Primary intracranial neoplasms in patients with HIV

Pembrolizumab in an HIV-infected patient with glioblastoma

Persons living with human immunodeficiency virus (PLWH) carry increased risk for developing malignancies, including glioblastoma. Despite extensive investigations, both human immunodeficiency virus (HIV) and glioblastoma are incurable. Treatment for a patient with combined glioblastoma and HIV remains an unexplored need. Preliminary evidence suggests that immunotherapy may be effective for the simultaneous treatment of both HIV and cancer by reversing HIV latency and T cell exhaustion. We present a case of glioblastoma in a PLWH who was treated with pembrolizumab. Treatment was well tolerated and safe with a mixed response. Our patient did not develop any opportunistic infections, immune-related adverse events, or worsening of his immunodeficiency. To our knowledge, this is the first reported case of a PLWH and glioblastoma treated with immunotherapy.

Ocular Motor Cranial Nerve Palsies and Increased Risk of Primary Malignant Brain Tumors: South Korean National Health Insurance Data

The aim of this study was to investigate the association between ocular motor cranial nerve palsies (OMCNP) and the occurrence of primary malignant brain tumors in a Korean population, using the national sample cohort database from Korea National Health Insurance Service (KNHIS). KNHIS data between 2010 and 2017 were analyzed. Our sample encompassed 118,686 participants, including 19,781 from a recently diagnosed OMCNP cohort and 98,905 from a matched control cohort through a 1:5 propensity score matching based on age and gender. To counteract the issue of reverse causation, we integrated a one-year time lag in our sensitivity analysis. Study participants were followed up until 31 December 2019. Cox proportional hazard regression analysis was used to compute the adjusted hazard ratio (HR) for primary malignant brain tumors according to the OMCNP diagnosis. Additionally, we performed a subgroup analysis to discern effects of various factors on the association between OMCNP and primary malignant brain tumors. HR for primary malignant brain tumors was 3.272 (95% confidence interval [CI]: 2.294 to 4.665) in the OMCNP cohort compared to the control cohort in a fully adjusted model for age, sex, socio-economic status, smoking, drinking, regular physical exercise, hypertension, diabetes, dyslipidemia, obesity, chronic kidney disease, and human immunodeficiency virus infection. Further subgroup analysis revealed that the risk of primary malignant brain tumors was significantly increased in women with OMCNP compared to men with OMCNP (HR: 5.118 in women vs. 2.441 in men, p = 0.0440), and in those aged <65 years than in those aged ≥65 years (HR: 6.951 in age < 65 years vs. 1.899 in age ≥ 65 years, p = 0.0006). Our population-based cohort study demonstrated a significantly increased risk of subsequent primary malignant brain tumors in patients with OMCNP. Particularly, OMCNP-afflicted women aged below 65 manifested a heightened probability of developing primary malignant brain tumors compared to those devoid of OMCNP.

Clinical characteristics and prognostic analysis of patients with HIV and glioma: A case series and literature review

Cerebral glial tumors have become increasingly common in human immunodeficiency virus (HIV)-positive patients. The present study aimed to report a series of such cases, explore their clinical and pathological characteristics and subject all the reported cases to a survival analysis. The characteristics, management and prognosis of 10 HIV-positive patients with brain gliomas enrolled in a single hospital were investigated in detail. Immunohistochemical assessment of CD31, CD68 and CD163 was performed in the 10 HIV-positive patients with glioma and 18 HIV-negative patients with glioma. The relevant literature was also reviewed using relevant search terms. The potential predictive factors were screened by univariate and multivariate logistic regression analyses, and a nomogram was established based on the potential predictive factors. A total of 50 patients, including the 10 primary cases, were included in the survival analysis. The median survival time was 9 months. The gliomas of HIV-negative patients had a lower cell count of CD163+ cells than those of HIV-positive patients. High CD4+ T-cell count and the use of highly active antiretroviral therapy (HAART) tended to increase the median survival duration, although not significantly according to the log-rank analysis. In the univariate analysis, only surgery, radiotherapy (RT) and World Health Organization (WHO) tumor grade had significant associations with overall survival. In the multivariate analysis, only RT and WHO grade were independent predictors. In conclusion, gliomas may occur more frequently in HIV-positive populations than is currently recognized. The survival duration of most HIV-positive patients with glioma is determined by the tumor rather than HIV status. Adjuvant radiotherapy and the WHO grade of the glioma are predicted to be independent prognostic factors. Surgical resection followed by RT plus regular HAART is recommended for patients with glioma who are HIV-positive.

Epstein-Barr virus-associated leiomyosarcoma of the larynx in an adult patient with human immunodeficiency virus infection: Case report and review of the literature

We investigated the clinical features, treatment, and prognosis of laryngeal leiomyosarcoma (LLMS) and Epstein-Barr virus-associated (EBV-associated) LMS. We report a case of EBV-associated LLMS in an adult patient with HIV infection. We also conducted a review of the English-language literature on LLMS and EBV-associated leiomyosarcoma. To the best of our knowledge, 62 cases of LLMS and EBV-associated leiomyosarcoma have been reported to date. Of patients with LLS, 18.9% had distant metastases and 17.0% had local recurrence. The overall 5-year survival rate was 64.0%. Distant metastases affected the survival of patients with LLMS (p = 0.04). EBV-positive patients had a low survival rate (p = 0.01). Among patients with EBV-associated LMS, 8.2% had distant metastases and recurrence and the overall 5-year survival rate was 50.0%. EBV-associated LLMS is rare. The EBV infection might be a poor prognostic factor of LLMS.

Glioblastoma multiforme in patients with human immunodeficiency virus: an integrated review and analysis

INTRODUCTION

As lifespans for persons living with HIV (PLWH) have improved over the last decade, there has been a simultaneous increase in non-AIDS-related cancer in that group. However, there is a paucity of data regarding the incidence of glioblastoma multiforme (GBM) in PLWH. Better understanding of the oncogenesis, natural history, and treatment outcomes of GBM in PLWH should lead to improved treatment strategies.

