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Chapter 21: HIV-Related Malignancies

Kathryn Lurain; Robert Yarchoan; Thomas S. Uldrick

INTRODUCTION

HIV increases the risk of several cancers, including Kaposi sarcoma, aggressive B-cell non-Hodgkin lymphomas, classical Hodgkin lymphoma, HPV-associated cancers (eg, cervical, anal), lung cancer, and oropharyngeal cancer. As people with HIV are aging, incidental cancers also occur in this patient population. Oncologists should be aware of the principles of treating cancer in people living with HIV. Treating these patients requires a multidisciplinary approach that takes into account potential drug-drug interactions and appropriate supportive care. Antiretroviral therapy is almost always indicated, and prophylaxis against opportunistic infections is sometimes required. In general, cancers in people living with HIV should be treated in the same manner as HIV-negative patients, and HIV alone should not be used as a reason to offer less aggressive cancer therapy. Treatments for Kaposi sarcoma, Kaposi sarcoma herpesvirus-associated multicentric Castleman disease, and HIV-related lymphomas are discussed in detail in this chapter. ART is an essential part of the treatment of HIV, regardless of CD4+ T cell count, to reduce the morbidity and mortality of HIV infection. ART may be sufficient in treating many cases of HIV-KS. Guidelines for the use of antiretroviral therapy can be found at www.aidsinfo.nih.gov (U.S. Department of Health and Human Services).

KAPOSI SARCOMA (KS)

Epidemiology of KS

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Epidemiology of KS
Population Incidence/100,000
United States, overall population, male 1.1✫
United States, overall population, female 0.1
HIV-infected in United States in era of effective combination HIV therapy 168
Africa, male 39.3
Africa, female 21.8
HIV-infected in East Africa in era of effective combination HIV therapy 321

✫Risk of KS is 4.5 times greater in African-American men than white men in the United States

Howlader N et al. SEER Cancer Statistics Review 1975–2014. Available at seer.cancer.gov [accessed June 2020]

Semeera A et al. Cancer Med 2016;5:1914–1928

Yanik EL et al. J Clin Oncol 2016;34:3276–3283

Pathology

  1. All KS is caused by Kaposi sarcoma herpesvirus (KSHV), also called human herpesvirus 8 (HHV-8), a gamma-herpesvirus first identified in 1994

  2. Pathology shows a highly vascular tumor with spindle-shaped cells that stain positive for KSHV latency-associated nuclear antigen (LANA)

 

Moore PS, Chang Y. N Engl J Med 1995;332:1181–1185

Work-up

  1. Biopsy to confirm diagnosis

  2. HIV serology, HIV viral load, and CD4+ T cell count

  3. Assessment of tumor extent:

    • Physical examination of the skin, oral mucosa, and lymph nodes

    • CBC with differential, chemistry panel

    • Chest x-ray

    • Chest CT scan not routinely indicated unless x-ray is abnormal or patient reports respiratory symptoms

    • Fecal occult blood testing and endoscopic evaluation if positive or patient reports gastrointestinal symptoms

Staging (ACTG TIS Staging for Kaposi sarcoma herpesvirus)

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Staging (ACTG TIS Staging for Kaposi sarcoma herpesvirus)
Good Risk (0) Poor Risk (1)
Tumor (T)
Confined to skin and/or lymph nodes

Tumor-associated edema, infection, or ulceration

Extensive/nodular oral KS

Gastrointestinal KS

KS in other ...

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