Pattern of Diseases among HIV-Infected Patients Attending Tertiary Cancer Center
1Soumya Surath Panda*, 1LalatenduMoharana, 1SpoorthyKolluri, 1Hemlata Das,
1SindhuKilaru, 1Saroj Prasad Panda, 2Jatindra Nath Mohanty
1Department of Medical Oncology, IMS and Sum hospital, SOA deemed to be University, Bhubaneswar, India
Medical Research Laboratory, IMS and Sum hospital, SOA deemed to be University, Bhubaneswar, India
Abstract
HIV-infected people are living longer with better-controlled infection and they are experiencing higher incidence of chronic and age-related diseases including cancer. HIV infection has been associated with an increased risk of kaposi's sarcoma (KS), cervical cancer and non-Hodgkin's lymphoma (NHL); referred to as AIDS-defining cancers because of their association with increased risk of HIV infection. However, the spectrum of cancer diagnosis has been shifting from AIDS-defining to non-AIDS defining cancers since the introduction and widespread use of antiretroviral therapy (ART). In the current study, we include 72patients and found malignant 56 and non- malignant 16. Novel associations may become apparent as HIV-infected people are increasingly surviving (50 years and above) due to increasing access to ART. Such studies will provide a valuable tool for future investigations.
Introduction
Little is known about cancer risk in Indian persons with HIV/AIDS .The cancer profile in Indian persons with HIV/AIDS may differ from that in the developed countries.HIV-infected individuals have an increased propensity to develop malignancy. Initially Kaposi's sarcoma (KS) , subsequently Non-Hodgkin lymphoma (NHL) and invasive cervical carcinoma were added as AIDS-defining conditions. The incidence of KS and NHL has decreased markedly after the use of potent antiretroviral therapy (ART), but there has been a relative increase in tumor types that collectively are referred to as non-AIDS-defining cancers (NADCs) compared with the general population.
PATHOGENESIS
Factors contributing to the increased incidence of malignancy in HIV infected patients include immunosuppression, direct effects of the HIV virus itself, coinfection with other oncogenic viruses, environmental factors, and possibly the use of antiretroviral drugs.
Immunosuppression — The development of neoplasia in HIV-infected patients is similar to that observed in solid organ transplant recipients who receive chronic immunosuppressive agents, as well as in patients with profound cell-mediated immune deficiencies. Untreated HIV infection is characterized by progressive immunologic deterioration. This immunologic decline, as reflected by the CD4 cell count, closely correlated with the increased incidence Kaposi sarcoma (KS) and NHL prior to the introduction of potent antiretroviral therapy (ART) .
Role of the HIV virus — HIV infection may have a direct effect on a variety of cellular processes that contribute to the development of cancer . Postulated mechanisms include the
activation of proto-oncogenes, alterations in cell cycle regulation, inhibition of tumor suppressor genes, or other genetic alterations that lead to oncogenesis.
Patients infected with HIV are at increased risk of coinfection with other viruses that are known to cause cancer .
HHV-8 infection — In 1994, a novel gamma herpesvirus was identified in biopsies from KS . This virus was subsequently named human herpesvirus 8 (HHV-8) or Kaposi's sarcoma- associated herpesvirus (KSHV). HHV-8 has also been associated with the multicentric form of Castleman’s disease and primary effusion lymphoma. Both of these entities are found primarily in patients with HIV infection.
HPV infection — The relationship of human papillomavirus (HPV) associated cervical dysplasia and neoplasia to HIV infection may be due to lifestyle risks for acquiring both viruses, as well as to attributes of and host responses to HPV. HIV-infected patients may be unable to clear oncogenic strains of HPV due to T cell deficiency.
Materials & Methods
We conducted a retrospective analysis of 72 HIV infected patients who visited our tertiary care cancer hospital between 2002 & 2011.
The following parameters were looked into : a) Gender distribution
b) Disease condition – Malignant and Non-malignant. Details of malignant and Non- malignant diseases were also noted
c) CD4 Count availability- If available, median CD4 Count
d) Whether on HAART (Highly Active Anti-Retroviral Therapy). if yes, median duration on HAART therapy
e) Which was the most common malignant condition among the HIV patients ? f) Different sub-types of NHL
g) Treatment details- Outcomes, Delays, Inter-current infection, Incidence of Neutropenia , CD4 count of patients on Chemotherapy and relation to infection.
Results
Out of 72 patients, 41(56.9%) were male and 31(43%) were female.
Disease Condition : Malignant - 56 patients (78%) and Non-malignant -16 patients (22%)
Distribution of Patients
57%
43%
Gender
Male (n=41) Female (n=31)
Non-malignant conditions
Malignant Conditions
HCC, RCC,Larynx,Hypopharynx,tongue,thyroid,vagina,NSGCT,stomach,bowen’s disease, neuroendocrine tumor of pancreas accounted for 1 case each.
22%
78%
Disease Condition
Non- malignant (n=16)
Malignant (n=56)
Other Parameters
AIDS Defining Condition was present in 27 / 56 (48.2%)
Median HB – 11.0, TC – 6700, TPC- 2.53L HIV & NHL
N = 14 / 72 (19.4%)
Median Age = 42 (32 – 60)
Subtype‘s
Received treatment - 10 / 14
Why Compromised - Poor PS - 5/7 , Not specified - 1/7 , HIV - 1/7
Conclusions
The most common cause for which HIV patients attended our hospital was surprisingly due to diseases not related to cancer (22.2%) such as tuberculosis , persistent generalized lymphadenopathy etc. As in the developed countries, the most important cancer associated
with AIDS in India is NHL. Kaposi sarcoma is conspicuously absent. Optimal treatment , whenever possible , should be given.
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