METHODS

We performed a comprehensive literature search of six electronic databases to identify eligible cases of GBM among PLWH. Kaplan-Meier estimates, Fisher's exact test, and logistic regression were used to interrogate the data. Epidemiologic data on global HIV prevalence was obtained from the 2016 UNAIDS incidence report, and CNS cancer incidence was obtained from the GDB 2016 Brain and Other CNS Cancer Collaborators.

RESULTS

There is an inverse relationship between the incidence of HIV and CNS cancer globally. Median overall survival (OS) from GBM diagnosis was 8 months. Estimates for survival at 1 and 2 years were 28 and 5%, respectively. There were no statistically significant predictors of OS in this setting. There was a significant difference (p < 0.01) in OS in PLWH and GBM when compared to TCGA age matched cohorts.

CONCLUSION

The diagnosis of GBM in PLWH is severely underreported in the literature. Despite maximal treatment, OS in this patient population is significantly less than in HIV-negative people. There was a poor prognosis of GBM in PLWH, which is inconsistent with previous reports. Further investigation is required for PLWH and concomitant GBM. Analyses must consider if HAART is maintained in PLWH during GBM treatment.

Human Immunodeficiency Virus in Adults Undergoing Surgery for Brain Tumors

Introduction

Early diagnosis and treatment of human immunodeficiency virus (HIV) can improve outcomes. HIV prevalence in brain tumor patients and the impact of an HIV diagnosis on patient outcomes are poorly understood.

Materials and methods

This was a prospective study of 100 consecutive brain tumor patients admitted to a Greater London Tertiary Neurosurgical center for surgery between January 2021 and October 2021. All brain tumors were included. All patients have appropriately consented. Blood was tested to detect HIV antibodies and p24 antigen. Outcomes were noted at 30-day postoperative follow-up.

Results

In 100 patients, there was one case of a known HIV-positive, seronegative patient, and no new diagnosis was made, giving a prevalence of 1%. The mean age of patients included was 61.7 ± 13.3, with 57% female. The patient with HIV suffered a postoperative pseudomonas infection, requiring intensive care, additional surgery, and antibiotics. This resulted in an inpatient stay of 55 days - an increase of 274% compared to patients without HIV.

Conclusion

Literature regarding the prevalence of HIV in glioma patients is inconclusive, of low quality, and primarily out-of-date. Our literature search found no similar study of rates of HIV in brain tumor patients in the United Kingdom. The incidence of both HIV and brain tumors, particularly glioblastomas, is low.

Primary intracranial smooth muscle tumor associated with Epstein-Barr virus in immunosuppressed children: two cases report and review of literature

Primary intracranial smooth muscle tumors are rare. Most cases are related to Epstein-Barr virus proliferation in immunocompromised patients such as organ solid recipients. Only a few cases have been reported in pediatric patients. The clinical features are very variable depending mainly on the location and size of the smooth muscle tumor (SMT) and the pathogenesis is poorly understood. We describe two cases of intracranial SMT localized in the temporal lobe and associated with EBV in immunosuppressed children. A review of the literature associated with intracranial leiomyomas was also done.

Diagnosis of primary CNS lymphoma in a HIV patient with multiple ring-enhancing lesions

Multiple ring-enhancing lesions on brain MRI in an immunocompromised patient are frequently associated with opportunistic infections such as toxoplasmosis. In this report, we describe the case of a patient with HIV/AIDS who was found to having multiple ring-enhancing lesions and was diagnosed with a primary central nervous system lymphoma.

Intracranial Leiomyoma Associated with Epstein-Barr Virus: A Cerebellopontine Angle Mass Presenting with Trigeminal Neuralgia

BACKGROUND

Primary intracranial leiomyoma is a rare smooth muscle tumor often associated with Epstein-Barr virus (EBV), with <30 cases reported worldwide. These tumors commonly occur in patients with immunocompromised status, especially those with human immunodeficiency virus. In the present report, we have described the case of an EBV-associated leiomyoma at the cerebellopontine angle. The patient had presented with trigeminal neuralgia, which, to the best of our knowledge, is the first reported anatomical location and presentation for this tumor type.

CASE DESCRIPTION

A 41-year-old male patient had presented with right-sided facial pain in the V1 and V2 dermatomes and previous workup and imaging studies. The patient had undergone treatment of a presumed right-side cerebellopontine angle meningioma as determined by the magnetic resonance imaging characteristics (no biopsy). The patient subsequently underwent right-sided retrosigmoid craniotomy and gross total resection of the tumor. The postoperative period was uneventful with resolution of the trigeminal neuralgia. Histopathologic examination revealed spindle cell neoplasm with histopathologic and immunohistochemical features consistent with leiomyoma. The tumor cells were positive for smooth muscle actin and desmin and were negative for S100, SOX-10, epithelial membrane antigen, glial fibrillary acidic protein, progesterone receptor, CD31, CD34, and E-cadherin.

CONCLUSIONS

Primary intracranial leiomyomas are rare tumors associated with EBV infection that occur in immunocompromised patients. These lesions should be considered in the differential diagnosis for patients with known immunocompromised status (e.g., human immunodeficiency virus), and tissue biopsy should be considered.

Secondary glioblastoma metastasis outside the central nervous system in a young HIV-infected patient

Glioblastoma is the most common adult primary brain tumor that occurs in the central nervous system and is characterized by rapid growth and diffuse invasiveness with respect to the adjacent brain parenchyma, which renders surgical resection inefficient. Although it is a highly infiltrative tumor, it is rarely disseminated beyond the central nervous system, wherein extracranial metastasis is a unique but rare manifestation of this kind of tumor. It is very common for acquired immunodeficiency syndrome (AIDS) patients to be infected with the human immunodeficiency virus (HIV), which suggests that a possible association between HIV infection and tumor development exists. In this paper, we present a new case of a young patient’s HIV-associated glioblastoma, with glioblastoma metastasis within the T9 vertebral body and lymph nodes in the anterior neck tissue. Initially, the patient was diagnosed with a grade III plastic astrocytoma. The patient lived a normal life for a year while being treated with temozolomide, radiotherapy, and highly active antiretroviral therapy. However, the tumor quickly evolved into a glioblastoma. We believe that the drastic progression of the tumor from a grade III anaplastic astrocytoma to a metastatic glioblastoma is due to the HIV infection that the patient had acquired, which contributed to a weakened immune system, thus accelerating progression of the cancer.

