HIV ASSOCIATED MALIGNANCIES Dr. G. VENKATESAN Asst. Surgeon GHTM, Tambaram

OPPORTUNISTIC MALIGNACIES Kaposi sarcoma Lymphoma of Brain Primary Secondary NHL HL Burkitt Lymphoma Cervical dysplasia / Ca Anal dysplasia / Sq cell Ca

KEY POINTS High index of clinical suscipion. Physicians must think in terms of not only the possibility of opportunistic infections but also malignancies when diagnosing and treating HIV positive patients. As CD4 count - occurrence as well as aggressiveness of the malignancies

CASE STUDY A 25 year- old HIV positive male patient is having difficulty in breathing, coughs with expectoration and reports having no appetite. What preliminary diagnosis would you make for this patient?

Cont… You take an x-ray of the patient and discover a mediastinal mass. Given this new information, what diagnosis would you make for this patient? What other possible diagnoses could you make?

KAPOSI’S SARCOMA (KS) Multicentric Neoplasm consisting of over growth of venular capillary endothelium Can occur as potentially occult lesions Unusual and rare before AIDS Most common in North America and Europe (HOMOSEXUALS) Closely linked with Human Herpesvirus HHV8

Cont… Most common site – skin, Lymph nodes 1 CD4 Count X Others – Mouth, Hard palate,Tip of nose, Penis, lower legs GIT, Liver, spleen, Lungs. Never involves Brain. Colourful lesions – Red, Violet, Brown, Black Well circumscribed, flat / raised. 1 CD4 Count X Aggressiveness

DIAGNOSIS Made on Clinical suspicion and confirmed by HPE Should be differentiated from bacillary angiomatosis

TREATMENT Single lesions – RT Multiple – Vincristine, Bleomycin, Doxorubicin Regress with HAART

IYMPHOMA Primary CNS lymphoma NHL HL Burkitt lymphoma

PRIMARY CNS LYMPHOMA 2nd most common SOL in HIV Strong association with EBV CD4 < 50 Difficult to diagnose with imaging Presentation – focal seizures, Resistant fever Lesions – more often solitary - Deep in white matter

Cont. . . Confirmed by biopsy PCR assay of CSF for EBV DNA (90%) DD – Toxo, Bact. Abscess, Cryptococcoma, Tuberculoma, Nocardia RT – difficult to treat.

SYSTEMIC LYMPOMA Non Hodgin L Hodgin L Burkitt L

NON HODGIN LYPHOMA B Lymphocytes – 80% T Lymphocytes – 20% Tend to occur largely at Extranodal sites – most in CNS, Bone marrow, GIT, Liver, Lungs Confirmation by HPE Treatment – Chemotheraphy, Radiotheraphy

HODGIN LYMPHOMA 5 fold in HIV More of mixed cellularity / lymphocyte depleted subtypes Not in CDC definition of AIDS Present in advanced stage of AIDS

BURKITT LYMPHOMA Small non-cleaved cell lymphoma Most in 10-19 years (young) C-myc translocation from Ch 8 to Ch 14/22 EBV Positive Chemotherapy

CERVICAL DYSPLASIA/ Ca Common cancer in women – 80% of all GYN cancers Type 2 HSV HPV – 16, 18, 31, 33 High risk factors Multiple partners or monogamous women whose partner have multiple partners. Early age at first sexual intercourse Family size Heavy smoking OCP > 8 years Lower socioeconomic status

Cont… Erosion, Endocervicitis, Ectropion – not precursors of CA Reserve cells beneath columnar EPI at SC jn – from metaplastic cells (becomes mature cells) Metaplasia Columnar Squamous Epidermidization Some M cells become atypical Atypical metaplasia – precursor of dysplasia

Cont… Dysplasia – altered / disorderly arrangement of cells. CIN I – Mild CIN II – MOD CIN III – Sev. - CA in situ Abnormal vaginal bleeding, discharge, postcoital bleeding, lower abd – pain O/E – red, friable, exophytic lesion or ulcer, bleeds on touch

INV Screening - Papanicolaou smear – standard single most effective screening test Colposcopy Cericography Cone – BX Punch BX Large loop excision of transformation zone (LLETZ) Other investigations

Treatment Surgery Conization Hysterectomy BSO Radical H Pelvic exenteration Cryosurgery Laser surgery Loop electrosurgical excision procedure (LEEP)

Cont. . . RT – Brachy therapy - Intracavitary radiation (Cobalt, Caesium, selectron) Chemo – Cisplatin, Ifosfamide(70% response)

Thank you