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mm3) CD4+ count
Lung Cancer 29 (2000) 147 – 149 www.elsevier.nl/locate/lungcan
Short communication
Pulmonary resection for lung cancer in HIV-positive patients with low (B200 lymphocytes/mm3) CD4+ count Fabio Massera *, Gaetano Rocco, Gerolamo Rossi, Mario Robustellini, Claudio Della Pona, Alberto Meroni, Adriano Rizzi Di6ision of Thoracic Surgery, ‘E. Morelli’ Regional Hospital, 23039 Sondalo, Italy Received 9 November 1999; received in revised form 8 February 2000; accepted 21 February 2000
Abstract The clinical improvement obtained with combination treatment has modified the therapeutic approach of lung cancer in HIV-positive patients. Aggressive surgical treatment has become a viable option for those patients in whom the CD4+ cell count was greater than 200 lymphocytes/mm3. We recently extended our surgical indications to include two HIV-positive patients with lung cancer (stage IIIA and IIB) and low ( B200 lymphocytes/mm3) CD4+ count. Both patients underwent a lobectomy and mediastinal nodal dissection. The postoperative course was uneventful. No evidence of recurrent cancer was seen at 12 and 20 months after the operation. Based on this limited experience, we conclude that a low CD4+ count should not represent, per se, an exclusion criterion for the surgical treatment of pleuropulmonary conditions in HIV-positive patients. © 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: AIDS; Lung cancer; Pulmonary resection
Advances in biological and clinical research have had a significant impact on disease progression of HIV-positive patients. With the newer protease inhibitors, reverse transcriptive inhibitors, and better sequencing of combination therapies, it is beginning to appear that the natural history of HIV infection can be altered in a substantial way and that life can be significantly
* Corresponding author. Tel.: + 39-034-2808622; fax: +39034-2808616. E-mail address: [email protected] (F. Massera).
prolonged [1]. As the risk of clinical progression is delayed, so the median survival of AIDS patients is increased. In this setting, the clinical outcome is related to a more aggressive treatment strategy based on the antiretroviral multidrug chemotherapy and on the chemoprevention of opportunistic infections [2]. The resulting ‘downstaging’ of seropositive patients has allowed the physicians to focus on the opportunistic diseases, more than on the immunological pattern, because the prognosis of HIV patients seems to depend on the prevention and
0169-5002/00/$ - see front matter © 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 9 - 5 0 0 2 ( 0 0 ) 0 0 1 2 9 - X
148
Patient gender
Age (years)
CDC-93 clinical staging
Histology
Surgery
Pathological staging
Follow-up (months)
Current status
1, male
45
C3
12
Dead
44
C3
Right upper lobectomy Right upper lobectomy
T2N2M0
2, male
Bronchoalveolar carcinoma Large cell carcinoma
T3N0M0
20
Alive
F. Massera et al. / Lung Cancer 29 (2000) 147–149
Table 1 HIV-positive patients with low (B200 lymphocytes/mm3) CD4+ count operated on for lung cancer
F. Massera et al. / Lung Cancer 29 (2000) 147–149
the management of the former. In this setting, the need for an early antiretroviral therapy in HIVpositive patients has been advocated in order to prevent those infections that may hinder early diagnosis or result in an incorrect tumor staging [3]. In HIV-positive patients, the lung is the target of opportunistic conditions inclusive of cancer, which is reported with increasing frequency [4]. Lung cancer in HIV patients is more aggressive, yielding shortened survival [3]. Few HIV patients have been deemed to have operable disease. However, aggressive surgical treatment with reduced postoperative morbidity (between 7 and 21%) and mortality (between 0.2 and 7.6%) has been reported [5]. Higher death rates (15%) have been related to concurrent opportunistic diseases, such as Pneumocystis carinii infection, to the so-called wasting syndrome, and, to suboptimal antiretroviral coverage [5]. Thurer et al. have reported the value of 200 CD4+ lymphocytes/mm3 as a predictor of high postoperative morbidity and mortality [6]. We have recently extended our surgical indications to include two HIV-positive patients with locally advanced lung cancer and low ( B200 lymphocytes/mm3) CD4 + count (Table 1). No postoperative morbidity was observed. One patient is currently alive 20 months after resection. No evidence of recurrent cancer was seen in the patient who died 1 year from the operation of toxoplasmic encephalitis. Crucial to the successful outcome was the acceptable preoperative performance status seen in both patients. One of them was received multidrug antiretroviral therapy for 1 month prior to resection. In conclusion, we support pulmonary resection in HIV-positive patients with low CD4+ count, which does not entail, per se, an increased postoperative morbidity and mortality. Moreover, the
.