HIV-associated cavernous sinus disease

Introduction

The underlying diagnosis of cavernous sinus disease is difficult to confirm in HIV-coinfected patients owing to the lack of histological confirmation. In this retrospective case series, we highlight the challenges in confirming the diagnosis and managing these patients.

Results

The clinical, laboratory and radiological data of 23 HIV-infected patients with cavernous sinus disease were analysed. The mean age of patients was 38 years. The mean CD4+ count was 390 cells/μL. Clinically, patients presented with unilateral disease (65%), headache (48%), diplopia (30%) and blurred vision (30%). Third (65%) and sixth (57%) nerve palsies in isolation and combination (39%) were most common. Isolated fourth nerve palsy did not occur. Tuberculosis (17%) was the most commonly identified disorder followed by high-grade B-cell lymphoma (13%), meningioma (13%), metastatic carcinoma (13%) and neurosyphilis (7%). In 22% of the patients, there was no confirmatory evidence for a diagnosis. The patients were either treated empirically for tuberculosis or improved spontaneously when antiretroviral therapy was started. Cerebrospinal fluid was helpful in 4/13 (31%) of patients where it was not contraindicated. Only 3/23 (13%) of the patients had a biopsy of the cavernous sinus mass. The outcomes varied, and follow-up was lacking in the majority of patients.

Conclusion

In HIV-infected patients, histological confirmation of cavernous sinus pathology is not readily available for various reasons. In resource-limited settings, one should first actively search for extracranial evidence of tuberculosis, lymphoma, syphilis and primary malignancy and manage appropriately. Only if such evidence is lacking should a referral for biopsy be considered.

Use of Mendelian andomization for dentifying isk actors for rain umors

Gliomas are a group of primary brain tumors, the most common and aggressive subtype of which is glioblastoma. Glioblastoma has a median survival of just 15 months after diagnosis. Only previous exposure to ionizing radiation and particular inherited genetic syndromes are accepted risk factors for glioma; the vast majority of cases are thought to occur spontaneously. Previous observational studies have described associations between several risk factors and glioma, but studies are often conflicting and whether these associations reflect true casual relationships is unclear because observational studies may be susceptible to confounding, measurement error and reverse causation. Mendelian randomization (MR) is a form of instrumental variable analysis that can be used to provide supporting evidence for causal relationships between exposures (e.g., risk factors) and outcomes (e.g., disease onset). MR utilizes genetic variants, such as single nucleotide polymorphisms (SNPs), that are robustly associated with an exposure to determine whether there is a causal effect of the exposure on the outcome. MR is less susceptible to confounding, reverse causation and measurement errors as it is based on the random inheritance during conception of genetic variants that can be relatively accurately measured. In previous studies, MR has implicated a genetically predicted increase in telomere length with an increased risk of glioma, and found little evidence that obesity related factors, vitamin D or atopy are causal in glioma risk. In this review, we describe MR and its potential use to discover and validate novel risk factors, mechanistic factors, and therapeutic targets in glioma.

Primary intracranial leiomyosarcoma among patients with AIDS in the era of new chemotherapeutic and biological agents

Primary intracranial leiomyosarcoma (PIL) is a rare non-infectious aetiology of focal mass lesions among HIV-infected individuals. With only 16 published cases worldwide, information on its pathophysiology, risk factors, clinical course and management options is limited. We report two cases of PIL in HIV-infected Filipino men who presented with 1-3 months history of persistent headache, progressing in severity. Both had cranial MRI revealing intracranial mass diagnosed as leiomyosarcoma by excision biopsy and immunohistochemical staining. Both patients underwent adjuvant cranial radiotherapy and chemotherapy. Biologics were initiated in one patient. Both patients were alive with evidence of the disease.

HIV-1 Envelope Protein gp120 Promotes Proliferation and the Activation of Glycolysis in Glioma Cell

Patients infected with human immunodeficiency virus (HIV) are more prone to developing cancers, including glioblastomas (GBMs). The median survival for HIV positive GBM patients is significantly shorter than for those who are uninfected, despite the fact that they receive the same treatments. The nature of the GBM–HIV association remains poorly understood. In this study, we analyzed the effect of the HIV envelope glycoprotein gp120 on GBM cell proliferation. Specifically, we performed cell cycle, western blot, protein synthesis and metabolomics analysis as well as ATP production and oxygen consumption assays to evaluate proliferation and metabolic pathways in primary human glioma cell line, U87, A172 cells and in the HIVgp120tg/GL261 mouse model. Glioma cells treated with gp120 (100 ng/mL for 7–10 days) showed higher proliferation rates and upregulation in the expression of enolase 2, hexokinase and glyceraldehyde-3-phosphate dehydrogenase when compared to untreated cells. Furthermore, we detected an increase in the activity of pyruvate kinase and a higher glycolytic index in gp120 treated cells. Gp120 treated GBM cells also showed heightened lipid and protein synthesis. Overall, we demonstrate that in glioma cells, the HIV envelope glycoprotein promotes proliferation and activation of glycolysis resulting in increased protein and lipid synthesis.

The possibility of cancer immune editing in gliomas. A critical review

The relationship between anti-tumoral immunity and cancer progression is complex. Recently, immune editing has emerged as a model to explain the interplay between the immune system and the selection of genetic alterations in cancer. In this model, the immune system selects cancer cells that grow as these are fit to escape immune surveillance during tumor development. Gliomas and glioblastoma, the most aggressive and most common of all primary malignant brain tumors are genetically heterogeneous, are relatively less antigenic, and are less responsive to immunotherapy than other cancers. In this review, we provide an overview of the relationship between glioma´s immune suppressive features, anti-tumoral immunity and cancer genomics. In this context, we provide a critical discussion of evidence suggestive of immune editing in this disease and discuss possible alternative explanations for these findings.

