Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
REVIEW ARTICLE
Year : 2010  |  Volume : 6  |  Issue : 4  |  Page : 432-441

AIDS: A radiation oncologist's perspective


Department of Radiation Oncology, Centre for Cancer, Kokilaben Dhirubhai Ambani Hospital and Research Institute, Four Banglows, Andheri (W), Mumbai - 400053, Maharashtra, India

Date of Web Publication24-Feb-2011

Correspondence Address:
Suman Mallik
Department of Radiation Oncology, Centre for Cancer, Kokilaben Dhirubhai Ambani Hospital and Research Institute, Four Banglows, Andheri (W), Mumbai - 400053, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.77078

Rights and Permissions
 > Abstract 

While HIV is often associated with tuberculosis and a number of opportunistic infections, the spectrum of diseases of patients with HIV infection encompasses a number of malignancies as well. Typically, these are the AIDS-defining malignancies, though other malignancies also comprise a significant caseload. Radiotherapy plays an integral part in anti-cancer treatment and its tolerance and efficacy in HIV+ patients are therefore important. The patient's level of immunity as manifested by the CD4 count has a significant bearing on treatment outcomes. In some cases, like primary central nervous system lymphoma (PCNSL), the occurrence of the malignancy itself is tied to the patient's immunity with increased incidence in patients with CD4 counts less than 50/mm 3 . The success of highly active antiretroviral therapy (HAART) has allowed administration of standard doses of radiotherapy and even chemotherapy in recent times leading to improved outcomes. In general, standard radiotherapy and concomitant chemo-radiotherapy protocols should be used wherever possible, so as not to compromise disease control. Local control and disease-specific survival rates in HIV patients are no worse than in HIV? patients, but this is only true for CD4 counts above 200/mm 3 . In certain situations like cervical intraepithelial neoplasia CIN, HAART itself is associated with disease regression. The question of increased radiosensitivity in HIV patients remains unresolved in most diseases and there are sparse data with regard to non-HIV associated malignancies in these patients. Greater caution and emphasis on good supportive care and HAART would appear to be essential when treating the malignancies in HIV+ patients with standard anti-cancer regimens.

Keywords: AIDS, malignancy, radiotherapy, toxicity


How to cite this article:
Mallik S, Talapatra K, Goswami J. AIDS: A radiation oncologist's perspective. J Can Res Ther 2010;6:432-41

How to cite this URL:
Mallik S, Talapatra K, Goswami J. AIDS: A radiation oncologist's perspective. J Can Res Ther [serial online] 2010 [cited 2019 Jul 19];6:432-41. Available from: http://www.cancerjournal.net/text.asp?2010/6/4/432/77078


 > Introduction Top


There are 33.4 million individuals estimated to be living with HIV, (WHO, 2008, http://www.who.int/hiv/data ) of whom around 2.7 million are newly infected every year with around 2.0 million estimated deaths annually of which more than 0.28 million are below 15 years. Prevalence of adult HIV in India is 0.3% (WHO 2007, apps.who.int/globalatlas). In 2001, the estimation was that in spite of the overall prevalence of HIV being 0.5%, due to the population size, in terms of numbers, it was second only to South Africa as far as people living with HIV/AIDS were concerned.

While HIV is often associated with tuberculosis and a number of opportunistic infections, the spectrum of diseases of patients with HIV infection encompasses a number of malignancies as well. Typically, these are the AIDS-defining malignancies, though other malignancies also comprise a significant caseload. With the HIV-1 epidemic, AIDS-related Kaposi's sarcoma and other non-Hodgkin's lymphoma and few other malignancies have definitely increased although AIDS has not caused an overall increase in the global risk of cancer. [1] Radiotherapy is one of the cornerstones of treatment of many malignancies. Response and tolerance to treatments like radiotherapy are the primary concern in an HIV+ individual. Another question that remains unanswered is whether HIV positivity makes a malignancy more aggressive and alters the natural history.

We have explored the issues of radiotherapy and HIV related malignancies based on available evidence to answer the optimal radiotherapeutic management in HIV+ patients with malignancies, especially in AIDS related malignancies [Table 1].
Table 1: AIDS related malignancies

Click here to view


Search strategy

Data of this review were identified by searches of Medline, current contents, PubMed, Embase, Cancer Lit, Aidsline using the search terms "AIDS and radiotherapy", "HIV and malignancies", "HIV and cancer cervix", "HIV and anal and cancer", "HIV and lymphoma", "HIV and NHL", "HIV and Hodgkin's disease", "HIV and PCNSL", "HIV and Kaposi's sarcoma", "Kaposi's and radiotherapy", "HIV and squamous carcinoma of conjunctiva", "HIV and leiomyosarcoma", "HIV and radiotherapy and toxicity", "HAART and radiotherapy", "HIV and radiotherapy and head-neck cancer, "HIV and breast cancer", "HIV and testicular cancer", and "HIV and lung cancer". Only papers published in English between 1974 and 2010 have been included.


 > Aids and Carcinoma Cervix Top


Incidence of cervical cancer is increasing with the incidence of HIV infection. Both HIV-1 and HIV-2 are associated with higher risk of cervical cancer. [2] Cervical cancer and HIV infection share similar etiology. In 1993, Centre for Disease Control (CDC) has included carcinoma cervix as an AIDS defining illness. [3],[4] Women with HIV-1, HIV-2, and HIV-1 and HIV-2 dual infection were all at increased risk of prevalent high grade squamous intraepithelial lesions HSIL s or invasive cervical cancer (ICC), compared with HIV women. Hawes et al. have reported that high grade squamous intraepithelial lesions are more common in HIV-2 infection compared to HIV-1, whereas low risk intraepithelial lesions are more common in HIV-1. Dual infection increases the incidence of low grade squamous intraepithelial lesion (LSIL) and HSIL significantly. [5] Human papilloma virus (HPV) (16, 18, 31, 33, 35, 45, 52, 53, 58 and 66) coinfection is associated with an increased risk of developing intraepithelial neoplasia and rapid progression to invasive cervical cancer. [5],[6],[7],[8],[9],[10] About 20% cases of CIN in HIV+ patients is associated with HPV infection. [11] Risk of squamous intraepithelial lesion is increased by 4.5 times in HIV-infected patients. Coinfection of HPV with HIV is thought to result in cell disruption, and consequently, dysregulation of the cellular and hormonal arms of local and systemic immunity, resulting in the inability to contain infection and disease progression. [12],[13],[14] Recurrence of CIN after treatment is more common in HIV+ women compared to HIV-ones (62% vs. 18%). Women with CD4 cell counts <200 per μl have a twofold increase in both prevalence and incidence of squamous intraepithelial lesion (SIL) compared with women with CD4 cell counts ≥200 per μl. HIV-1, HIV-2, dual infection, CD4 level, and HIV viral load have significantly increased the risk of having ICC and CIN.

Treatment

Highly active antiretroviral therapy (HAART) is an integral part of therapy of HIV+ women with cervical cancer. SIL can regress with the use of HAART, and the rate of regression of lesion is more with the use of HAART. [15] International Atomic Energy Association (IAEA) has developed a guideline for treatment of HIV associated cervical cancer depending on CD4 counts.

IAEA TECDOC guideline

Patients with intact immune system: CD4 > 200 per μl

• No evidence that customary management needs to be changed

Patients with moderate immune impairment: CD4 > 50 but <200 per μl

• Standard management approach but with caution (intolerance and infection)

Patients with severe immune impairment: CD4 < 50 per μl

• Palliative fractionation

Chance of occurrence of enhanced radiation toxicity is the most concerning factor for an oncologist. The increased toxicity is due to inherent radiosensitivity and glutathione deficiency. [16],[17]

Shrivastava et al. have shown in their series of HIV+ carcinoma cervix patients that only 12 out of 32 patients could complete the full course of radiation including brachytherapy. Out of these 12 cases, 11 experienced complete response. This means response of the disease to treatment is almost same as with non-seropositive patients but the challenge is to complete the treatment and choose the modalities judiciously. [18],[19]


 > Aids and Anal Canal Carcinoma Top


Anal canal carcinomas are rare form of disease comprising 4% of malignancies of lower gastrointestinal tract. It is the disease of middle-aged adults, with female sexual preponderance. The incidence is much higher in men who practice anal receptive intercourse and those who are HIV+.

