to decrease throughout the study period.

Acute kidney injury and inflammatory immune reconstitution syndrome in mixed genotype (A/E) hepatitis B virus co-infection in HIV-associated lymphoma

We report a first case of HIV-associated lymphoma (HAL) presenting with acute kidney injury (AKI) and inflammatory immune reconstitution syndrome (IRIS). A 39-year-old male, treated with nonsteroidal anti-inflammatory drugs (NSAIDs) for one month prior to admission, developed AKI, left testicular tumor, and recurrent swelling of the right parotid gland. A resected testicular tumor exhibited features intermediate between diffuse large B-cell lymphoma and Burkitt lymphoma. Renal biopsy showed hydro-degeneration of renal tubules, interstitial inflammatory cells, and a small number of lymphoma cells in the sub-capsule, compatible with acute interstitial nephritis. His renal dysfunction rapidly recovered following chemotherapy and combination antiretroviral therapy (cART). He developed pneumonia concomitantly with a decrease in HIV-RNA level and an increase in CD4+ cells after the first cycle of chemotherapy, which spontaneously resolved after the second cycle of chemotherapy without additional anti-infection drugs; thus, his pneumonia fulfilled the diagnostic criteria for IRIS. We suggest that IRIS may frequently develop during chemotherapy for HAL, but may be overlooked. He was coinfected with hepatitis B virus (HBV), which genotypes known as is associated with liver-related mortality and response to antiviral therapy; recently, an intimate interplay between HIV and HBV in the onset of lymphoma has been reported. Therefore, we addressed the HBV genotype in the patient. The analysis revealed that he exhibited a mixed genotype (A/E) not native to Japan and primarily found in Europe and North America or West Africa. These findings suggest that universal vaccination for juveniles against HBV is warranted in Japan.

Extranodal lymphoma masquerading as carcinoma of the breast in an HIV-positive male patient

This report describes a male patient infected with the HIV, with antiretroviral therapy (ART)-induced gynaecomastia. He presented with a right-sided breast mass which clinically resembled a carcinoma. A core biopsy suggested non-Hodgkin's lymphoma of diffuse large B cell histology. Also presented are his 18-fluoro-deoxy-glucose-positron emission tomography (FDG PET)-CT scan findings which showed a highly avid mass (standardised uptake value (SUV) 34.5) in his right breast. In spite of a very good clinical response after the first cycle of chemotherapy, his disease relapsed at multiple sites and progressed early. This case illustrates the aggressive course of HIV-associated extranodal lymphomas, and also highlights the issues concerning the use of ART and chemotherapy.