Clinical Characteristics and Prognostic Analysis of Glioma in Human Immunodeficiency Virus-Infected Patients

OBJECTIVE

To perform a survival analysis of human immunodeficiency virus (HIV)-patients with glioma and to assess the relationship between various prognostic factors and overall survival (OS).

METHODS

We reported in detail the management and prognosis of 2 HIV-infected patients with glioma in our hospital and performed a quantitative and comprehensive systematic literature review of patients with HIV-associated glioma. We combined our treatment experience with retrospectively obtained treatment information and studied the survival time to statistically analyze whether age, sex, World Health Organization (WHO) grade, surgery, radiotherapy, chemotherapy, and combined radiotherapy and chemotherapy could predict patient survival.

RESULT

The study included 34 cases, including our own 2 cases. The median survival was 9 months. On survival analysis, among the aforementioned parameters, WHO grade (low-grade glioma/high-grade glioma), surgery (surgical resection/stereotactic biopsy), and radiotherapy showed a significant association with OS by univariate analysis. Multivariate analysis showed WHO grade and surgery were significant predictors of OS.

CONCLUSIONS

Most patients had astrocytoma or high-grade glioma. The median survival of all HIV-infected patients with gliomas was shorter than that of GBM patients with glioblastoma multiforme. Surgery and WHO grade were independent prognostic factors for OS.

Pazopanib-mediated Long-term Disease Stabilization after Local Recurrence and Distant Metastasis of Primary Intracranial Leiomyosarcoma: A Case Report on the Efficacy of Pazopanib as a Salvage Therapy

Primary intracranial leiomyosarcoma (LMS) is an extremely rare tumor of the central nervous system. Only sporadic case reports have been published, and therefore data regarding long-term prognosis remain scarce. A 76-year-old woman presented with a right parietal mass, which had grown rapidly in the month prior to admission. Neuroimaging showed a resemblance to intraosseous meningioma. Gross total resection of the tumor was achieved, and histological diagnosis confirmed LMS. Because positron emission tomography (PET) with fluorodeoxyglucose (FDG) just after the resection showed no abnormal uptake, we diagnosed the tumor as primary intracranial LMS. Follow-up PET at 16 months after treatment showed two foci of FDG uptake in the bilateral lungs. Histological diagnosis by surgical resection identified the lesions as lung metastases of LMS. In addition, follow-up head magnetic resonance imaging (MRI) at 31 months showed local recurrence, and we conducted salvage therapy using CyberKnife system (Accuray incorporated) and pazopanib. To date, for 15 months after local recurrence, she is alive with intracranial recurrent disease remained inactive.

Impact of Human Immunodeficiency Virus in the Pathogenesis and Outcome of Patients with Glioblastoma Multiforme

Background

Improvement in antiviral therapies have been accompanied by an increased frequency of non-Acquired Immune Deficiency Syndrome (AIDS) defining malignancies, such as glioblastoma multiforme. Here, we investigated all reported cases of human immunodeficiency virus (HIV)-positive patients with glioblastoma and evaluated their clinical outcomes. A comprehensive review of the molecular pathogenetic mechanisms underlying glioblastoma development in the setting of HIV/AIDS is provided.

Methods

We performed a PubMed search using keywords “HIV glioma” AND “glioblastoma,” and “AIDS glioma” AND “glioblastoma.” Case reports and series describing HIV-positive patients with glioblastoma (histologically-proven World Health Organization grade IV astrocytoma) and reporting on HAART treatment status, clinical follow-up, and overall survival (OS), were included for the purposes of quantitative synthesis. Patients without clinical follow-up data or OS were excluded. Remaining articles were assessed for data extraction eligibility.

Results

A total of 17 patients met our inclusion criteria. Of these patients, 14 (82.4%) were male and 3 (17.6%) were female, with a mean age of 39.5±9.2 years (range 19–60 years). Average CD4 count at diagnosis of glioblastoma was 358.9±193.4 cells/mm³. Tumor progression rather than AIDS-associated complications dictated patient survival. There was a trend towards increased median survival with HAART treatment (12.0 vs 7.5 months, p=0.10)

Conclusion

Our data suggests that HAART is associated with improved survival in patients with HIV-associated glioblastoma, although the precise mechanisms underlying this improvement remain unclear.

Perioperative concerns in neurosurgical patients with human immunodeficiency virus infection

Background:

The perioperative management of human immunodeficiency virus (HIV) infected patients undergoing neurosurgery is challenging due to the presence of HIV-related multi-system derangements, opportunistic infections and malignancies, history of substance abuse, and adverse effects of anti-retroviral therapy (ART), together with the inherent risks of neurosurgery. The possible adverse impact of HIV disease on the anesthetic outcome due to the associated co-morbidities, and conversely, the role of surgery and anesthesia in HIV disease progression due to their immunosuppressive effects, and also, the fear of HIV transmission among the attending medical personnel are the important perioperative concerns in such surgeries.

Aim:

To present our experience in the perioperative management of HIV-infected patients who underwent neurosurgery at our institute in the past 5 years and highlight the relevant perioperative issues.

Materials and Methods:

A retrospective analysis of the records of HIV-infected neurosurgical patients was undertaken to determine their HIV status and ART, anesthesia and surgery details, perioperative complications, and instances of postoperative worsening of HIV disease or its transmission, if any.

Results:

Seven HIV infected patients with variable severity of HIV infection and systemic disease underwent neurosurgery for different indications. Their perioperative management was modified in accordance with the co-morbidities and the type of neurosurgery. There was no obvious adverse impact of the HIV disease on the anesthetic outcome, no obvious clinical evidence of post-surgery worsening of the HIV disease, and no instance of HIV transmission in our patients.