A population study conducted in Denmark has shown the risk factors to be more than 10 sex partners (RR = 2.5), anal wart (RR = 11.7) and anal intercourse before the age 30 (RR = 3.4), while 88% patients were positive for HPV DNA. [20] Anal canal cancers are considered as a sexually transmitted disease. [21],[22],[23]

HIV+ male homosexuals have increased risk of having anal intraepithelial neoplasia (AIN), the precursor of squamous cell carcinoma. [24] Contrary to cervical cancer, SIL of anal canal and anal intraepithelial neoplasia do not regress with HAART. [25] Based on two large randomized studies on anal cancer, united kingdom coordinating committee on cacer research (UKCCR) and European organization for research and treatment of cancer (EORTC ), standard of care of anal canal cancer is chemoradiation using 5-fluorouracil (5-FU) and mitomycin C (MMC). [26],[27],[28],[29]

Toxicity due to intensive chemoradiation is the primary concern for HIV+ anal cancer. In pre-HAART era, side effects were more frequent and poorer outcome was associated with combined chemoradiation. [30],[31],[32],[33],[34],[35],[36]

Hoffman et al. compared two groups of patients based on CD4 count (>200 per μl vs. <200 per μl), treated with concomitant chemoradiation. Nine patients had CD4 count >200 per μl and eight patients had the count <200 per μl. Both groups experienced excellent response (100 and 87%, respectively), but grade 3 toxicities were higher (87% vs. 66%) in the group with lesser CD4 count. [37]

Cleator et al. treated 12 HIV+ anal carcinoma patients with concomitant chemoradiation (5-FU + MMC) and achieved 82% complete response with 45% grade 3 toxicity. [38] Similarly, Edelman et al. treated 17 HIV+ patients of anal carcinoma with routine chemoradiation protocol (5FU + MMC + Radio Theropy (RT) up to 50.4 Gy). They reported 82% complete response rate with 67% actuarial survival at 18 months; 47% experienced severe skin toxicity and 53% experienced severe hematologic toxicity. [39]

Christopher et al. did a match pair comparison of 10 HIV+ anal carcinoma patients who were on HAART with 10 HIV− patients using concomitant chemoradiation schedule. Though complete response rate was 100% in HIV+ patients, local control was inferior compared to HIV− patients at 44 months (P = 0.03). Inferior local control did not reflect on overall survival (OS) which was comparable at 5 years (70% vs. 69%) in spite of having comorbidities. Acute chemoradiation toxicity was higher in HIV+ cohort, but there was no difference in late toxicity. [40]

Vatra et al. retrospectively analyzed clinical data of 20 HIV+ patients with 24 HIV− patients. Clinical response, remission rate and 3 months mortality were better in HIV+ arm. In this series, less number of patients in HIV+ group received chemotherapy compared to those in HIV− one. [32]

In a recently published report, Yuji Seo et al. compared 19 consecutive immunocompetent patients with 17 immunodeficient (14 were HIV+) patients of anal canal carcinoma treated with chemoradiation protocol. With a median follow-up of 3.1 years, there were no differences in OS, disease specific survival and colostomy free survival. [41]

As there is no hard evidence that the tumor control is worse with chemoradiation and chemoradiation can cause progression of AIDS, HIV+ patients should be considered to be treated in a similar way as that of HIV− patients for anal cancer. Special precautions should be taken in HIV+ patients to prevent or to support toxicity especially with CD4 count <200 per μl.


 > AIDS and Kaposi's Sarcoma Top


Before the advent of HAART, the incidence of Kaposi's sarcoma (KS) was 20,000 times higher in patients with AIDS than in the general population. [42] Moriz Kaposi in 1872 first described the disease as "sarcoma idiopathicum multiple haemorrhagicum". Later, in 1912, Sternberg termed the disease as "Kaposi's Sarcoma" (KS). In 1981, the epidemic form was first described by Hymes. [43] Epidemic form is caused by HHV-8 (KSHV) . It is common in homosexual men and is the most frequent neoplasm in AIDS patients. In HIV+ patients, the clinical presentation varies from very early signs and symptoms to very extensive growth. Papular and macular lesions appear in the skin, most commonly at feet, legs, face, genitalia or they may be exophytic in advanced cases. These may be associated with lymphedema. Extracutaneous spread is common in patients not undergoing HAART. [44]

Classically, KS is classified into four types: i) endemic KS, ii) classical KS, iii) pediatric (lymphadenopathic) KS and iv) epidemic (AIDS related) KS. KS is further classified into two risk groups based on prognosis [Table 2]. [45]
Table 2: Risk stratification of Kaposi's Sarcoma (45)

Click here to view


HAART is one of the integral components of treatment of epidemic KS. It inhibits HIV replication, diminished production of HIV-1 transactivating protein, inhibits angiogenic activity and ameliorates immune response against KSHV/HHV8. [46],[47],[48],[49],[50],[51]

Different chemotherapeutic agents have been proved to be beneficial, especially in widespread disease, and these include liposomal doxorubicin, paclitaxel, vincristine, vinblastine and bleomycin. [52],[53],[54],[55],[56],[57],[58],[59],[60],[61]

Apart from chemotherapeutic agents, immunotherapy with interferon alpha is useful in immunocompetent patients with CD4 count >200 per μl. Antiangiogenic agents like thalidomide and tyrosine kinase inhibitors also have been used with some success. [62],[63],[64],[65],[66],[67]

Local therapy of KS includes radiotherapy, intralesional chemotherapy, cryotherapy and photodynamic therapy. Superficial therapies with orthovoltage X-ray or electron beam therapy are useful to achieve response and symptom palliation. [42],[44],[68],[69],[70],[71],[72],[72],[73],[74],[75],[76],[77]

In a retrospective study at University of Mondor, 643 patients with KS were treated by radiation therapy at doses ranging from 10 to 30 Gy by 45-70 KV X-ray or 4 MV photon. They achieved good palliation of symptoms with response rate of 92% for cutaneous KS, 100% for oral epidemic Kaposi's sarcoma EKS , 89% for eyelids, conjunctiva and genitals. [70]

Stelzer et al. treated 14 patients with 71 lesions in three dose schedules: 20 Gy in 10 fractions, 40 Gy in 20 fractions and 8 Gy in single fractions. Complete response rate was higher in 20 and 40 Gy groups compared to 8 Gy group with hazard ratio (HR) of 1.58 (95% CI 1.01-2.48) and 1.65 (95% CI 1.06-2.57), respectively, but on the other hand, adverse events were more in higher dose groups (20 and 40 Gy) with HR 3.67 (95% CI 1.17-11.52) and 7.65 (2.65-22.13), respectively. [78],[79]

In a randomized controlled trial, Singh et al. compared two dose fractionation schedules for cutaneous EKS: 24 Gy in 12 fractions and 20 Gy in 5 fractions in a total of 60 patients. Age (P = 0.05), stage (P = 0.02), associated systemic illness (P = 0.0024) and Stage I (P = 0.0024) had impact on OS. Patients who received 20 Gy in 5 fractions had a better local control compared to the ones who received 24 Gy in 12 fractions arm, though not statistically significant (Median 455 days and 150 days, respectively, with P = 0.1). There were also no significant differences in toxicity. [80]


 > AIDS and Lymphoma Top


The incidence of non-Hodgkin's lymphoma (NHL) has increased significantly with the AIDS epidemic, in that 2-3% of newly diagnosed AIDS cases are of NHL. [1],[81]

AIDS related lymphomas comprise B-cell tumors of aggressive type which include diffuse large B-cell lymphoma, B-cell immunoblastic lymphoma, Burkitt or Burkitt-like lymphoma.

The HIV-associated lymphomas can be categorized into:

  • aggressive B-cell lymphoma,
  • primary central nervous system lymphoma (PCNSL),
  • primary effusion lymphoma,
  • Hodgkin lymphoma, and
  • plasmablastic multicentric Castleman disease.


Before HAART era, reduced dose chemotherapy was the dictum for HIV associated NHL due to poor tolerability to chemotherapy. Along with HAART, unacceptable toxicity can be avoided even with standard dose chemotherapy. [82],[83],[84]

Before HAART, similar to chemotherapy, radiotherapy was also associated with higher toxicity. Post HAART era radiotherapy data are meager.


