27th June 2023

HIV/AIDS associated malignancy

Kaposi’s sarcoma

Kaposi’s sarcoma is an angioproliferative neoplasm classically seen on the lower limbs of mostly elderly men, predominantly of Mediterranean extraction, however, is many orders of magnitude more frequent in patients with immunosuppression due to HIV or iatrogenic immunosuppression. It is caused by the Kaposi’s sarcoma herpes virus, which establishes lifelong latency. Kaposi’s sarcoma is much more common in men who have sex with men, even in the absence of HIV, and it is also more common in Sub-Saharan Africa. It is less frequent among patients on antiretroviral treatment.

Key features on presentation:

• Skin lesions – multiple pigmented lesions, often following Langer lines, raised or flat, with pink to purple colouration
• Oral lesions are more common in HIV, often nodular lesions within the oral mucosa
• Lymphadenopathy is more common in children and teenagers
• The tumour may spread to the lungs and gastrointestinal tract if HIV-related Kaposi’s sarcoma is left untreated

Diagnosis is often clinical, but biopsy for histological confirmation with diagnosis is recommended.
Management of Kaposi’s sarcoma in the context of HIV is with antiretroviral therapy. Other treatment depends on the stage of the cancer:

• T0 cancer can be managed with antiretroviral therapy
• In more advanced cancer, liposomal anthracycline therapy with doxorubicin or daunorubicin should be given alongside antiretroviral therapy
• Surgery can be used for symptoms or to control local growth

Prognosis is poorer in older patients and the presence of the human herpes virus.

Non-Hodgkin’s lymphoma

People living with HIV are at 100 times greater risk of developing Non-Hodgkin’s Lymphoma (NHL) than the general population. In the context of known HIV infection, non-Hodgkin’s lymphoma is an AIDS-defining malignancy, with 1 in 5 people with HIV developing this. Patients with AIDS-related lymphoma are more likely to develop high-grade B-cell lymphomas. The development of AIDS-related lymphoma is likely due to a combination of mechanisms:

• Loss of immunity, especially of antigen presentation cells
• Cytokine release causing B-cell activation
• Infection including EBV and human herpes virus-8
• HIV gene products (e.g. Tat) are oncogenic within B-cells

Risk factors for non-Hodgkin lymphoma in HIV include:

• Lower CD4+ T-cell count and higher HIV viral load
• Increased age
• Male sex
• Epstein-Barr virus exposure increases the risk for aggressive B-cell non-Hodgkin lymphoma.

People with HIV are more likely to present with more advanced non-Hodgkin lymphoma than other patients, with involvement of more distant sites.

Presenting features may include systemic ‘B-symptom’ type features:

• Fevers
• Night sweats
• Weight loss

Examination will likewise demonstrate clinical features in keeping with haematological malignancy:

• Splenomegaly or hepatosplenomegaly
• Rash
• Lymphadenopathy

Management is related to the cell type of the cancer involved:

• AIDS-related lymphoma is managed with cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP)
• Methotrexate may be given in addition
• Rituximab-based chemotherapy regimens may also be used
• Burkitt’s lymphoma is also treated with chemotherapy

Prognosis is generally poor, with relapse common. HAART improves outcomes with this condition.