Conclusion:

A goodunderstanding of the HIV disease and its perioperative implications during neurosurgery helps in better patient management and enables a safe outcome.

Giant-cell glioblastoma of childhood associated with HIV-1 and JC virus coinfection

PURPOSE

John Cunningham (JC) viral DNA sequence has seldom been reported in patients with brain tumors such as high grade gliomas and medulloblastomas, pointing to a role in the etiopathogenesis of such tumors.

RESULTS

We present a unique clinical case of an HIV-positive pediatric patient with multifocal leukoencephalopathy and confirmed JC virus (JCV) infection that developed a giant-cell glioblastoma.

CONCLUSIONS

Experimental data with infected primates has previously hypothesized an association of human giant-cell glioblastoma with JCV or progressive multifocal leukoencephalopathy, though such association has not been documented in the literature for humans. Future studies with larger cohorts and molecular pathological analyses are still needed to corroborate the role of the widely spread human neurotropic virus in early transformation and in the development of brain tumors with different histology in the setting of HIV-related severe immunosuppression.

Cancer immunoediting in malignant glioma

Significant work from many laboratories over the last decade in the study of cancer immunology has resulted in the development of the cancer immunoediting hypothesis. This contemporary framework of the naturally arising immune system-tumor interaction is thought to comprise 3 phases: elimination, wherein immunity subserves an extrinsic tumor suppressor function and destroys nascent tumor cells; equilibrium, wherein tumor cells are constrained in a period of latency under immune control; and escape, wherein tumor cells outpace immunity and progress clinically. In this review, we address in detail the relevance of the cancer immunoediting concept to neurosurgeons and neuro-oncologists treating and studying malignant glioma by exploring the de novo immune response to these tumors, how these tumors may persist in vivo, the mechanisms by which these cells may escape/attenuate immunity, and ultimately how this concept may influence our immunotherapeutic approaches.

Sarcomas other than Kaposi sarcoma occurring in immunodeficiency: interpretations from a systematic literature review

PURPOSE OF REVIEW

In immunodeficiency, an increased sarcoma risk is confirmed for Kaposi's sarcoma. Whether rates of other sarcoma subtypes are elevated in the setting of immunodeficiency is not known. We therefore reviewed published case reports on HIV and AIDS patients and organ transplant recipients with sarcomas. For comparison, we assessed sarcomas in the U.S. general population using Surveillance Epidemiology End Results (SEER) data.

RECENT FINDINGS

A total of 176 non-Kaposi sarcoma were identified, 75 in people with HIV and AIDS and 101 in transplant recipients. Leiomyosarcomas (n = 101) were the most frequently reported sarcomas, followed by angiosarcomas (n = 23) and fibrohistiocytic tumors (n = 17). Leiomyosarcomas were reported with two age peaks, in children and young adults. Epstein-Barr virus (EBV) was detected in the tumor cells in 85 and 88% of leiomyosarcomas in HIV-infected people and transplant recipients, respectively. Angiosarcomas and fibrohistiocytic tumors were most frequently reported in men. Among kidney transplant recipients, 20% of sarcomas arose at the site of an arteriovenous fistula. In comparison, leiomyoscarcomas, angiosarcomas, and fibrohistiocytic tumors comprised 16.9, 3.8, and 18.7% of sarcomas in the U.S. general population.

SUMMARY

Leiomyosarcoma and angiosarcoma may occur disproportionately in immunodeficiency. Leiomyosarcomas appear causatively linked to EBV, whereas angiosarcomas might be correlated with an arteriovenous fistula. Additional studies are necessary to understand the contribution of immunodeficiency to the cause of these sarcomas.

Primary intracranial leiomyosarcoma: review of the literature and presentation of a case

BACKGROUND

Primary intracranial leiomyosarcoma (LMS) is a rare tumor of the central nervous system and therefore has only been reported sporadically.

METHODS

The MEDLINE database was searched for relevant case reports and series published in English from 1969 to March 2012. These papers were reviewed to identify clinical and histopathological features, treatment modalities, and prognoses of patients with primary intracranial LMS.

RESULTS

We reviewed 37 patients, including our patient, with primary intracranial LMS. Of these cases, 16 (43.2%) involved immunosuppression, 4 (10.8%) involved radiation-induced LMS, 3 (8.1%) cases involved a potential leiomyosarcomatous transformation of a brain lesion, and 7 (18.9%) cases, including the presented case, had no specific medical history. The treatment for these cases included resection (33/37, 89.2%), postoperative radiotherapy (20/37, 54.1%), and chemotherapy (7/37, 18.9%).

CONCLUSIONS

The best method for the treatment of LMS could not be determined due to the limited number of cases that have been reported. However, optimized surgical resection, postoperative radiotherapy, and sarcoma-based chemotherapy may improve treatment outcomes.

Primary intracranial β-human chorionic gonadotropin-producing leiomyosarcoma in a 2-year-old immunocompetent child

The authors present a rare case of primary intracranial leiomyosarcoma (LMS) in a young, immunocompetent boy. The patient presented with an expanding right forehead mass. Diagnostic workup revealed multiple large intracranial tumors. The largest mass was resected, and pathological analysis revealed LMS. Given the poor prognosis of this tumor, the family declined further care, and the child died 3 months later. Primary LMSs are extremely rare tumors in the pediatric population, especially in patients who are not immunocompromised.

Meningeal Hemangiopericytoma with Intracranial Metastases in an HIV-Positive Male: Case Report and Review of the Literature

Background

Meningeal hemangiopericytoma is a rare, aggressive CNS tumor that tends to invade locally, metastasize, and has a high rate of recurrence. HIV classically increases the risk of 3 AIDS-defining malignancies: Kaposi's sarcoma, non-Hodgkin's lymphoma and invasive cervical cancer. More recently, considerable interest has been paid to the link between HIV and a wider range of non-AIDS-defining cancers. An HIV-positive patient with meningeal hemangiopericytoma is described.