 > AIDS and Hodgkin's Lymphoma Top


Although there have been multiple reports of Hodgkin's lymphoma in association with AIDS in the last two decades, Hodgkin's still does not form a part of the CDC definition. HIV related Hodgkin's lymphoma presents in an aggressive fashion, often with bone marrow involvement or extranodal presentation. [1],[85],[86],[87],[88]


 > AIDS and PCNSL Top


Before the onset of HIV, primary CNS lymphoma was a rare entity. PCNSL occurs in patients with severe immunodeficiency and most of them are of B cell origin. [89],[90],[91],[92]

75% of PCNSL develops in patients who already have AIDS and most commonly in severely immunocompromised (50% with CD4 <50/dl) individuals. PCNSL manifests clinically in 2-6% of AIDS patients and 12% in autopsy. Affected persons usually present with features of intracranial space occupying lesions like cognitive dysfunction, psychomotor slowing, personality changes, disorientation, features of raised intra cranial tensionICT , cranial nerve palsy and hypothalamic dysfunction. Microscopically, it shows angiogenic growth pattern. Tuft of tumor cells are found within and around cerebral blood vessels and split the blood vessel wall. Elevated levels of immunoglobulins recognized by a V4-34 gene segment encoded antibody have been reported in association with Epstein Barr virus (EBV) infection. EBNA-2 and LMP-1 contribute to malignant transformation at various levels. EBV-DNA in CSF by polymerase chain reaction (PCR) is highly specific for PCNSL in AIDS and a reliable marker for monitoring response to therapy. PCNSL is associated with HHV8 and HHV6 infections.

Initial approach for treatment of PCNSL was cranial RT only. Several studies have reported of improvement of survival with addition of RT. [93],[94],[95]

RT alone in PCNSL has low cure rate and high local recurrence rate. Though PCNSL resembles extranodal NHL pathologically, it behaves more aggressively from a radiotherapeutic viewpoint. [96],[97],[98],[99]

PCNSL relapses frequently with only RT and has a median survival of only 12-18 months and a 5-year survival of <5-10% . [100]

Multimodal treatments have been introduced by DeAngelis et al., including radiotherapy, chemotherapy and steroids. Though their study was nonrandomized, the impact of RT in combination with high-dose methotrexate and steroids was so obvious (median survival 44 months) that it has been widely accepted as the treatment of choice. [101],[102]

In DeAngelis protocol, whole brain radiotherapy is started after few cycles of high-dose methotrexate and is followed by steroid and high-dose ara-C. RT consists of whole brain radiotherapy of 40 Gy followed by tumor boost of 15.4 Gy. A small retrospective study by Shibamoto and colleagues suggested that whole brain radiotherapy is required for treatment of PCNSL. As in this study, 83% patients experienced recurrence out of field in the small field group compared to 22% in the group with wider margin (<4 cm vs. >4 cm). [103]

There is no strong evidence of dose escalation of RT for treatment of PCNSL. In an RTOG phase II study, a total of 60 Gy (40 Gy whole brain + 20 Gy to gross tumor with 2 cm margin) was prescribed to gross tumor with 2 cm margin. With a median survival of 19 months, 61% recurrences occurred at the boost region and there was no clear dose response over 40 Gy.

Combination of radiotherapy along with high-dose methotrexate has got a significant adverse effect in the form of leukoencephalopathy, which has been reported. [104],[105]

Bessel et al. assessed the effect of reduced dose radiotherapy in patients with PCNSL, receiving CHOD/BVAM (cyclophosphamide, doxorubicin, vincristine, methotrexate, dexamethasone/carmustine, vincristine, methotrexate, cytarabine) regimen. In one group, 31 patients received 45 Gy standard whole brain RT, and in the second one, 26 patients received 30.6 Gy dose if there was complete response to chemotherapy. Three-year relapse risk was higher in lesser dose group (25% vs. 83%, P = 0.01). Treatment modality was the only predictor of relapse. Age more than 60 years showed a negative impact on OS in multivariate analysis. RT dose was an important predictor of OS in patients younger than 60 years (3-year OS: 92% vs. 60% for patients receiving 45 and 30.6 Gy, respectively; P = 0.04). So, reduction of dose of RT even after achieving complete response (CR) after chemotherapy has increased risk of recurrence. [106]

Newell et al. retrospectively reviewed 111 patients of HIV related PCNSL. Median survival was only 50 days (range 4-991 days). Patients who received HAART (P = 0.01) and/or radiotherapy (P = 0.0001) showed improved survival. Those who received radiotherapy of more than 30 Gy dose showed a favorable outcome. Poor performance status and encephalopathy predicted shorter survival duration. Other important predictors were CD4 count (≤125 vs. >125, P = 0.03) and performance status [Eastern Cooperative Oncology Group (ECOG ≤ 2 vs. 3, P = 0.04)]. [107]

Three hundred and thirty-eight consecutive PCNSL patients were analyzed at Memorial Sloan Kettering Cancer Centre between 1983 and 2003. On multivariate analysis, age and performance status were the only significant predictors of survival. Based on the multivariate data, they stratified their patients into three recursive partitioning analysis groups [Table 3]. [108]
Table 3: Recursive partitioning analysis groups of primary
central nervous system lymphoma[108]


Click here to view


To reduce the RT related toxicity, options of reduction of RT dose have been evaluated. After the advent of HAART, long-term survival in PCNSL in HIV+ is not uncommon. Combined HIV, RT and chemotherapy related leukoencephalopathy is of greater concern. Sequencing of chemotherapy with radiotherapy has not been standardized yet in HIV associated PCNSL. But for younger patients with good CD4 count and good performance status, standard approach is justified though there is no strong evidence of that in HIV+ patients.


 > Squamous Carcinoma of Conjunctiva Top


It is a type of ocular surface squamous neoplasia (OSSN). OSSN is the most common ocular surface tumor in HIV infected individuals in Africa. The spectrum varies from noninvasive (CIN) to invasive forms. It is associated with HPV and HIV infections. Incidence of squamous cell carcinoma of conjunctiva (SCCC) is increasing because of the spread of HIV infection. [109],[110],[111]

In a case control study, Ateenyi Agaba et al. have shown that out of 94 patients of SCCC, 79 suffered from HIV, and cutaneous HPV was detected in 45% of cases. Most common types of HPV were 5 and 8. [112]

Apart from these two, other HPV types like 19-25 and 36-38 are associated with SCCC, but not 16 and 18. [113] Primary management of SCCC is surgical resection. [114] Adjuvant radiation therapy has shown some benefit. Radiotherapy is delivered by beta rays (strontium applicator),, brachytherapy or superficial X-rays. [115],116],[117]

In an adjuvant setting, 25-40 Gy dose is delivered. Usually, this superficial therapy is well tolerated and the control rate is around 97%. [116]


 > HIV and Non-HIV Associated Malignancies Top


Radiotherapy tolerance for standard doses of radiotherapy in HIV-infected patients with prostate cancer is the same as in non-HIV infected patients. [118],[119],[120],[121]

Lung cancer is the non-HIV associated malignancy with highest incidence in HIV-infected patients compared to normal population. [122],[123] Data suggest a higher chance of severe esophagitis in HIV-infected lung cancer patients on radiotherapy. [124],[125],[126],[127] HAART has modest survival benefit in early stage lung cancer patients, but not in patients with advanced stage disease. [128],[129]

There are little data available on radiotherapy in non-KS head and neck malignancies in HIV patients. Whatever little is available suggests that tolerance to standard doses is the same as the general population. [130],[131]

Patients with testicular seminoma have in general tolerated standard doses of radiotherapy well. [132],[133],[134],[135],[136] Breast cancer patients, in general, have tolerated standard doses of radiotherapy well, but not chemotherapy, though the data are quite sparse. [137],[138],[139]

Data on disease control and toxicity for colorectal cancer patients with HIV treated by radiotherapy are frankly inconclusive. [140],[141],[142]

Per se, local control and disease-specific survival rates in HIV patients are no worse than HIV− patients, but this is only true, in general, for patients with higher CD4 counts (above 200/mm 3 ). [143]


 > HIV and Radiotherapy Toxicities Top


The question of increased radiosensitivity in HIV patients remains unresolved in most diseases, barring KS and PCNSL in the pre-HAART era. Most of the other AIDS-defining malignancies such as cervical and anal carcinomas can be safely treated by standard dose chemo-radiotherapy. [143] There are sparse data with regard to non-HIV associated malignancies in these patients. The idea that lower CD4 counts correlate with worse skin/mucosal/GU/GI toxicities has been challenged. [37],[38],[39],[144],[145]


 > Conclusion Top


HIV is associated with a wide spectrum of malignancies and pre-malignant conditions. The patient's level of immunity as manifested by the CD4 count has a significant bearing on treatment outcomes. In some cases, like PCNSL, the occurrence of the malignancy itself is tied to the patient's immunity with increased incidence in patients with CD4 counts less than 50/mm 3 . The success of HAART has allowed administration of standard doses of radiotherapy and even chemotherapy in recent times, leading to improved outcomes. In general, standard radiotherapy and concomitant chemo-radiotherapy protocols should be used wherever possible, so as not to compromise disease control. Per se, local control and disease-specific survival rates in HIV patients are no worse than in HIV− patients, but this is only true for CD4 counts above 200/mm 3 . In certain situations like CIN, HAART itself is associated with disease regression. The question of increased radiosensitivity in HIV patients remains unresolved in most diseases and there are sparse data with regard to non-HIV associated malignancies in these patients. Greater caution and emphasis on good supportive care and HAART would appear to be essential when treating HIV+ patients of malignancies with standard anti-cancer regimens.

