Michael

A. Braun,

MD

Donald

A. Killam,

#{149}

MD

Scot

Lung Cancer In Patients for Human Immunodeficlency The authors describe the clinical and radiographic findings of lung carcinoma in six patients infected with the human immunodeficiency virus (HIV). These patients were in a younger age group than is cornrnonly associated with lung cancer. The radiographic findings included mediastinal adenopathy (n 5), hilar masses with distal atelectasis (n = 3), parenchyrnal masses (n = 3), pleural effusions (n 2), and pleural thickening (n = 1). Recognition of any of these findings should raise the diagnostic possibility of lung cancer in this group of younger patients.

I

terms:

syndrome 60.32

Acquired

(AIDS),

Radiology

1990;

60.2518

neoplasms,

175:341-343

complications are a significant cause of morbidity and mortality in patients infected with the human immunodeficiency virus (HIV). It is estimated that more than 50% of patients nodeficiency

with syndrome

acquired (AIDS)

immude-

velop pulmonary manifestations at some time in the course of their disease (1). The intrathoracic abnormalities include both infections (mainly opportunistic) most frequently

and neoplasms. recognized

The infec-

tions include Pneumocystis carinii pneumonia, tuberculosis (both typical and atypical mycobacterial, ie, Mycobacterium avium complex), and,

cur

frequently,

with

infected the

fungal

increased

patients

clinical

and

viral

and

PATIENTS We retrospectively

From

the Department and

Received 1990;

quests c

Division

of Radiology

(M.A.B.,

Oncology (S.C.R., J.C.R.), Albany Medical Center Hospital, 43 New Scotland Aye, Albany, NY 12208. December

the

of Medical

October 24, 1989; revision requested 12; revision received January 26,

accepted

to D.A.K. RSNA, 1990

February

1. Address

reprint

re-

C. Ruckdeschel,

MD

frequency

(2-5).

in HIV-

We describe

radiographic

AND

features

METHODS reviewed

means of transbronchial endoscopic biopsy (n 3), autopsy (n 1), cytologic examination of pleural fluid (n = 1), and

pathologic

examination

of a surgical

spec-

imen (n = 1). In all patients the pulmonary abnormality was initially suggested by plain chest radiographs and further

defined by computed tomographic (CT) scans. Only one patient had coexistent intrathoracic disease (P carinii pneumonia). The remainder were free of concomitant opportunistic

Kaposi

infections,

sarcoma

lymphoma,

on the

basis

or

of clinical,

radiographic, and pathologic grounds. At presentation all patients but one had advanced disease (stage III or greater) as determined by combined radiographic and pathologic

staging.

in-

of bronchogenic carcinoma encountered in six HIV-infected patients and suggest that this disease should be included in the differential diagnosis of intrathoracic abnormality in patients with AIDS.

D.A.K.)

#{149} John

Seropositive Virus’

fections. Malignant lymphoma (B cell) and Kaposi sarcoma are the most frequently encountered malignant diseases. It has been speculated that infection with HIV may increase the frequency of other malignancies. Several case reviews and retrospective analyses have raised the possibility that primary lung carcinoma may oc-

immunodeficiency #{149} Lung

MD

NTRATHORACIC

less Index

C. Remick,

#{149}

the radio-

graphs and charts of six HIV-infected patients who presented to our institution from April 1988 to March 1989 and who were subsequently proved at pathologic examination to have primary lung carcinoma. All patients were seropositive for the HIV antibody prior to the diagnosis of lung carcinoma. Two of the six patients had Centers for Disease Control criteria for the diagnosis of AIDS because of opportunistic infections. Pathologic diagnoses were established in all patients by

RESULTS The age range was 30-48 years, with a mean of 40 years (Table). Four patients

were

less

than

40 years

of

age. Presenting clinical symptoms included cough, dyspnea, chest pain, fever, and hemoptysis. All the patients were smokers, and four of six had a significant history (20 packyears or more) of tobacco use. One patient had had a minimal asbestos exposure as a temporary construction worker but had no clinical or radiographic evidence of asbestosis or asbestos-related pleural disease. There were no other risk factors for developing lung carcinoma among this group.

The radiographic manifestations (Figs 1-4) included mediastinal adenopathy (n 5), hilar masses (n 3), pulmonary masses (n = 3), pleural effusions (n 2), and pleural-based masses (n = 1). These presentations do not differ from the classic radiographic manifestations of lung cancer. Only one of our patients (case 4) had concomitant intrathoracic disease (P carinii pneumonia), which ob-

Abbreviations: ficiency ciency

syndrome.