Case Description

A 36-year-old HIV-positive male presented with worsening headache and ataxia. The patient had experienced similar neurologic symptoms 4 months prior and MRI at that time had showed an extra-axial left cerebellar mass most consistent with benign meningioma. Repeat MRI showed the tumor had increased in size by a factor of greater than 20 in this 4-month period, with 4 small additional foci of similar enhancement. Subtotal resection was performed on the mass and final pathological diagnosis was meningeal hemangiopericytoma.

Conclusions

This represents the first reported case of meningeal hemangiopericytoma in an HIV-positive patient. This is also the shortest time to intracranial metastasis ever reported for a meningeal hemangiopericytoma. Although the increased risk in the HIV-positive population of non-AIDS-defining cancers that has been observed in recent years can largely be attributed to cancers with a known viral pathogenesis, it is speculated that HIV infection in this patient may have contributed to the occurrence or unique behavior of this rare tumor.

Human immunoglobulin G levels of viruses and associated glioma risk

Few consistent etiological factors have been identified for primary brain tumors. Inverse associations to asthma and low levels of varicella-zoster virus, immunoglobulin (Ig) levels in prevalent cases have indicted a role for the immune system in the development of glioma. Because samples from prevalent cases of glioma could be influenced by treatments such as steroids and chemotherapy, we investigated pre-diagnostic samples from three large Scandinavian cohorts. To test the hypothesis that immune response levels to these viruses are associated etiologically with glioma risk, we investigated pre-diagnostic immunoglobulin levels for cytomegalovirus (CMV), varicella-zoster virus (VZV), adenovirus (Ad), and Epstein-Barr virus (EBV) including the nuclear antigen (EBNA1) using plasma samples from 197 cases of adult glioma and 394 controls collected from population-based cohorts in Sweden and Denmark. Low VZV IgG levels were marginally significantly more common in glioma cases than the controls (odds ratio (OR) = 0.68, 95% CI 0.41–1.13) for the fourth compared with the first quartile (p = 0.06 for trend). These results were more prominent when analyzing cases with blood sampling at least 2 years before diagnosis (OR = 0.63, 95% CI 0.37–1.08) (p = 0.03). No association with glioma risk was observed for CMV, EBV, and adenovirus.

Epstein-Barr virus-associated adrenal smooth muscle tumors and disseminated diffuse large B-cell lymphoma in a child with common variable immunodeficiency: a case report and review of the literature

This article reports the clinical and the histological features in a 7-year-old girl affected by common variable immunodeficiency (CVID) who developed multiple Epstein-Barr virus-associated tumors, represented by bilateral adrenal smooth muscle tumors (EBV-SMT) and multifocal diffuse large B-cell lymphoma. The EBV-SMTs showed features compatible with a benign or at least a low-malignant potential neoplasm. A peculiar feature observed in both EBV-SMTs was the occurrence of numerous lymphocytes intermingled with the spindle cells, which consisted of CD3+ CD5+ T-cells, with a predominant cytotoxic CD8+ component. Interestingly, EBV status differed in the neoplasms, since the EBV-SMTs were negative for LMP1 and positive for EBER, whereas the B-cell lymphoma expressed both EBV markers. Furthermore, EBV-LMP1 deletion was positive only in the EBV-SMTs, thus indicating that these tumors were the consequence of 2 distinct, EBV-dependent transformations. Similarly, lymphocyte clonality assay also showed different clonal bands in different sites (skin and nasal cavity), suggesting the development of intratumoral mutations. Finally, the authors review all 127 previously reported EBV-SMT, with discussion of their clinical and pathological features.

Efficacy and safety/toxicity study of recombinant vaccinia virus JX-594 in two immunocompetent animal models of glioma

The purpose of this study was to investigate the oncolytic potential of the recombinant, granulocyte macrophage colony-stimulating factor (GM-CSF)-expressing vaccinia virus (VV) JX-594 in experimental malignant glioma (MGs) in vitro and in immunocompetent rodent models. We have found that JX-594 killed all MG cell lines tested in vitro. Intratumoral (i.t.) administration of JX-594 significantly inhibited tumor growth and prolonged survival in rats-bearing RG2 intracranial (i.c.) tumors and mice-bearing GL261 brain tumors. Combination therapy with JX-594 and rapamycin significantly increased viral replication and further prolonged survival in both immunocompetent i.c. MG models with several animals considered “cured” (three out of seven rats >120 days, terminated experiment). JX-594 infected and killed brain tumor-initiating cells (BTICs) from patient samples grown ex vivo, and did so more efficiently than other oncolytic viruses MYXV, Reovirus type-3, and VSV^ΔM51. Additional safety/toxicity studies in nontumor-bearing rodents treated with a supratherapeutic dose of JX-594 demonstrated GM-CSF-dependent inflammation and necrosis. These results suggest that i.c. administered JX-594 triggers a predictable GM-CSF-mediated inflammation in murine models. Before proceeding to clinical trials, JX-594 should be evaluated in the brains of nonhuman primates and optimized for the viral doses, delivery routes as well as the combination agents (e.g., mTOR inhibitors).

Epstein-Barr virus-associated intracranial leiomyosarcoma in an HIV-positive adolescent

A 17-year-old African American female with human immunodeficiency virus infection presented with an unresectable intracranial neoplasm with mass effect upon the brainstem. Stereotactic biopsy revealed an Epstein-Barr virus (EBV)-associated leiomyosarcoma. Radiation therapy and gemcitabine were used to shrink the mass with the aim to make it surgically resectable. Prolonged neutropenia and recurrent skin infections led to the discontinuation of gemcitabine. The mass stabilized after radiation therapy and has decreased in size in 15 months of follow-up. EBV has been demonstrated in most smooth muscle tumors associated with acquired immunodeficiency syndrome and other immunocompromised states. This is the first documented case of an EBV-positive intracranial leiomyosarcoma in a pediatric human immunodeficiency virus patient.