 
 > References Top

1.Rabkin CS, Yellin F. Cancer incidence in a population with a high prevalence of infection with human immunodeficiency virus type 1. J Natl Cancer Inst 1994;86:1711-6.  Back to cited text no. 1
    
2.Kahesa C, Mwaiselage J, Wabinga HR, Ngoma T, Kalyango JN, Karamagi CA. Association between invasive cancer of the cervix and HIV-1 infection in Tanzania: The need for dual screening. BMC Public Health 2008;8:262.  Back to cited text no. 2
    
3.From the Centers for Disease Control and Prevention. 1993 revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. JAMA 1993;269:729-30.   Back to cited text no. 3
    
4.From the Centers for Disease Control and prevention. 1993 revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. JAMA 1993;269:460-1.   Back to cited text no. 4
    
5.Hawes SE, Critchlow CW, Faye Niang MA, Diouf MB, Diop A, Touré P, et al. Increased risk of high-grade cervical squamous intraepithelial lesions and invasive cervical cancer among African women with human immunodeficiency virus type 1 and 2 infections. J Infect Dis 2003;188:555-63.  Back to cited text no. 5
    
6.Palefsky JM, Minkoff H, Kalish LA, Levine A, Sacks HS, Garcia P, Young M, et al. Cervicovaginal human papillomavirus infection in human immunodeficiency virus-1 (HIV)-positive and high-risk HIV-negative women. J Natl Cancer Inst 1999;91:226-36.  Back to cited text no. 6
    
7.Conti M, Agarossi A, Parazzini F, Muggiasca ML, Boschini A, Negri E, Casolati E. HPV, HIV infection, and risk of cervical intraepithelial neoplasia in former intravenous drug abusers. Gynecol Oncol 1993;49:344-8.  Back to cited text no. 7
    
8.Ellerbrock TV, Chiasson MA, Bush TJ, Sun XW, Sawo D, Brudney K, et al. Incidence of cervical squamous intraepithelial lesions in HIV-infected women. JAMA 2000;283:1031-7.  Back to cited text no. 8
    
9.Tornesello ML, Duraturo ML, Giorgi-Rossi P, Sansone M, Piccoli R, Buonaguro L, et al. Human papillomavirus (HPV) genotypes and HPV16 variants in human immunodeficiency virus-positive Italian women. J Gen Virol 2008;89:1380-9.  Back to cited text no. 9
    
10.Schuman P, Ohmit SE, Klein RS, Duerr A, Cu-Uvin S, Jamieson DJ, et al. Longitudinal study of cervical squamous intraepithelial lesions in human immunodeficiency virus (HIV)-seropositive and at-risk HIV-seronegative women. J Infect Dis 2003;188:128-36.  Back to cited text no. 10
    
11.Wright TC Jr, Ellerbrock TV, Chiasson MA, Van Devanter N, Sun XW. Cervical intraepithelial neoplasia in women infected with human immunodeficiency virus: Prevalence, risk factors, and validity of Papanicolaou smears. New York Cervical Disease Study. Obstet Gynecol 1994;84:591-7.  Back to cited text no. 11
    
12.Sun XW, Kuhn L, Ellerbrock TV, Chiasson MA, Bush TJ, Wright TC Jr. Human papillomavirus infection in women infected with the human immunodeficiency virus. N Engl J Med 1997;337:1343-9.  Back to cited text no. 12
    
13.Ahdieh L, Klein RS, Burk R, Cu-Uvin S, Schuman P, Duerr A, et al. Prevalence, incidence, and type-specific persistence of human papillomavirus in human immunodeficiency virus (HIV)-positive and HIV-negative women. J Infect Dis 2001;184:682-90.  Back to cited text no. 13
    
14.Rowhani-Rahbar A, Hawes SE, Sow PS, Toure P, Feng Q, Dem A, et al. The impact of HIV status and type on the clearance of human papillomavirus infection among Senegalese women. J Infect Dis 2007;196:887-94.  Back to cited text no. 14
    
15.Ahdieh-Grant L, Li R, Levine AM, Massad LS, Strickler HD, Minkoff H, et al. Highly active antiretroviral therapy and cervical squamous intraepithelial lesions in human immunodeficiency virus-positive women. J Natl Cancer Inst 2004;96:1070-6.  Back to cited text no. 15
    
16.Formenti SC, Chak L, Gill P, Buess EM, Hill CK. Increased radiosensitivity of normal tissue fibroblasts in patients with acquired immunodeficiency syndrome (AIDS) and with Kaposi's sarcoma. Int J Radiat Biol 1995;68:411-2.  Back to cited text no. 16
    
17.Vallis KA. Glutathione deficiency and radiosensitivity in AIDS patients.Lancet 1991;337:918-9.  Back to cited text no. 17
    
18.Shrivastava SK, Engineer R, Rajadhyaksha S, Dinshaw KA. HIV infection and invasive cervical cancers, treatment with radiation therapy: Toxicity and outcome. Radiother Oncol 2005;74:31-5.  Back to cited text no. 18
    
19.Gichangi P, Bwayo J, Estambale B, Rogo K, Njuguna E, Ojwang S, et al. HIV impact on acute morbidity and pelvic tumor control following radiotherapy for cervical cancer. Gynecol Oncol 2006;100:405-11.  Back to cited text no. 19
    
20.Frisch M, Glimelius B, van den Brule AJ, Wohlfahrt J, Meijer CJ, Walboomers JM, et al. Sexually transmitted infection as a cause of anal cancer. N Engl J Med 1997;337:1350-8.  Back to cited text no. 20
    
21.Bjørge T, Engeland A, Luostarinen T, Mork J, Gislefoss RE, Jellum E, et al. Human papillomavirus infection as a risk factor for anal and perianal skin cancer in a prospective study. Br J Cancer 2002;87:61-4.  Back to cited text no. 21
    
22.Northfelt DW. Cervical and anal neoplasia and HPV infection in persons with HIV infection. Oncology (Williston Park) 1994;8:33-7.  Back to cited text no. 22
    
23.Melbye M, Sprøgel P. Aetiological parallel between anal cancer and cervical cancer. Lancet 1991;338:657-9.  Back to cited text no. 23
    
24.Goldie SJ, Kuntz KM, Weinstein MC, Freedberg KA, Welton ML, Palefsky JM. The clinical effectiveness and cost-effectiveness of screening for anal squamous intraepithelial lesions in homosexual and bisexual HIV-positive men. JAMA 1999;281:1822-9.  Back to cited text no. 24
    
25.Palefsky JM, Holly EA, Ralston ML, Da Costa M, Bonner H, Jay N, et al. Effect of highly active antiretroviral therapy on the natural history of anal squamous intraepithelial lesions and anal human papillomavirus infection. J Acquir Immune Defic Syndr 2001;28:422-8.  Back to cited text no. 25
    
26.Nigro ND, Vaitkevicius VK, Considine B Jr. Combined therapy for cancer of the anal canal: A preliminary report. Dis Colon Rectum 1974;17:354-6.  Back to cited text no. 26
    
27.Cummings BJ. Anal cancer. Int J Radiat Oncol Biol Phys 1990;19:1309-15.  Back to cited text no. 27
    
