Computed tomographic diagnosis of bronchogenic carcinoma in HIV-infected patients

doi:10.1016/S0169-5002(99)00124-5

Lung Cancer

Volume 28, Issue 3, June 2000, Pages 203-209

https://doi.org/10.1016/S0169-5002(99)00124-5 Get rights and content

Abstract

Purpose: To describe the features of bronchogenic carcinoma (BC) on plain radiography and computed tomography (CT) in human immunodeficiency virus (HIV)-infected patients; to evaluate percutaneous transthoracic needle biopsy (PTNB) in this setting; and to assess outcome. Patients and methods: We reviewed the medical charts, radiographs and chest CT scans in 15 AIDS patients with histologically proven BC. All but one of the patients were young men (mean age 48 years) with a long history of smoking (mean 40 pack-years). Adenocarcinoma was the predominant cell type (46.6%). The stage of the malignancy did not correlate with the CD4 cell count (mean 189 per mm³). The diagnosis was obtained by means of PTNB (n=7), bronchoscopy (n=4), thoracotomy (n=2), pleural biopsy (n=1) or extrathoracic biopsy (n=1). Results: Parenchymal masses and nodules were the most common features (66.6%) on chest radiographs and CT. BC was peripheral in 11 cases (73%) and was located in the upper lobe in ten cases (66.6%). Enlarged lymph nodes were present in 60% of patients and metastases in 30%. PTNB was diagnostic in seven of the eight patients who underwent the procedure; complications included two pneumothoraces and one secondary implantation of tumor cells along the needle tract. Three lobectomies and one pneumonectomy were performed for stage I disease. The mean survival time among the patients who underwent surgery was 14 months. These survivals are more encouraging than some of those previously reported in the literature, furthermore, patients die of competing illnesses. Conclusion: BC in HIV-infected patients is similar to that in the general population. Early diagnosis can be achieved by means of PTNB. Surgical resection, when feasible, significantly improves survival.

Introduction

Many authors have reported an increasing frequency of bronchogenic carcinoma in human immunodeficiency virus (HIV)-infected patients [1], [2], [3], [4], [5], [6]. These patients, who are usually younger than the general population with lung carcinoma, have a grim prognosis. Their poor outcome is probably related to the high proportion of patients in whom bronchogenic carcinoma (BC) is diagnosed at an advanced stage, ruling out surgical treatment. BC usually shows up as a peripheral or central mass or nodule on the chest radiograph, features resembling those of a number of opportunistic infections, and also those of lung cancer in the general population. To improve the outcome of these patients we need to obtain a positive diagnosis as early as possible. We describe our findings in 15 consecutive HIV-infected patients with lung cancer, based on plain radiographic and computed tomographic features. We also report the diagnostic value of transthoracic needle biopsy, and survival data.

Section snippets

Patients and methods

We reviewed the medical charts (Table 1), plain radiographs and computed tomography (CT) scans of 15 HIV-infected patients in whom lung cancer was diagnosed between 1988 and 1994. All but one of the patients were men, and the mean age was 48 years (range 29–60 years). Six patients were homosexuals, four were intravenous drug users, two were infected by blood transfusion and one was infected after a cornea transplant operation. Two patients had no identified risk factor for HIV infection.

Results

Chest radiographic and CT findings are listed in Table 2. All the chest radiographs were abnormal, with parenchymal nodules or masses (n=11), hilar masses (n=3) and parenchymal air-space opacities (n=1). Pleural effusion was present in three patients. The main parenchymal lesion was located in an upper lobe in ten patients and in a lower lobe in five patients. There were 11 peripheral lesions and four central lesions.

The size range of the non-small-cell carcinomas on the CT scans was 20–80 mm

Discussion

Patients infected with HIV infection and AIDS are at an increased risk of opportunistic infections and malignancies such as Kaposi’s sarcoma and non-Hodgkin lymphomas. The increase in lung cancer among young HIV-infected patients has led some authors to speculate that the tumor may be associated with AIDS [3]. In a recent publication, Chan et al. [4] reviewed 261 cases of bronchogenic carcinoma during the pre-AIDS period and 232 cases during the AIDS era. Their results suggested that HIV

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Cited by (26)