Primary intracranial leiomyosarcoma: a case report and review of the literature

INTRODUCTION

Malignant tumours of the central nervous system (CNS) represent the second most common cancer type in the paediatric population of developed countries, and mortality caused by CNS tumours is the highest among paediatric cancers. Tumours of mesenchymal origin occurring either as primary or secondary lesions of the central nervous system are very rare in children. This paper describes the case of a 5-year-old non-immunocompromised male who presented with a right frontal primary intracranial leiomyosarcoma associated with large subdural collections.

DISCUSSION AND CONCLUSION

Following surgical excision and adjuvant chemoradiotherapy, the patient has remained disease-free for 18 months. The literature is reviewed and the possible association of the chronic subdurals to the later development of the leiomyosarcoma explored.

Application of magnetic resonance spectroscopy in the differentiation of high-grade brain neoplasm and inflammatory brain lesions

This study aims at evaluating the application of magnetic resonance spectroscopy (MRS) in the differential diagnosis of brain tumors and inflammatory brain lesions. The examinations of 81 individuals, who performed brain MRS and were retrospectively analyzed. The patients with ages between 10 and 80 years old, were divided into two groups. Group A consisted of 42 individuals with diagnoses of cerebral toxoplasmosis and Group B was formed of 39 individuals with diagnosis of glial neoplasms. On analyzing the ROC curve, the discriminatory boundary for the Cho/Cr ratio between inflammatory lesions and tumors was 1.97 and for the NAA/Cr ratio it was 1.12. RMS is an important method useful in the distinction of inflammatory brain lesions and high-degree tumors when the Cho/Cr ratio is greater than 1.97 and the NAA/Cr ratio is less than 1.12. And so this method is important in the planning of treatment and monitoring of the therapeutic efficiency.

Primary central nervous system lymphoma

Primary central nervous system lymphomas (PCNSL) are aggressive malignancies that arise in distinct anatomical sites, which display unique structural, biological and immunological conditions. So far, despite recent therapeutic advances, these malignancies exhibit one of the worst prognoses among all non-Hodgkin lymphomas (NHL). For a long time, radiotherapy (RT) has been the standard treatment, producing a response rate of 60-65% and a notable neurological improvement in most cases. However, relapse usually occurred within a few months after RT, with a median survival of 14 months and a 5-year survival of approximately 15-24%. Although the introduction of systemic chemotherapy has consistently improved survival, the prognosis of PCNSL is still dismal, with high rates of local relapse and consequent death. Defining the optimum therapeutic management is difficult because of potential selection biases in large retrospective reviews and the limited number of prospective studies. Although studies published on PCNSL are increasing, several therapeutic questions still remain unanswered after a decade of research.

Astrocyte elevated gene-1: recent insights into a novel gene involved in tumor progression, metastasis and neurodegeneration

Tumor progression and metastasis are complex processes involving intricate interplay among multiple gene products. Astrocyte elevated gene (AEG)-1 was cloned as an human immunodeficiency virus (HIV)-1-inducible and tumor necrosis factor-alpha (TNF-alpha)-inducible transcript in primary human fetal astrocytes (PHFA) by a rapid subtraction hybridization approach. AEG-1 down-regulates the expression of the glutamate transporter EAAT2; thus, it is implicated in glutamate-induced excitotoxic damage to neurons as evident in HIV-associated neurodegeneration. Interestingly, AEG-1 expression is elevated in subsets of breast cancer, glioblastoma multiforme and melanoma cells, and AEG-1 cooperates with Ha-ras to augment the transformed phenotype of normal immortal cells. Moreover, AEG-1 is overexpressed in >95% of human malignant glioma samples when compared with normal human brain. Overexpression of AEG-1 increases and siRNA inhibition of AEG-1 decreases migration and invasion of human glioma cells, respectively. AEG-1 contains a lung-homing domain facilitating breast tumor metastasis to lungs. These findings indicate that AEG-1 might play a pivotal role in the pathogenesis, progression and metastasis of diverse cancers. Our recent observations indicate that AEG-1 exerts its effects by activating the nuclear factor kappa B (NF-kappaB) pathway and AEG-1 is a downstream target of Ha-ras and plays an important role in Ha-ras-mediated tumorigenesis. These provocative findings are intensifying interest in AEG-1 as a crucial regulator of tumor progression and metastasis and as a potential mediator of neurodegeneration. In this review, we discuss the cloning, structure and function(s) of AEG-1 and provide recent insights into the diverse actions and intriguing properties of this molecule.

Granular cell astrocytoma of the cerebellum: report of the first case

Granular cell astrocytomas are an uncommon morphologic variant of infiltrating gliomas characterized by relatively large tumor cells with granular cytoplasm occupying variable proportions of the tumor. These tumors are thought to be more aggressive than similar tumors with no granular cell component. The tumor occurred in a 9-year-old girl who was immunocompromised owing to liver transplantation. Histologically, the tumor corresponded to World Health Organization grade II. It extensively infiltrated the cerebellum and was composed, predominantly, of large cells with eosinophilic granular cytoplasm. These cells coexpressed glial fibrillary acidic protein and CD68. Of the 49 cases of granular cell astrocytomas reported to date, none have involved the cerebellum. The tumor described herein represents the first case of cerebellar granular cell astrocytoma. Pathologic features and diagnostic pitfalls are explored.

Atteintes du système nerveux central et infection par le VIH-1

Central nervous system complications are common in HIV-1 infected patients and occur either as a result of concomitant immunosuppression (opportunistic infections, lymphoma and tumors), as a primary manifestation of HIV infection, or as an adverse effect of therapy (immune restoration and toxicity). These complications contribute largely to patient morbidity and mortality. In the era of highly active antiretroviral therapy (HAART) these disease states have changed in presentation, outcome and incidence. We review in detail the epidemiology, pathogenesis, clinical features, diagnosis, and management of these disorders.

