We reviewed 19 cases diagnosed RCC with HIV infection in Beijing Youan Hospital which is the largest HIV follow-up center in China. Our study is the largest published series about this kind of crew at present.
The average onset age of RCC in the general population is more than 60 with a male preponderance[10],while our study shows an earlier age of 51. Similarly, in an Australian statewide series of 7 HIV-positive patients, the median age of RCC diagnosis was also slightly younger at 52 years old[4].Smoking seemed like a risk factor in A Transatlantic Case Series report, in which 7of 9 patients had smoking history[9].However we did not find conclusive evidence in our series, due to only 5 patients had long smoking history. We can not draw the conclusion that hypertension is the risk facror, because only 4 patients complicated with hypertension, while smoking, obesity, hypertension, and chronic kidney disease had already been identified as risk factors in general population[11].The majority of cases presented as incidental findings screened out by imaging examination, while no patients presented typicaly triad syndrome(hematuria, flank pain, and abdominal mass ), and only 1 patient presented hematuria and flank pain. This phenomenon was consistent with the general population because of the adhibition and diversity of screening methods[12]. In our study we investigated patients’ immunal status in terms of CD4+ T-lymphocyte cell count and HIV viral load, and we found no evidence on the relationship between immunal deficiency and tumor progression, even though the cases with no regular HAART treatment.
To our surprise, 73.7% of the patients had stage pT1 tumors in the case of immunal deficiency, which may predict better outcomes, and this proportion was close to that of the general population(75%)[13]. In our series, patients with patoligical classification of clear cell carcinoma accounting for 89.5% of all cases was slightly higher than the proportion of general population(70%-85%)[14]. Fuhrman grade is the most widely accepted histologic prognostic factor[15]. A large-sample study of 5453 patients in the United States showed that patients with Furhman grade 2 and 3 jointly accounted for 71.4%, and grade 1,2,3 all had good outcomes[16]. In our report,11 patients( 73.3%) with Fuhrman grade 2 and 3 which was close to the above research also had good outcomes.
All the patients underwent operations successfully which were selected in accordance with general population, and 15 patients with radical nephrectomy and 4 with partial nephrectomy. The 4 patients who underwent partial nephrectomy are still alive without local recurrence or distant metastasis with mean follow-up of 43 months, the same outcome as in general patients[17].There were a large number of literatures on radical versus partial nephrectomy for cT1 renal cell carcinoma. A recent study consisted of a total number of 2459 adults in the united states who were treated with radical or partial nephrectomy. It was documented that radical nephrectomy was associated with an increased risk of chronic kidney disease compared with partial nephrectomy, but there were no statistically significant difference in cancer-specific mortality(CSM) or all-cause mortality (ACM)among patients with cT1 RCC between radical nephrectomy and partial nephrectomy[18]. We can not draw the same conclusions as the above study because of inherent defects of our study, but the 4 patients with partial nephrectomy did have good outcomes considering the immunal deficiency. More randomized controlled studies are necessary to confirm the good prognosis of partial nephrectomy versus radical nephrectomy in HIV-positive population, so as to reduce concerns that partial nephrectomy may predispose to recurrence and metastasis because of immunal deficiency special for young HIV-positive population.
We have little experience to share on adjuvant treatment selection, due to good outcomes of our cases. We recommended patients with Furman grade 2–3 and grade 3 accepted cytokine therapy, however only 2 patients agree to the scheme considering of side effects. We used targeted therapy in 2 patients with lung metastasis, but 1 patient still occurred brain metastasis and 1 died of lung metastasis. Checkpoint inhibitors have been identified to induce signifcant responses in RCC[19]. However, due to the role of PD-1+ T cells in HIV transcription in treated aviremic individuals and concerns of unforeseen side effects[20], the cases of cancers with HIV infection were rarely reported. In a recent literature, 16 HIV-positive nivolumab recipients were identified, including 8 non– small-cell lung cancer patients, 2 Hodgkin lymphoma patients, 2 RCC patients, and 4 off-label cancer patients. 1 of RCC patients was unable to assess side effects, response to treatment and outcomes. The other RCC patient received 3 doses of Nivolumab with poor outcome, and occurred grade 3 pneumonitis[21]. The latest study including 17 HIV-positive cancer patients showed that Checkpoint inhibitors seemed like to have comparable efficacy and tolerable adverse effects,and CD4+ T-lymphocyte cell count and viral load were not affected. In this study, the only one RCC patient with stage III responded to immunal thepapy with stable disease, and had slight side effects[22].