HIV Page 6

Introduction
Significant contributors to morbidity and mortality in HIV. Kaposi sarcoma Lymphoma Intraepithelial dysplasia of the cervix and anus return to main menu

Kaposi's Sarcoma
Multicentric neoplasm: multiple vascular nodules -- skin, mucous membranes, viscera. Minor to extensive involvement. A sexually transmitted to factor appears to play a significant role in Kaposi sarcoma development. (HHV 8 maybe this viral cofactor) Almost exclusively associated with homosexual men. With the decline of HIV infection rates in this population, the rate of appearance of Kaposi sarcoma has also declined. Can be an early manifestation of HIV infection (normal CD₄ T cell counts) With better management of opportunistic infections, Kaposi's sarcoma is now appearing as a late manifestation of HIV infection ay result from cytokine dysregulation. Characteristics of tumor. vascular in nature color: reddish to purple to brown (bruise-like) size: few mm -- several cm Tissues affected: Skin Lymph nodes Gastrointestinal tract Lung Spleen Kaposi's Sarcoma: Treatment Since less than 10% of AIDS patients with Kaposi sarcoma die of malignancy -- death from opportunistic infection is much more common, treatment that suppresses immune function should be avoided. Treatment is palliative, not associated with enhanced survival. Circumstances for Treatment: Cosmetic problems; significant discomfort -- localized irradiation (HIV patients are especially sensitive to radiation therapy side effects) intralesional vinblastine cryotherapy (if possible) Large number of lesions: single agent chemotherapy etoposide (VP-16,VePe-sid) vinblastine (Velban) oxorubicin (Adriamycin) bleomycin (Blenoxane) IFN-alpha The most important predictor of therapeutic response to single agent chemotherapy is CD₄ T cell count. In life-threatening cases, combination therapy is indicated: drug combinations include -- low dose doxorubicin (Adriamycin), bleomycin (Blenoxane), and vinblastine (Velban). return to main menu

Lymphoma
About 6% of HIV patients develop lymphoma (approximately and 120-fold increase over the incidence in the general population) Late manifestation of HIV-- CD₄ T cell count < 200 per microliter As HIV patients live longer because of improved antiretroviral treatment, better management and prophylaxis of opportunistic infections, lymphomas may appear more frequently. Three major lymphoma types occur in HIV infected patients: grade III or IV immunoblastic lymphoma Burkitt's lymphoma primary CNS lymphoma Most (90%) are B-cell phenotype; about half contain Epstein-Barr viral DNAImmunoblastic lymphoma Accounts for about 60% of lymphoma seen in HIV more common in older patients generally high-grade Burkitt's lymphoma (small noncleaved cell lymphoma) Accounts for about 20% of lymphoma seen in HIV. Age-group: 10 to 19 years of age. Frequency in HIV population: about 1000-fold higher than in the general population. About 50% of HIV-Burkitt's lymphoma contain Epstein-Barr viral genome (and African Burkitt's lymphoma -- 97% contain Epstein-Barr) Primary CNS lymphoma Accounts for about 20 percent of lymphoma in HIV. Most primary CNS lymphomas are positive for Epstein-Barr. CNS lymphoma in HIV patients-- associated with advanced disease (CD4 T cell count less than 40 per microliter) Focal neurological deficits including headaches, seizures, cranial nerve involvement. Clinical presentations: varied focal seizures -- rapidly growing mass lesions At least 80% of HIV lymphoma patients present with: extranodal disease (including gastrointestinal sites, 25%) and night sweats and than in fever than weight loss return to main menu HIV-Lymphoma Treatment Low response rates and high incidence of opportunistic infections were associated with standard intensive therapeutic approaches -- now largely abandoned Median survival for patients treated with intensive protocols: 4-6 months. (Note these patients usually have relatively advanced HIV disease with low CD₄ T cell counts) Low-dose protocols are presently being evaluated. Primary CNS lymphoma: Nearly always unsuccessful-- median survival two to four months. Palliative approaches: radiation glucocorticoids return to main menu