Primary Meningeal Epstein-Barr Virus-related Leiomyosarcoma in a Man Infected With Human Immunodeficiency Virus

We describe the clinical, radiologic, surgical, and pathologic findings of a 29-year-old Peruvian human immunodeficiency virus-infected man with a primary parasellar meningeal leiomyosarcoma involving the left lesser esphenoidal wing and the cavernous sinus. Over a period of 13 months, he developed headache, vomiting, insomnia, and diplopia. Magnetic resonance imaging revealed a left parasellar extra-axial mass that was isointense in T1, hypointense in T2, and gadolinium-enhanced. The patient underwent subtotal resection of the tumor. The neoplasm was composed of spindle cells with smooth-muscle features. It showed moderate atypia, inconspicuous nucleoli, and scanty mitosis. No tumor necrosis was detected. The immunohistochemistry revealed strong positivity for vimentin, desmin, and smooth-muscle alpha-actin. A low-grade leiomyosarcoma was diagnosed. The in situ hybridization showed positive nuclear reactivity for Epstein-Barr virus-encoded RNA. The immunohistochemistry was negative for Epstein-Barr virus latent membrane protein 1. The main differential diagnosis of primary meningeal smooth-muscle tumors includes meningioma and peripheral nerve sheath tumors. Epstein-Barr virus has been demonstrated in most smooth-muscle tumors associated with acquired immune deficiency syndrome (AIDS). Primary meningeal smooth-muscle tumors, exceedingly rare neoplasms, remarkably affect young adults with AIDS. Comparatively, most AIDS-related visceral (nonmeningeal) smooth-muscle tumors have been reported in children. The permissiveness and tumorigenesis associated with Epstein-Barr virus may depend on the age of human immunodeficiency virus infection.

Gliomas following organ transplantation: analysis of the contents of a tumor registry

Object. The author and others have described a series of patients in whom gliomas have developed following solid organ transplantation. Additionally, patients infected with human immunodeficiency virus reportedly have an increased incidence of gliomas. The author sought to examine the association between the immunosuppressive state in organ transplant recipients and the development of gliomas.

Methods. Reported cases of tumor in the transplant population of the Israel Penn International Transplant Tumor Registry (IPITTR) were examined. These cases were compared with predicted cases in the 2001 American Cancer Society (ACS) estimates.

Of the 7256 malignant tumors listed in the IPITTR database, 19 (0.3%) were primary brain tumors, including 14 gliomas. Tumors known to occur at an increased frequency in transplant recipients accounted for a 1.6- to 2.9-fold increased percentage of cases in the IPITTR compared with 2001 ACS estimates. Tumors not thought to occur with an increased frequency in this population, such as gastrointestinal malignancy and lung cancer, had ratios of 0.19 to 0.35. The corresponding ratio for primary brain tumors was 0.19. None of the six cases previously described by the author and his colleagues was reported to the IPITTR.

Conclusions. Primary brain tumors, including gliomas, do not appear to be overrepresented in the IPITTR, indicating that they may not arise with increased frequency in transplant recipients. Nevertheless, one cannot exclude the possibility that neurooncologists may have underreported such cases to this voluntary tumor registry.

Oligodendroglioma in a patient with AIDS: case report and review of the literature

In the last years, new techniques of neuroimages and histopathological methods have been added to the management of cerebral mass lesions in patients with AIDS. Stereotactic biopsy is necessary when after 14 days of empirical treatment for Toxoplasma gondii encephalitis there is no clinical or neuroradiologic improvement. We report a woman with AIDS who developed a single focal brain lesion on the right frontal lobe. She presented a long history of headache and seizures. After two weeks of empirical treatment for toxoplasma encephalitis without response, a magnetic resonance image with spectroscopy was performed and showed a tumoral pattern with a choline peak, diminished of N-acetyl-aspartate and presence of lactate. A stereotactic biopsy was performed. Histopathological diagnosis was a diffuse oligodendroglioma type A. A microsurgical resection of the tumor was carried out and antiretroviral treatment was started. To date she is in good clinical condition, with undetectable plasma viral load and CD4 T cell count > 200 cell/uL.

Feline intracranial neoplasia: retrospective review of 160 cases (1985-2001)

The purpose of this study was to determine the frequency of different tumor types within a large cohort of cats with intracranial neoplasia and to attempt to correlate signalment, tumor size and location, and survival time for each tumor. Medical records of 160 cats with confirmed intracranial neoplasia evaluated between 1985 and 2001 were reviewed. Parameters evaluated included age, sex, breed, FeLV/FIV status, clinical signs, duration of signs, number of tumors, tumor location(s), imaging results, treatment, survival times, and histopathologic diagnosis. Most of the cats were older (11.3 +/- 3.8 years). Primary tumors accounted for 70.6% of cases. Metastasis and direct extension of secondary tumors accounted for only 5.6 and 3.8% of cases, respectively. Twelve cats (7.5%) had 2 or more discrete tumors of the same type, whereas 16 cats (10.0%) had 2 different types of intracranial tumors. The most common tumor types were meningioma (n = 93, 58.1%), lymphoma (n = 23, 14.4%), pituitary tumors (n = 14, 8.8%), and gliomas (n = 12, 7.5%). The most common neurological signs were altered consciousness (n = 42, 26.2%), circling (n = 36, 22.5%), and seizures (n = 36, 22.5%). Cats without specific neurological signs were common (n = 34, 21.2%). The tumor was considered an incidental finding in 30 (18.8%) cats. In addition to expected relationships (eg, meninges and meningioma, pituitary and pituitary tumors), we found that lesion location was predictive of tumor type with diffuse cerebral or brainstem involvement predictive of lymphoma and third ventricle involvement predictive of meningioma.

Epstein-Barr virus-associated smooth muscle tumor of the basal ganglia in an HIV+ child: case report and review of the literature

We describe the clinicopathologic features of an Epstein-Barr virus (EBV)-associated smooth muscle tumor arising in the basal ganglia of a 10-year-old human immunodeficiency virus (HIV)-positive child. Only a few cases of intracranial smooth muscle tumors are reported in the literature and virtually all of these have been extra-axial, involving the dura or sinuses in HIV+ adults. Our case underscores the need to include an EBV-associated smooth muscle tumor in the differential diagnosis when evaluating intracranial mass lesions in immunodeficient children.