149
timing of the surgical option is essential to decision-making for the treatment of AIDS-related conditions; criteria for pulmonary resection in these patients are: 1, favorable biological condition elicited by the performance status, the immunological pattern and the presence of opportunistic infections; 2, positive response to antiretroviral treatment; 3, compliance to the treatment plan; 4, completeness of the surgical resection; 5, prognosis of the HIV infection; and 6, prognosis of the surgically correctable disease. As a consequence, emphasis should be put on the need for an individualized treatment and a multidisciplinary approach where the patient, the oncologist and the thoracic surgeon each play a definite role in determining a successful outcome [6].
References [1] Spira R, Marimoutou C, Binquet C, Lacoste D, Dabis F. Rapid change in the use of antiretroviral agents and improvement in a population of HIV-infected patients: France 1995 to 1997. J Acquired Immune Defic Syndr Hum Retrovirol 1998;18:358 – 64. [2] Jacobson MA, French M. Altered natural history of AIDS-related opportunistic infections in the era of potent combination antiretroviral therapy. AIDS 1998;12:s157 – 63. [3] Peyrade F, Taillan B, Lebrun C, Dujardin P. Cancer in patients infected with the human immunodeficiency virus. The unusual aspects. Presse Med 1999;28:809 – 14. [4] Grulich AE, Wan X, Law MG, Coates M, Kaldor JM. Risk of cancer in people with AIDS. AIDS 1999;13:839 – 43. [5] Mouroux J, Riquet M, Padovani B, Debesse B, Richelme H. Surgical management of thoracic manifestations in human immunodeficiency virus-positive patients: indications and results. Br J Surg 1995;82:39 – 43. [6] Thurer RJ, Jacobs JP, Holland IIFW, Cintron JR. Surgical treatment of lung cancer in patients with human immunodeficiency virus. Ann Thorac Surg 1995;60:599 – 602.
Short communication
Pulmonary resection for lung cancer in HIV-positive patients with low (B200 lymphocytes/mm3) CD4+ count Fabio Massera *, Gaetano Rocco, Gerolamo Rossi, Mario Robustellini, Claudio Della Pona, Alberto Meroni, Adriano Rizzi Di6ision of Thoracic Surgery, ‘E. Morelli’ Regional Hospital, 23039 Sondalo, Italy Received 9 November 1999; received in revised form 8 February 2000; accepted 21 February 2000
Abstract The clinical improvement obtained with combination treatment has modified the therapeutic approach of lung cancer in HIV-positive patients. Aggressive surgical treatment has become a viable option for those patients in whom the CD4+ cell count was greater than 200 lymphocytes/mm3. We recently extended our surgical indications to include two HIV-positive patients with lung cancer (stage IIIA and IIB) and low ( B200 lymphocytes/mm3) CD4+ count. Both patients underwent a lobectomy and mediastinal nodal dissection. The postoperative course was uneventful. No evidence of recurrent cancer was seen at 12 and 20 months after the operation. Based on this limited experience, we conclude that a low CD4+ count should not represent, per se, an exclusion criterion for the surgical treatment of pleuropulmonary conditions in HIV-positive patients. © 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: AIDS; Lung cancer; Pulmonary resection
Advances in biological and clinical research have had a significant impact on disease progression of HIV-positive patients. With the newer protease inhibitors, reverse transcriptive inhibitors, and better sequencing of combination therapies, it is beginning to appear that the natural history of HIV infection can be altered in a substantial way and that life can be significantly
* Corresponding author. Tel.: + 39-034-2808622; fax: +39034-2808616. E-mail address: [email protected] (F. Massera).
