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Diagnosis and Management of HIV-Related Cancers. Part A: Module A2 Session 11. Objectives. Understand the pathology of Kaposi’s sarcoma Explain the clinical features, management, treatment and options for KS Describe the clinical features, management and treatment of NHL and CNS lymphoma

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Part A: Module A2 Session 11


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part a module a2 session 11

Diagnosis and Management of

HIV-Related Cancers

Part A: Module A2

Session 11

objectives
Objectives
  • Understand the pathology of Kaposi’s sarcoma
  • Explain the clinical features, management, treatment and options for KS
  • Describe the clinical features, management and treatment of NHL and CNS lymphoma
  • Discuss in-country diagnosis, management and treatment of HIV-related cancers
kaposi s sarcoma ks
Kaposi’s Sarcoma (KS)
  • Introduction/pathology
  • Clinical Features
  • Management and Treatment
  • Treatment Options
introduction pathology
Introduction/Pathology
  • KS is a spindle-shaped cell tumor thought to be caused by human herpes virus-8 (HHV-8)
  • May occur at any time regardless of the CD4 cell count, but becomes more common and aggressive as CD4 count drops occur almost equally among men and women
  • Peak age is from 15-45 years---like that of HIV infection
  • Is often disseminated and involves many organs of the body—skin, lymph nodes, mouth, lungs, brain, gastrointestinal system, liver and spleen
  • Usually responds poorly to anti-cancer treatments because of underlying immunosuppression
ks clinical features
KS: Clinical Features
  • Painless, non-itching skin lesions which may be macular, papular, nodular or plaque-like
  • Oral lesions may occur first and are usually present when there are KS lesions elsewhere
  • Generalized or localized swelling of the face, genital area, or one or more of the lower and upper limbs due to lymphatic infiltration causing lymphedema
  • Generalized lymphadenopathy due to adenopathic KS
  • Localized lesions (i.e., eye, foot or hand)
  • Occasionally a patient may present with abdominal pain, GI bleeding, and distension due to visceral KS which may lead to abdominal obstruction
ks clinical features continued
KS: Clinical Features, continued
  • Cerebral KS may present as a space-occupying lesion, which is difficult to differentiate from other possible causes
  • Disseminated pulmonary KS presents with progressive shortness of breath and persistent cough with frothy or blood-stained sputum. In some patients, nodular lesions may be present on chest x-ray,and bloody or blood-stained pleural effusion
  • Diagnosis is confirmed by punch biopsy of a cutaneous lesion
  • Biopsy of oral lesions may be complicated by excessive bleeding and should be done by an oral surgeon if necessary
ks standard treatment chemotherapy or radiotherapy
KS: Standard Treatment-- Chemotherapy or Radiotherapy
  • For treatment of systemic KS, alpha interferon alone has been used in patients with severe immunodepression
  • For rapidly progressive and/or disseminated mucocutaneous disease, or when the tumor compromises the function of vital organs, chemotherapy may effect rapid tumor regression and be life-saving
  • Among the drugs reported to be effective: liposomal daunorubicin; adriamycin, bleomycin + either vincristine or vinblastine; vincristine/vinblastine; bleomycin/vinca alkaloids
  • Before considering referral of a patient with KS, the benefits and disadvantages should be weighed and discussed with the patient and caring family
ks indications for treatment
KS: Indications for Treatment
  • Numerous, unattractive, painful, or ulcerating lesions
  • Bulky lesions of the mouth or tongue which interfere with feeding
  • Large eye lesions which interfere with vision
  • Life threatening complications like disseminated pulmonary KS associated with severe shortness of breath, massive oral lesions which interfere with feeding, and GI visceral lesions that obstruct internal functions
ks indications for treatment continued
KS: Indications for Treatment, continued
  • Severe swelling due to lymphatic obstruction affecting the face, genital organs and limbs
  • Occasionally patients may request treatment for cosmetic reasons. They should be properly counseled on the available treatment options and their advantages and disadvantages.
  • Treatment of Kaposi’s and other cancers with chemotherapy has an impact on the immune system. If the patient has only one or two KS lesions, it might be better to postpone chemotherapy because of the potential negative impact
ks treatment options
KS: Treatment Options
  • Surgical excision: For isolated lesions or nodules; recurrence may be a problem
  • Radiation: Effective for localized lesions Most effective for relief of bleeding (80%) and least effective for relief of edema (<30%)

Side effects range from mild erythema to moist desquamation of the skin and blistering, painful mucosal reactions in oral lesions

Response progressive over few weeks;complete remission (70% cases), but usually temporary; If recurring, further treatment can be given

ks treatment options continued
KS: Treatment Options, continued
  • Chemotherapy:

Intralesional cytotoxic chemotherapy can be used for

some lesions.Systemic chemotherapy is more often used for widespread KS

Good results are obtained with combination therapy

even in reduced doses

Drugs tend to depress bone marrow and cause

pancytopenia so they are best given with a near normal

white cell count

Neutropenia is a common complication of HIV disease,

meaning that many HIV patients cannot be put on

chemotherapy

Visceral KS responds poorly to chemotherapy

non hodgkin s lymphoma
Non-Hodgkin’s Lymphoma
  • Clinical Features
  • Management and Treatment
clinical features
Clinical Features
  • Systemic symptoms include fever, night sweats, and unexplained weight loss
  • Clinical features include lymphadenopathy, splenomegaly, pancytopenia, bowel obstruction, ascites, cranial nerve lesions, spinal cord suppression, and nerve root lesions plus cutaneous, testicular, and lung mass lesions
management and treatment
Management and Treatment
  • Various chemotherapy protocols (as used in seronegative patients) given in several courses over a number of months
  • Prognosis is often poor, particularly with a CD4 cell count <100/l
central nervous system lymphoma
Central Nervous System Lymphoma
  • Clinical Features
  • Management and Treatment
cns lymphoma clinical features
CNS Lymphoma: Clinical Features
  • Occurs at total CD4 counts well under 100 cells and is a typical end-stage complication
  • Definitive diagnosis is made by brain biopsy or CSF cytology in the presence of a space-occupying lesion (s) on CT or MRI scan
  • Because brain biopsy may be difficult to obtain, patients who fail a trial therapy for toxoplasmosis are often assumed to have CNS lymphoma
management and treatment1
Management and Treatment
  • There is no effective cytotoxic chemotherapy and irradiation is considered palliative
  • Survival after diagnosis is usually limited to a few months