28.Epidermoid anal cancer: Results from the UKCCCR randomised trial of radiotherapy alone versus radiotherapy, 5-fluorouracil, and mitomycin. UKCCCR Anal Cancer Trial Working Party. UK Co-ordinating Committee on Cancer Research. Lancet 1996;348:1049-54.   Back to cited text no. 28
    
29.Bartelink H, Roelofsen F, Eschwege F, Rougier P, Bosset JF, Gonzalez DG, et al. Concomitant radiotherapy and chemotherapy is superior to radiotherapy alone in the treatment of locally advanced anal cancer: Results of a phase III randomized trial of the European Organization for Research and Treatment of Cancer Radiotherapy and Gastrointestinal Cooperative Groups. J Clin Oncol 1997;15:2040-9.  Back to cited text no. 29
    
30.Efron JE, Pikarsky AJ, Gervaz P, Locker G, Weiss EG, Wexner SD, et al. The efficacy of chemoradiation therapy in HIV seropositive patients with squamous cell carcinoma of the anus. Colorectal Dis 2001;3:402-5.  Back to cited text no. 30
    
31.Kim JH, Sarani B, Orkin BA, Young HA, White J, Tannebaum I, et al. HIV-positive patients with anal carcinoma have poorer treatment tolerance and outcome than HIV-negative patients. Dis Colon Rectum 2001;44:1496-502.  Back to cited text no. 31
    
32.Vatra B, Sobhani I, Aparicio T, Girard PM, Puy Montbrun TD, Housset M, et al. Anal canal squamous-cell carcinomas in HIV positive patients: Clinical features, treatments and prognosis. Gastroenterol Clin Biol 2002;26:150-6.  Back to cited text no. 32
    
33.Bottomley DM, Aqel N, Selvaratnam G, Phillips RH. Epidermoid anal cancer in HIV infected patients. Clin Oncol (R Coll Radiol) 1996;8:319-22.  Back to cited text no. 33
    
34.Chadha M, Rosenblatt EA, Malamud S, Pisch J, Berson A. Squamous-cell carcinoma of the anus in HIV-positive patients. Dis Colon Rectum 1994;37:861-5.  Back to cited text no. 34
    
35.Holland JM, Swift PS. Tolerance of patients with human immunodeficiency virus and anal carcinoma to treatment with combined chemotherapy and radiation therapy. Radiology 1994;193:251-4.  Back to cited text no. 35
    
36.Place RJ, Gregorcyk SG, Huber PJ, Simmang CL. Outcome analysis of HIV-positive patients with anal squamous cell carcinoma. Dis Colon Rectum 2001;44:506-12.  Back to cited text no. 36
    
37.Hoffman R, Welton ML, Klencke B, Weinberg V, Krieg R. The significance of pretreatment CD4 count on the outcome and treatment tolerance of HIV-positive patients with anal cancer. Int J Radiat Oncol Biol Phys 1999;44:127-31.  Back to cited text no. 37
    
38.Cleator S, Fife K, Nelson M, Gazzard B, Phillips R, Bower M. Treatment of HIV-associated invasive anal cancer with combined chemoradiation. Eur J Cancer 2000;36:754-8.  Back to cited text no. 38
    
39.Edelman S, Johnstone PA. Combined modality therapy for HIV-infected patients with squamous cell carcinoma of the anus: Outcomes and toxicities. Int J Radiat Oncol Biol Phys 2006;66:206-11.  Back to cited text no. 39
    
40.Oehler-Jänne C, Seifert B, Lütolf UM, Ciernik IF. Local tumor control and toxicity in HIV-associated anal carcinoma treated with radiotherapy in the era of antiretroviral therapy. Radiat Oncol 2006;1:29.  Back to cited text no. 40
    
41.Seo Y, Kinsella MT, Reynolds HL, Chipman G, Remick SC, Kinsella TJ. Outcomes of chemoradiotherapy with 5-Fluorouracil and mitomycin C for anal cancer in immunocompetent versus immunodeficient patients. Int J Radiat Oncol Biol Phys 2009;75:143-9.  Back to cited text no. 41
    
42.Di Lorenzo G. Update on classic Kaposi sarcoma therapy: New look at an old disease. Crit Rev Oncol Hematol 2008;68:242-9.  Back to cited text no. 42
    
43.Hymes KB, Cheung T, Greene JB, Prose NS, Marcus A, Ballard H, et al. Kaposi's sarcoma in homosexual men-a report of eight cases. Lancet 1981;2:598-600.  Back to cited text no. 43
    
44.Di Lorenzo G, Konstantinopoulos PA, Pantanowitz L, Di Trolio R, De Placido S, Dezube BJ. Management of AIDS-related Kaposi's sarcoma. Lancet Oncol 2007;8:167-76.  Back to cited text no. 44
    
45.Krown SE, Testa MA, Huang J. AIDS-related Kaposi's sarcoma: Prospective validation of the AIDS Clinical Trials Group staging classification. AIDS Clinical Trials Group Oncology Committee. J Clin Oncol 1997;15:3085-92.  Back to cited text no. 45
    
46.Cattelan AM, Calabro ML, Aversa SM, Zanchetta M, Meneghetti F, De Rossi A, et al. Regression of AIDS-related Kaposi's sarcoma following antiretroviral therapy with protease inhibitors: Biological correlates of clinical outcome. Eur J Cancer 1999;35:1809-15.  Back to cited text no. 46
    
47.Cattelan AM, Calabrò ML, Gasperini P, Aversa SM, Zanchetta M, Meneghetti F, et al. Acquired immunodeficiency syndrome-related Kaposi's sarcoma regression after highly active antiretroviral therapy: Biologic correlates of clinical outcome. J Natl Cancer Inst Monogr 2001;28:44-9.  Back to cited text no. 47
    
48.Pati S, Pelser CB, Dufraine J, Bryant JL, Reitz MS Jr, Weichold FF. Antitumorigenic effects of HIV protease inhibitor ritonavir: Inhibition of Kaposi sarcoma. Blood 2002;99:3771-9.  Back to cited text no. 48
    
49.Sgadari C, Barillari G, Toschi E, Carlei D, Bacigalupo I, Baccarini S, et al. HIV protease inhibitors are potent anti-angiogenic molecules and promote regression of Kaposi sarcoma. Nat Med 2002;8:225-32.  Back to cited text no. 49
    
50.Stebbing J, Portsmouth S, Gazzard B. How does HAART lead to the resolution of Kaposi's sarcoma? J Antimicrob Chemother 2003;51:1095-8.  Back to cited text no. 50
    
51.Stebbing J, Portsmouth S, Gotch F, Gazzard B. Kaposi's sarcoma--an update. Int J STD AIDS 2003;14:225-7.  Back to cited text no. 51
    
52.Northfelt DW, Dezube BJ, Thommes JA, Miller BJ, Fischl MA, Friedman-Kien A, et al. Pegylated-liposomal doxorubicin versus doxorubicin, bleomycin, and vincristine in the treatment of AIDS-related Kaposi's sarcoma: Results of a randomized phase III clinical trial. J Clin Oncol 1998;16:2445-51.  Back to cited text no. 52
    
53.Osoba D, Northfelt DW, Budd DW, Himmelberger D. Effect of treatment on health-related quality of life in acquired immunodeficiency syndrome (AIDS)-related Kaposi's sarcoma: A randomized trial of pegylated-liposomal doxorubicin versus doxorubicin, bleomycin, and vincristine. Cancer Invest 2001;19:573-80.  Back to cited text no. 53
    
54.Stewart S, Jablonowski H, Goebel FD, Arasteh K, Spittle M, Rios A, et al. Randomized comparative trial of pegylated liposomal doxorubicin versus bleomycin and vincristine in the treatment of AIDS-related Kaposi's sarcoma. International Pegylated Liposomal Doxorubicin Study Group. J Clin Oncol 1998;16:683-91.  Back to cited text no. 54
    
55.Gill PS, Wernz J, Scadden DT, Cohen P, Mukwaya GM, von Roenn JH, et al. Randomized phase III trial of liposomal daunorubicin versus doxorubicin, bleomycin, and vincristine in AIDS-related Kaposi's sarcoma. J Clin Oncol 1996;14:2353-64.  Back to cited text no. 55
    
56.Cooley T, Henry D, Tonda M, Sun S, O'Connell M, Rackoff W. A randomized, double-blind study of pegylated liposomal doxorubicin for the treatment of AIDS-related Kaposi's sarcoma. Oncologist 2007;12:114-23.  Back to cited text no. 56
    