prolonged [1]. As the risk of clinical progression is delayed, so the median survival of AIDS patients is increased. In this setting, the clinical outcome is related to a more aggressive treatment strategy based on the antiretroviral multidrug chemotherapy and on the chemoprevention of opportunistic infections [2]. The resulting ‘downstaging’ of seropositive patients has allowed the physicians to focus on the opportunistic diseases, more than on the immunological pattern, because the prognosis of HIV patients seems to depend on the prevention and
0169-5002/00/$ - see front matter © 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 9 - 5 0 0 2 ( 0 0 ) 0 0 1 2 9 - X
148
Patient gender
Age (years)
CDC-93 clinical staging
Histology
Surgery
Pathological staging
Follow-up (months)
Current status
1, male
45
C3
12
Dead
44
C3
Right upper lobectomy Right upper lobectomy
T2N2M0
2, male
Bronchoalveolar carcinoma Large cell carcinoma
T3N0M0
20
Alive
F. Massera et al. / Lung Cancer 29 (2000) 147–149
Table 1 HIV-positive patients with low (B200 lymphocytes/mm3) CD4+ count operated on for lung cancer
F. Massera et al. / Lung Cancer 29 (2000) 147–149
the management of the former. In this setting, the need for an early antiretroviral therapy in HIVpositive patients has been advocated in order to prevent those infections that may hinder early diagnosis or result in an incorrect tumor staging [3]. In HIV-positive patients, the lung is the target of opportunistic conditions inclusive of cancer, which is reported with increasing frequency [4]. Lung cancer in HIV patients is more aggressive, yielding shortened survival [3]. Few HIV patients have been deemed to have operable disease. However, aggressive surgical treatment with reduced postoperative morbidity (between 7 and 21%) and mortality (between 0.2 and 7.6%) has been reported [5]. Higher death rates (15%) have been related to concurrent opportunistic diseases, such as Pneumocystis carinii infection, to the so-called wasting syndrome, and, to suboptimal antiretroviral coverage [5]. Thurer et al. have reported the value of 200 CD4+ lymphocytes/mm3 as a predictor of high postoperative morbidity and mortality [6]. We have recently extended our surgical indications to include two HIV-positive patients with locally advanced lung cancer and low ( B200 lymphocytes/mm3) CD4 + count (Table 1). No postoperative morbidity was observed. One patient is currently alive 20 months after resection. No evidence of recurrent cancer was seen in the patient who died 1 year from the operation of toxoplasmic encephalitis. Crucial to the successful outcome was the acceptable preoperative performance status seen in both patients. One of them was received multidrug antiretroviral therapy for 1 month prior to resection. In conclusion, we support pulmonary resection in HIV-positive patients with low CD4+ count, which does not entail, per se, an increased postoperative morbidity and mortality. Moreover, the
.
149
timing of the surgical option is essential to decision-making for the treatment of AIDS-related conditions; criteria for pulmonary resection in these patients are: 1, favorable biological condition elicited by the performance status, the immunological pattern and the presence of opportunistic infections; 2, positive response to antiretroviral treatment; 3, compliance to the treatment plan; 4, completeness of the surgical resection; 5, prognosis of the HIV infection; and 6, prognosis of the surgically correctable disease. As a consequence, emphasis should be put on the need for an individualized treatment and a multidisciplinary approach where the patient, the oncologist and the thoracic surgeon each play a definite role in determining a successful outcome [6].
References [1] Spira R, Marimoutou C, Binquet C, Lacoste D, Dabis F. Rapid change in the use of antiretroviral agents and improvement in a population of HIV-infected patients: France 1995 to 1997. J Acquired Immune Defic Syndr Hum Retrovirol 1998;18:358 – 64. [2] Jacobson MA, French M. Altered natural history of AIDS-related opportunistic infections in the era of potent combination antiretroviral therapy. AIDS 1998;12:s157 – 63. [3] Peyrade F, Taillan B, Lebrun C, Dujardin P. Cancer in patients infected with the human immunodeficiency virus. The unusual aspects. Presse Med 1999;28:809 – 14. [4] Grulich AE, Wan X, Law MG, Coates M, Kaldor JM. Risk of cancer in people with AIDS. AIDS 1999;13:839 – 43. [5] Mouroux J, Riquet M, Padovani B, Debesse B, Richelme H. Surgical management of thoracic manifestations in human immunodeficiency virus-positive patients: indications and results. Br J Surg 1995;82:39 – 43. [6] Thurer RJ, Jacobs JP, Holland IIFW, Cintron JR. Surgical treatment of lung cancer in patients with human immunodeficiency virus. Ann Thorac Surg 1995;60:599 – 602.