Chest CT Findings in Patients with HIV Presenting to the Emergency Department: A Single Institute Experience
2023, Current Problems in Diagnostic Radiology
Citation Excerpt :
The association between HIV infection and lung cancer is likely multifactorial, with higher rates of smoking among PLWH as well as direct immunosuppressive mechanisms of HIV infection contributing.21,22,25,28 Previous studies of the imaging characteristics of lung cancer in PLWH have reported parenchymal masses or nodules, predominantly peripherally located in the upper lobes, to be the most common imaging feature.26,29 Additionally, lymphadenopathy and pleural effusions are frequently observed, with Fishman et al. reporting lymphadenopathy in 10 cases and pleural effusions in 10 cases in their study of 30 PLWH with bronchogenic carcinoma.26
The aim of this study was to analyze chest CT imaging findings and relevant clinical factors in patients with HIV presenting to the emergency department (ED).
A retrospective review was performed to identify patients with HIV who received chest CT imaging evaluation in the acute ED setting. Analyzed patients included adults with a known diagnosis of HIV who presented to the ED at a single tertiary care center between 2004 and 2020 and received chest CT imaging. Chest CT findings were assessed by 2 radiologist readers, and relevant clinical data were gathered. Statistical analysis was performed to determine if imaging and clinical factors demonstrate significant associations with CD4 count, viral load, and antiretroviral therapy status.
A total of 113 patients with HIV were identified who presented to the ED and underwent chest CT imaging evaluation (mean age 47 ± 11 years). Frequently detected chest CT findings included infectious pneumonia (24%), malignancy (11%), pleural effusion (17%), pericardial effusion (13%), and pulmonary embolism (4%). CD4 count, viral load, and active retroviral therapy demonstrated statistically significant associations with a number of key imaging and clinical factors, including presence of pneumonia, malignancy, average length of hospital admission, and survival.
Patients with HIV present with a wide range of imaging findings when presenting in the acute ED setting. CD4 count, viral load, and active retroviral therapy status demonstrate statistically significant associations with multiple key imaging findings and clinical factors. Chest CT plays an integral role in the clinical management of this unique patient population.
Prospective CT screening for lung cancer in a high-risk population: HIV-positive smokers
2014, Journal of Thoracic Oncology
Epidemiological evidence suggests that HIV-infected individuals are at increased risk of lung cancer, but no data exist because large computed tomography (CT) screening trials routinely exclude HIV-infected participants.
From 2006 to 2013, we conducted the world's first lung cancer screening trial of 224 HIV-infected current/former smokers to assess the CT detection rates of lung cancer. We also used 130 HIV-infected patients with known lung cancer to determine radiographic markers of lung cancer risk using multivariate analysis.
Median age was 48 years with 34 pack-years smoked. During 678 person-years, one lung cancer was found on incident screening. Besides this lung cancer case, 18 deaths (8%) occurred, but none were cancer related. There were no interim diagnoses of lung or extrapulmonary cancers. None of the pulmonary nodules detected in 48 participants at baseline were diagnosed as cancer by study end. The heterogeneity of emphysema across the entire lung as measured by CT densitometry was significantly higher in HIV-infected subjects with lung cancer compared with the heterogeneity of emphysema in those without HIV (p ⩽ 0.01). On multivariate regression analysis, increased age, higher smoking pack-years, low CD4 nadir, and increased heterogeneity of emphysema on quantitative CT imaging were all significantly associated with lung cancer.
Despite a high rate of active smoking among HIV-infected participants, only one lung cancer was detected in 678 patient-years. This was probably because of the young age of participants suggesting that CT screening of high-risk populations should strongly consider advanced age as a critical inclusion criterion. Future screening trials in urban American must also incorporate robust measures to ensure HIV patient compliance, adherence, and smoking cessation.
Human immunodeficiency virus infection as a prognostic factor in surgical patients with non-small cell lung cancer
2012, Annals of Thoracic Surgery
The purpose of this study was to assess the effect of human immunodeficiency virus (HIV) infection on postoperative survival among non-small cell lung cancer (NSCLC) patients.
A retrospective cohort study compared 22 HIV-infected lung cancer patients to 2,430 lung cancer patients with HIV-unspecified status who underwent resection at Johns Hopkins Hospital from 1985 to 2009. Subcohort comparative analyses were performed using individual matching methods.
Thirty-day mortality rates did not differ between HIV-infected and HIV-unspecified patients. Survival rates for HIV-infected lung cancer patients were significantly shorter than for HIV-unspecified patients (median, 26 versus 48 months; p = 0.001). After adjustment, the relative hazard of mortality among HIV-infected NSCLC patients was more than threefold that of HIV-unspecified patients (adjusted hazard ratio, 3.08; 95% confidence interval: 1.85 to 5.13). When additional surgical characteristics were modeled in a matched subcohort, the association remained statistically significant (adjusted hazard ratio, 2.31; 95% confidence interval: 1.11 to 4.81). Moreover, HIV-infected lung cancer patients with CD4 counts less than 200 cells/mm³ had shortened median survival compared with patients whose CD4 counts were 200 cells/mm³ or greater (8 versus 40 months; p = 0.031). Postoperative pulmonary and infectious complications were also elevated in the HIV-infected group (p = 0.001 and p < 0.001, respectively). After surgery, median time to cancer progression was shorter among HIV-infected patients (20.4 months) versus HIV-unspecified patients (p = 0.061).