57.Lichterfeld M, Qurishi N, Hoffmann C, Hochdorfer B, Brockmeyer NH, Arasteh K, Mauss S, et al. Treatment of HIV-1-associated Kaposi's sarcoma with pegylated liposomal doxorubicin and HAART simultaneously induces effective tumor remission and CD4+ T cell recovery. Infection 2005;33:140-7.  Back to cited text no. 57
    
58.Hofheinz RD, Gnad-Vogt SU, Beyer U, Hochhaus A. Liposomal encapsulated anti-cancer drugs. Anticancer Drugs 2005;16:691-707.  Back to cited text no. 58
    
59.Belotti D, Vergani V, Drudis T, Borsotti P, Pitelli MR, Viale G, et al. The microtubule-affecting drug paclitaxel has antiangiogenic activity. Clin Cancer Res 1996;2:1843-9.  Back to cited text no. 59
    
60.Tulpule A, Groopman J, Saville MW, Harrington W Jr, Friedman-Kien A, Espina BM et al. Multicenter trial of low-dose paclitaxel in patients with advanced AIDS-related Kaposi sarcoma. Cancer 2002;95:147-54.  Back to cited text no. 60
    
61.Welles L, Saville MW, Lietzau J, Pluda JM, Wyvill KM, Feuerstein I, et al. Phase II trial with dose titration of paclitaxel for the therapy of human immunodeficiency virus-associated Kaposi's sarcoma. J Clin Oncol 1998;16:1112-21.  Back to cited text no. 61
    
62.Dezube BJ, Pantanowitz L, Aboulafia DM. Management of AIDS-related Kaposi sarcoma: Advances in target discovery and treatment. AIDS Read 2004;14:236-8, 243-4, 251-3.  Back to cited text no. 62
    
63.Stürzl M, Roth WK, Brockmeyer NH, Zietz C, Speiser B, Hofschneider PH. Expression of platelet-derived growth factor and its receptor in AIDS-related Kaposi sarcoma in vivo suggests paracrine and autocrine mechanisms of tumor maintenance. Proc Natl Acad Sci U S A 1992;89:7046-50.  Back to cited text no. 63
    
64.Kreuter A, Rasokat H, Klouche M, Esser S, Bader A, Gambichler T, Altmeyer P, et al. Liposomal pegylated doxorubicin versus low-dose recombinant interferon Alfa-2a in the treatment of advanced classic Kaposi's sarcoma; retrospective analysis of three German centers. Cancer Invest 2005;23:653-9.  Back to cited text no. 64
    
65.Krown SE, Li P, Von Roenn JH, Paredes J, Huang J, Testa MA. Efficacy of low-dose interferon with antiretroviral therapy in Kaposi's sarcoma: A randomized phase II AIDS clinical trials group study. J Interferon Cytokine Res 2002;22:295-303.  Back to cited text no. 65
    
66.Shepherd FA, Beaulieu R, Gelmon K, Thuot CA, Sawka C, Read S, et al. Prospective randomized trial of two dose levels of interferon alfa with zidovudine for the treatment of Kaposi's sarcoma associated with human immunodeficiency virus infection: A Canadian HIV Clinical Trials Network study. J Clin Oncol 1998;16:1736-42.  Back to cited text no. 66
    
67.Pistritto G, Ventura L, Mores N, Lacal PM, D'Onofrio C. Regulation of PDGF-B and PDGF receptor expression in the pathogenesis of Kaposi's sarcoma in AIDS. Antibiot Chemother 1994;46:73-87.  Back to cited text no. 67
    
68.Margaretiæ D, Faj D, Tomas I, Dmitroviæ B, Krajina Z. Total skin electron treatment of extensive cutaneous lesions in Kaposi sarcoma. Croat Med J 2002;43:342-5.  Back to cited text no. 68
    
69.Kigula-Mugambe JB, Kavuma A. Epidemic and endemic Kaposi's sarcoma: A comparison of outcomes and survival after radiotherapy. Radiother Oncol 2005;76:59-62.  Back to cited text no. 69
    
70.Kirova YM, Belembaogo E, Frikha H, Haddad E, Calitchi E, Levy E, et al. Radiotherapy in the management of epidemic Kaposi's sarcoma: A retrospective study of 643 cases. Radiother Oncol 1998;46:19-22.  Back to cited text no. 70
    
71.Yildiz F, Genc M, Akyurek S, Cengiz M, Ozyar E, Selek U, et al. Radiotherapy in the management of Kaposi's sarcoma: Comparison of 8 Gy versus 6 Gy. J Natl Med Assoc 2006;98:1136-9.  Back to cited text no. 71
    
72.Macklis RM. Atypical radiation toxicity in patients with classical Kaposi's sarcoma. Tumori 1991;77:491-5.  Back to cited text no. 72
    
73.Becker G, Bottke D. Radiotherapy in the management of Kaposi's sarcoma. Onkologie 2006;29:329-33.  Back to cited text no. 73
    
74.Walmsley S, Northfelt DW, Melosky B, Conant M, Friedman-Kien AE, Wagner B. Treatment of AIDS-related cutaneous Kaposi's sarcoma with topical alitretinoin (9-cis-retinoic acid) gel. Panretin Gel North American Study Group. J Acquir Immune Defic Syndr 1999;22:235-46.  Back to cited text no. 74
    
75.Ramírez-Amador V, Esquivel-Pedraza L, Lozada-Nur F, De la Rosa-García E, Volkow-Fernández P, Súchil-Bernal L, et al. Intralesional vinblastine vs. 3% sodium tetradecyl sulfate for the treatment of oral Kaposi's sarcoma. A double blind, randomized clinical trial. Oral Oncol 2002;38:460-7.  Back to cited text no. 75
    
76.Tappero JW, Berger TG, Kaplan LD, Volberding PA, Kahn JO. Cryotherapy for cutaneous Kaposi's sarcoma (KS) associated with acquired immune deficiency syndrome (AIDS): A phase II trial. J Acquir Immune Defic Syndr 1991;4:839-46.  Back to cited text no. 76
    
77.Hebeda KM, Huizing MT, Brouwer PA, van der Meulen FW, Hulsebosch HJ, Reiss P, et al. Photodynamic therapy in AIDS-related cutaneous Kaposi's sarcoma. J Acquir Immune Defic Syndr Hum Retrovirol 1995;10:61-70.  Back to cited text no. 77
    
78.Stelzer KJ, Griffin TW. A randomized prospective trial of radiation therapy for AIDS-associated Kaposi's sarcoma. Int J Radiat Oncol Biol Phys 1993;27:1057-61.  Back to cited text no. 78
    
79.Dedicoat M, Vaithilingum M, Newton R. Treatment of Kaposi's sarcoma in HIV-1 infected individuals with emphasis on resource poor settings. Cochrane Database Syst Rev 2003:CD003256.  Back to cited text no. 79
    
80.Singh NB, Lakier RH, Donde B. Hypofractionated radiation therapy in the treatment of epidemic Kaposi sarcoma--a prospective randomized trial. Radiother Oncol 2008;88:211-6.  Back to cited text no. 80
    
81.Rabkin CS, Testa MA, Huang J, Von Roenn JH. Kaposi's sarcoma and non-Hodgkin's lymphoma incidence trends in AIDS Clinical Trial Group study participants. J Acquir Immune Defic Syndr 1999;21:S31-3.  Back to cited text no. 81
    
82.Little RF, Pittaluga S, Grant N, Steinberg SM, Kavlick MF, Mitsuya H, et al. Highly effective treatment of acquired immunodeficiency syndrome-related lymphoma with dose-adjusted EPOCH: Impact of antiretroviral therapy suspension and tumor biology. Blood 2003;101:4653-9.  Back to cited text no. 82
    
83.Ratner L, Lee J, Tang S, Redden D, Hamzeh F, Herndier B, et al. Chemotherapy for human immunodeficiency virus-associated non-Hodgkin's lymphoma in combination with highly active antiretroviral therapy. J Clin Oncol 2001;19:2171-8.  Back to cited text no. 83
    
84.Kaplan LD, Lee JY, Ambinder RF, Sparano JA, Cesarman E, Chadburn A, et al. Rituximab does not improve clinical outcome in a randomized phase 3 trial of CHOP with or without rituximab in patients with HIV-associated non-Hodgkin lymphoma: AIDS-Malignancies Consortium Trial 010. Blood 2005;106:1538-43.  Back to cited text no. 84
    
85.Spina M, Berretta M, Tirelli U. Hodgkin's disease in HIV. Hematol Oncol Clin North Am 2003;17:843-58.  Back to cited text no. 85
    
86.Spina M, Vaccher E, Nasti G, Tirelli U. Human immunodeficiency virus-associated Hodgkin's disease. Semin Oncol 2000;27:480-8.  Back to cited text no. 86
    
87.Thompson LD, Fisher SI, Chu WS, Nelson A, Abbondanzo SL. HIV-associated Hodgkin lymphoma: A clinicopathologic and immunophenotypic study of 45 cases. Am J Clin Pathol 2004;121:727-38.  Back to cited text no. 87
    
88.Hessol NA, Katz MH, Liu JY, Buchbinder SP, Rubino CJ, Holmberg SD. Increased incidence of Hodgkin disease in homosexual men with HIV infection. Ann Intern Med 1992;117:309-11.  Back to cited text no. 88
    
89.Freeman CR, Shustik C, Brisson ML, Meagher-Villemure K, Dylewski I. Primary malignant lymphoma of the central nervous system. Cancer 1986;58:1106-11.  Back to cited text no. 89
    
90.Hochberg FH, Miller DC. Primary central nervous system lymphoma. J Neurosurg 1988;68:835-53.  Back to cited text no. 90
    
91.Gray F, Gherardi R, Scaravilli F. The neuropathology of the acquired immune deficiency syndrome (AIDS). A review. Brain 1988;111:245-66.  Back to cited text no. 91
    
92.Forsyth PA, DeAngelis LM. Biology and management of AIDS-associated primary CNS lymphomas. Hematol Oncol Clin North Am 1996;10:1125-34.  Back to cited text no. 92
    
93.Fine HA, Mayer RJ. Primary central nervous system lymphoma. Ann Intern Med 1993;119:1093-104.  Back to cited text no. 93
    
94.Baumgartner JE, Rachlin JR, Beckstead JH, Meeker TC, Levy RM, Wara WM, et al. Primary central nervous system lymphomas: Natural history and response to radiation therapy in 55 patients with acquired immunodeficiency syndrome. J Neurosurg 1990;73:206-11.  Back to cited text no. 94
    
95.Corn BW, Donahue BR, Rosenstock JG, Hyslop T, Brandon AH, Hegde HH, et al. Performance status and age as independent predictors of survival among AIDS patients with primary CNS lymphoma: A multivariate analysis of a multi-institutional experience. Cancer J Sci Am 1997;3:52-6.  Back to cited text no. 95
    
96.Laperriere NJ, Cerezo L, Milosevic MF, Wong CS, Patterson B, Panzarella T. Primary lymphoma of brain: Results of management of a modern cohort with radiation therapy. Radiother Oncol 1997;43:247-52.  Back to cited text no. 96
    
97.Nelson DF, Martz KL, Bonner H, Nelson JS, Newall J, Kerman HD, et al. Non-Hodgkin's lymphoma of the brain: Can high dose, large volume radiation therapy improve survival? Report on a prospective trial by the Radiation Therapy Oncology Group (RTOG): RTOG 8315. Int J Radiat Oncol Biol Phys 1992;23:9-17.  Back to cited text no. 97
    
98.Nelson DF. Radiotherapy in the treatment of primary central nervous system lymphoma (PCNSL). J Neurooncol 1999;43:241-7.  Back to cited text no. 98
    
99.Brada M, Dearnaley D, Horwich A, Bloom HJ. Management of primary cerebral lymphoma with initial chemotherapy: Preliminary results and comparison with patients treated with radiotherapy alone. Int J Radiat Oncol Biol Phys 1990;18:787-92.  Back to cited text no. 99
    
100.Shibamoto Y, Ogino H, Hasegawa M, Suzuki K, Nishio M, Fujii T, et al. Results of radiation monotherapy for primary central nervous system lymphoma in the 1990s. Int J Radiat Oncol Biol Phys 2005;62:809-13.  Back to cited text no. 100
    
101.DeAngelis LM, Yahalom J, Thaler HT, Kher U. Combined modality therapy for primary CNS lymphoma. J Clin Oncol 1992;10:635-43.  Back to cited text no. 101
    
102.Schultz C, Scott C, Sherman W, Donahue B, Fields J, Murray K, et al. Preirradiation chemotherapy with cyclophosphamide, doxorubicin, vincristine, and dexamethasone for primary CNS lymphomas: Initial report of radiation therapy oncology group protocol 88-06. J Clin Oncol 1996;14:556-64.  Back to cited text no. 102
    
103.Shibamoto Y, Hayabuchi N, Hiratsuka J, Tokumaru S, Shirato H, Sougawa M, et al. Is whole-brain irradiation necessary for primary central nervous system lymphoma? Patterns of recurrence after partial-brain irradiation. Cancer 2003;97:128-33.  Back to cited text no. 103
    
104.Abrey LE, DeAngelis LM, Yahalom J. Long-term survival in primary CNS lymphoma. J Clin Oncol 1998;16:859-63.  Back to cited text no. 104
    
105.DeAngelis LM. Primary CNS lymphoma: Treatment with combined chemotherapy and radiotherapy. J Neurooncol 1999;43:249-57.  Back to cited text no. 105
    
106.Bessell EM, López-Guillermo A, Villá S, Verger E, Nomdedeu B, Petit J, Byrne P, et al. Importance of radiotherapy in the outcome of patients with primary CNS lymphoma: An analysis of the CHOD/BVAM regimen followed by two different radiotherapy treatments. J Clin Oncol 2002;20:231-6.  Back to cited text no. 106
    
107.Newell ME, Hoy JF, Cooper SG, DeGraaff B, Grulich AE, Bryant M, et al. Human immunodeficiency virus-related primary central nervous system lymphoma: Factors influencing survival in 111 patients. Cancer 2004;100:2627-36.  Back to cited text no. 107
    
108.Abrey LE, Ben-Porat L, Panageas KS, Yahalom J, Berkey B, Curran W, et al. Primary central nervous system lymphoma: The Memorial Sloan-Kettering Cancer Center prognostic model. J Clin Oncol 2006;24:5711-5.  Back to cited text no. 108
    
109.Ateenyi-Agaba C. Conjunctival squamous-cell carcinoma associated with HIV infection in Kampala, Uganda. Lancet 1995;345:695-6.  Back to cited text no. 109
    
110.Newton R, Ziegler J, Beral V, Mbidde E, Carpenter L, Wabinga H, et al. A case-control study of human immunodeficiency virus infection and cancer in adults and children residing in Kampala, Uganda. Int J Cancer 2001;92:622-7.  Back to cited text no. 110
    
111.Guech-Ongey M, Engels EA, Goedert JJ, Biggar RJ, Mbulaiteye SM. Elevated risk for squamous cell carcinoma of the conjunctiva among adults with AIDS in the United States. Int J Cancer 2008;122:2590-3.  Back to cited text no. 111
    
112.Ateenyi-Agaba C, Franceschi S, Wabwire-Mangen F, Arslan A, Othieno E, Binta-Kahwa J, et al. Human papillomavirus infection and squamous cell carcinoma of the conjunctiva. Br J Cancer 2010;102:262-7.  Back to cited text no. 112
    
113.Gichuhi S, Irlam JJ. Interventions for squamous cell carcinoma of the conjunctiva in HIV-infected individuals. Cochrane Database Syst Rev 2007:CD005643.  Back to cited text no. 113
    
114.Shields JA, Shields CL, De Potter P. Surgical management of conjunctival tumors. The 1994 Lynn B. McMahan Lecture. Arch Ophthalmol 1997;115:808-15.  Back to cited text no. 114
    
115.Cerezo L, Otero J, Aragón G, Polo E, de la Torre A, Valcárcel F, et al. Conjunctival intraepithelial and invasive squamous cell carcinomas treated with strontium-90. Radiother Oncol 1990;17:191-7.  Back to cited text no. 115
    
116.Kearsley JH, Fitchew RS, Taylor RG. Adjunctive radiotherapy with strontium-90 in the treatment of conjunctival squamous cell carcinoma. Int J Radiat Oncol Biol Phys 1988;14:435-43.  Back to cited text no. 116
    
117.Soares CG, Vynckier S, Järvinen H, Cross WG, Sipilä P, Flühs D, et al. Dosimetry of beta-ray ophthalmic applicators: Comparison of different measurement methods. Med Phys 2001;28:1373-84.  Back to cited text no. 117
    