The HIV-infected NSCLC patients have more postoperative complications, rapid progression to disease recurrence, and poorer postoperative survival. Optimizing immune status before surgery and careful patient selection based on diffusion capacity of lung for carbon monoxide may improve patient outcomes.
Lung cancer in HIV infection
2012, Clinical Lung Cancer
Citation Excerpt :
Only a handful of small studies have focused on the radiological characteristics of HIV-associated lung cancer patients.64-67 Among 15 such patients, parenchymal masses and nodules were the most common features (67%) on chest radiographs and computerized tomography (CT) scans.65 Masses were peripheral in 11 cases (73%) and were located in the upper lobes in 10 cases (67%).
Lung cancer is the most prevalent non–AIDS-defining malignancy in the highly active antiretroviral therapy era. Smoking plays a significant role in the development of HIV-associated lung cancer, but the cancer risk is two to four times greater in HIV-infected persons than in the general population, even after adjusting for smoking intensity and duration. Lung cancer is typically diagnosed a decade or more earlier among HIV-infected persons (mean age, 46 years) compared to those without HIV infection. Adenocarcinoma is the most common histological subtype, and the majority of patients are diagnosed with locally advanced or metastatic carcinoma. Because pulmonary infections are common among HIV-infected individuals, clinicians may not suspect lung cancer in this younger patient population. Surgery with curative intent remains the treatment of choice for early-stage disease. Although there is increasing experience in using radiation and chemotherapy for HIV-infected patients who do not have surgical options, there is a need for prospective studies because this population is frequently excluded from participating in cancer trials. Evidence-based treatments for smoking-cessation with demonstrated efficacy in the general population must be routinely incorporated into the care of HIV-positive smokers.
Lung cancer in HIV-positive patients
2010, Journal of Thoracic Oncology
Citation Excerpt :
Radiographically, patients presented with peripherally located masses and infiltrates (29/41), often involving the upper lobes (27/29 of peripheral tumors). Adenopathy occurred in about half of patients, whereas effusions occurred in about one third.43,65,80 The most common histologic diagnosis is adenocarcinoma (34–67%) followed by squamous cell (17–39%), large cell (3–16%), and bronchoalveolar (2–3%) cancer in HIV-positive patients.
Malignancies account for more than a third of all deaths in human immunodeficiency virus (HIV)-positive patients. Although acquired immunodeficiency syndrome-related mortality is decreasing with the introduction of effective antiretroviral therapy, the incidence of lung cancer in patients with HIV remains high. Lung cancer has now become the leading cause of mortality among the nonacquired immunodeficiency syndrome defining malignancies. Within the HIV population, the incidence of lung cancer is estimated to be approximately 2 to 4 times that of the general population. Often these patients present with advanced disease (stage III or IV) at a younger age and have an inferior overall survival, when compared with non-HIV patients. Development of lung cancer in patients with HIV has been linked to various factors including immunosuppression, CD4 count, viral load, and smoking. This article reviews the impact of HIV on the incidence, risk factors, clinical presentation, and treatment of lung cancer.
Lung cancer, a new challenge in the HIV-infected population
2006, Lung Cancer
HIV infection predisposes patients to AIDS-defining malignancies, some of which, such as Kaposi's sarcoma and non-Hodgkin lymphoma, can affect the lungs. In 1996, AIDS-related mortality started to fall sharply in industrialized countries following the introduction of highly active antiretroviral treatments (HAART). This was accompanied by an increase in the proportion of deaths attributable to non AIDS-defining solid tumors, and especially lung cancer (LC). The increased risk of LC relative to the general population of the same age seems to be due partly to a higher prevalence of smoking among HIV-infected subjects. The average age of HIV-infected patients at LC diagnosis is about 45 years. Most patients are symptomatic at diagnosis and have only mild or moderate immunosuppression. LC is diagnosed when it is locally advanced or metastatic (stages III–IV) in 75–90% of cases, as in patients with unknown HIV serostatus. Adenocarcinoma is the most frequent histologic type. The prognosis of LC is poorer in HIV-infected patients than in the general population. Data on the efficacy and toxicity of chemotherapy in this setting are rare and rather imprecise. Surgery remains the reference treatment for localized disease in patients with adequate functional status and general health, regardless of their immune status. Prospective clinical trials are needed to define the optimal LC treatment strategies in HIV-infected patients.

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Computed tomographic diagnosis of bronchogenic carcinoma in HIV-infected patients

Abstract

Introduction

Section snippets

Patients and methods

Results

Discussion

Chest

Chest

Chest

Chest

Lung cancer in patients seropositive for human immunodeficiency virus

Radiology