118.Levinson A, Nagler EA, Lowe FC. Approach to management of clinically localized prostate cancer in patients with human immunodeficiency virus. Urology 2005;65:91-4.  Back to cited text no. 118
    
119.O'Connor JK, Nedzi LA, Zakris EL. Prostate adenocarcinoma and human immunodeficiency virus: Report of three cases and review of the literature. Clin Genitourin Cancer 2006;5:85-8.  Back to cited text no. 119
    
120.Pantanowitz L, Bohac G, Cooley TP, Aboulafia D, Dezube BJ. Human immunodeficiency virus-associated prostate cancer: Clinicopathological findings and outcome in a multi-institutional study. BJU Int 2008;101:1519-23.  Back to cited text no. 120
    
121.Ng T, Stein NF, Kaminetsky J, Berman S, Marans HY, McDermott B, et al. Preliminary results of radiation therapy for prostate cancer in human immunodeficiency virus-positive patients. Urology 2008;72:1135-8.  Back to cited text no. 121
    
122.Engels EA, Brock MV, Chen J, Hooker CM, Gillison M, Moore RD. Elevated incidence of lung cancer among HIV-infected individuals. J Clin Oncol 2006;24:1383-8.  Back to cited text no. 122
    
123.Cadranel J, Garfield D, Lavolé A, Wislez M, Milleron B, Mayaud C. Lung cancer in HIV infected patients: Facts, questions and challenges. Thorax 2006;61:1000-8.  Back to cited text no. 123
    
124.Costleigh BJ, Miyamoto CT, Micaily B, Brady LW. Heightened sensitivity of the esophagus to radiation in a patient with AIDS. Am J Gastroenterol 1995;90:812-4.  Back to cited text no. 124
    
125.Leigh BR, Lau DH. Severe esophageal toxicity after thoracic radiation therapy for lung cancer associated with the human immunodeficiency virus: A case report and review of the literature. Am J Clin Oncol 1998;21:479-81.  Back to cited text no. 125
    
126.Spano JP, Massiani MA, Bentata M, Rixe O, Friard S, Bossi P, et al. Lung cancer in patients with HIV Infection and review of the literature. Med Oncol 2004;21:109-15.  Back to cited text no. 126
    
127.Tirelli U, Spina M, Sandri S, Serraino D, Gobitti C, Fasan M, et al. Lung carcinoma in 36 patients with human immunodeficiency virus infection. The Italian Cooperative Group on AIDS and Tumors. Cancer 2000;88:563-9.  Back to cited text no. 127
    
128.Bazoes A, Bower M, Powles T. Smoke and mirrors: HIV-related lung cancer. Curr Opin Oncol 2008;20:529-33.  Back to cited text no. 128
    
129.Bower M, Powles T, Nelson M, Shah P, Cox S, Mandelia S, et al. HIV-related lung cancer in the era of highly active antiretroviral therapy. AIDS 2003;17:371-5.  Back to cited text no. 129
    
130.Kao GD, Devine P, Mirza N. Oral cavity and oropharyngeal tumors in human immunodeficiency virus-positive patients: Acute response to radiation therapy. Arch Otolaryngol Head Neck Surg 1999;125:873-6.  Back to cited text no. 130
    
131.Harris MA, Wise MS, Bonington A, Slevin NJ. Case report: Radical radiotherapy for early laryngeal cancer in a patient with human immunodeficiency virus: No evidence of increased toxicity. Br J Radiol 2004;77:519-20.  Back to cited text no. 131
    
132.Bernardi D, Salvioni R, Vaccher E, Repetto L, Piersantelli N, Marini B, et al. Testicular germ cell tumors and human immunodeficiency virus infection: A report of 26 cases. Italian Cooperative Group on AIDS and Tumors. J Clin Oncol 1995;13:2705-11.  Back to cited text no. 132
    
133.Fizazi K, Amato RJ, Beuzeboc P, Petit N, Bouhour D, Thiss A, et al. Germ cell tumors in patients infected by the human immunodeficiency virus. Cancer 2001;92:1460-7.  Back to cited text no. 133
    
134.Hentrich MU, Brack NG, Schmid P, Schuster T, Clemm C, Hartenstein RC. Testicular germ cell tumors in patients with human immunodeficiency virus infection. Cancer 1996;77:2109-16.  Back to cited text no. 134
    
135.Powles T, Bower M, Daugaard G, Shamash J, De Ruiter A, Johnson M, et al. Multicenter study of human immunodeficiency virus-related germ cell tumors. J Clin Oncol 2003;21:1922-7.  Back to cited text no. 135
    
136.Timmerman JM, Northfelt DW, Small EJ. Malignant germ cell tumors in men infected with the human immunodeficiency virus: Natural history and results of therapy. J Clin Oncol 1995;13:1391-7.  Back to cited text no. 136
    
137.Widrick P, Boguniewicz A, Nazeer T, Remick SC. Breast cancer in a man with human immunodeficiency virus infection. Mayo Clin Proc 1997;72:761-4.  Back to cited text no. 137
    
138.Rose PG, Fraire AE. Multiple primary gynecologic neoplasms in a young HIV-positive patient. J Surg Oncol 1993;53:269-72.  Back to cited text no. 138
    
139.Hurley J, Franco S, Gomez-Fernandez C, Reis I, Velez P, Doliny P, et al. Breast cancer and human immunodeficiency virus: A report of 20 cases. Clin Breast Cancer 2001;2:215-20.  Back to cited text no. 139
    
140.Cappell MS, Yao F, Cho KC. Colonic adenocarcinoma associated with the acquired immune deficiency syndrome. Cancer 1988;62:616-9.  Back to cited text no. 140
    
141.Yegüez JF, Martinez SA, Sands DR, Sands LR, Hellinger MD. Colorectal malignancies in HIV-positive patients. Am Surg 2003;69:981-7.  Back to cited text no. 141
    
142.Wasserberg N, Nunoo-Mensah JW, Gonzalez-Ruiz C, Beart RW Jr, Kaiser AM. Colorectal cancer in HIV-infected patients: A case control study. Int J Colorectal Dis 2007;22:1217-21.  Back to cited text no. 142
    
143.Housri N, Yarchoan R, Kaushal A. Radiotherapy for patients with the human immunodeficiency virus: Are special precautions necessary? Cancer 2010;116:273-283.  Back to cited text no. 143
    
144.Wexler A, Berson AM, Goldstone SE, Waltzman R, Penzer J, Maisonet OG, et al. Invasive anal squamous-cell carcinoma in the HIV-positive patient: Outcome in the era of highly active antiretroviral therapy. Dis Colon Rectum 2008;51:73-81.  Back to cited text no. 144
    
145.Blazy A, Hennequin C, Gornet JM, Furco A, Gérard L, Lémann M, et al. Anal carcinomas in HIV-positive patients: High-dose chemoradiotherapy is feasible in the era of highly active antiretroviral therapy. Dis Colon Rectum 2005;48:1176-81.  Back to cited text no. 145
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]


This article has been cited by
1 Mastitis caused byMycobacterium kansasiiinfection in a dog
Atsuko Murai,Soichi Maruyama,Masahiko Nagata,Masashi Yuki
Veterinary Clinical Pathology. 2013; 42(3): 377
[Pubmed] | [DOI]
2 Oncothermia in HIV-Positive and -Negative Locally Advanced Cervical Cancer Patients in South Africa
Carrie A. Strauss,Jeffrey A. Kotzen,Ans Baeyens,Irma Maré
Conference Papers in Medicine. 2013; 2013: 1
[Pubmed] | [DOI]
3 Tumorigenesis related to retroviral infections
Braoudaki, M., Tzortzatou-Stathopoulou, F.
Journal of Infection in Developing Countries. 2011; 5(11): 751-758
[Pubmed]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  >Abstract>Introduction>Aids and Carcino...>Aids and Anal Ca...>AIDS and Kaposi'...>AIDS and Lymphoma>AIDS and Hodgkin...>AIDS and PCNSL>Squamous Carcino...>HIV and Non-HIV ...>HIV and Radiothe...>Conclusion>Article Tables
  In this article
>References

 Article Access Statistics
    Viewed4611    
    Printed195    
    Emailed1    
    PDF Downloaded675    
    Comments [Add]    
    Cited by others 3    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]