AIDS

=

acquired

immunode-

HIV

=

human

immunodefi-

virus.

341

Lung

Cancer

in HIV-Seropositive

Patients

Risk

Case/Sex/Age

(y)

Interval

Factors

1/M/39

IVDA,

2/M/48

HS

Tobacco

HS

Use

Associated

(pack-years)

(mo)*

Tumor

Stage

Diseases

84

15

Adenocarcinoma

IlIb

PCP,

16

50

Adenocarcinoma

IlIb

Hepatitis

Radiographic

PPD+

Lung B, ITP

mass,

pleural

mediastinal Hilar mass, sion,

IVDA

1

30

Small

4/M/38

HS

4

15

5/M/37

IVDA

1

6/M/46

IVDA

2

cell

Limited

Hepatitis

Hilar

Adenocarcinoma

IIIb

PCP

Lung

20

Adenocarcinoma

I

TB, asbestos posure

50

Squamous carcinoma

IV

TB,

carcinoma

effusion,

adenopathy mediastinal

enopathy, 3/M/30

Findings

pleural

pleural

mass,

ad-

effu-

thickening

mediastinal

adenopathy mass,

mediastinal

adenopathy

Note.-HS

homosexual,

=

derivative converter, * Interval between

ITP

TB

HIV

idiopathic

tuberculosis.

infection

and

thrombocytopenia.

lung

cancer

a. 1. Case

fusion

and

thoracentesis (arrowheads).

2.

(a) Radiograph

enlarged

low

right

shows lobulated Hydropneumothorax

obtained paratracheal

right

pleural is also

scured the mass on radiographs but not on CT scans. Two patients had been treated for tuberculosis in the distant past, and one patient had been treated for P carinii pneumonia. There was no other clinical or radiographic evidence of concomitant opportunistic

infection,

lymphoma,

or

Kaposi sarcoma. The range of the time interval between detection of HIV infection and diagnosis of lung cancer was 1-84 months, with a median of 3 months. There was a predominant histologic type of carcinoma (adenocarcinoma), although different cell types were observed in small

number

of patients.

DISCUSSION This report is meant to emphasize primary lung carcinoma can occur in the young HIV-infected population and to heighten the awareness that

342

=

intravenous

drug

abuse,

PCP

Radiology

#{149}

hepatitis

=

Lung

mass

Hilar mass, adenopathy

P carinii

pneumonia.

mediastinal

PPD+

=

purified

protein

diagnosis.

b.

Figure

this

IVDA

cell

ex-

before

thoracentesis

nodes

(arrows).

thickening present.

shows (b)

(arrows)

large

Radiograph

and

right

right

pleural

obtained

after

suprahilar

ef-

Figure

2. Case

volving rows).

hilar

3.

and

Right

suprahilar

paratracheal

mass

nodes

in-

(ar-

mass

of this complication. The diagnosis of lung carcinoma may be delayed in these patients for two reasons. The first is that these patients are in a younger age group than is usually associated with bronchogenic carcinoma. The second reason is that these patients have a high frequency of opportunistic infections and AIDS-related malignancies that have radiographic findings similar to those of bronchogenic carcinoma. The diagnosis of lung carcinoma must be considered in HIV-seropositive patients who present with intrathoracic adenopathy. This, however, will be a less common diagnosis than tuberculous infection, which has been the most common cause of intrathoracic adenopathy in the AIDS patients at our institution. Similarly, lung carcinoma must be included in the differential diagnosis of solitary parenchymal masses in addition to

fungal infection (cryptococcosis) and lymphoma. Pleural effusions, which may have many varied causes in these patients (including fungal infection, tuberculosis, and Kaposi sar-

coma),

may

be a presenting

manifes-

tation of lung carcinoma. There is suspicion that HIV infection may increase the incidence of other malignancies besides Kaposi sarcoma and non-Hodgkin lymphoma. Small cell carcinoma of the lung has been documented in two young

AIDS

patients

(3, 4). Irwin

et al (2) re-

ported a case of adenosquamous carcinoma occurring in a 35-year-old HIV-infected man. Monfardini et al (5) reported eight cases of lung cancer that occurred in young intravenous drug abusers who were HIV seropositive. However, it was not stated whether these eight cases reflected an increased prevalence of lung cancer compared with the preyalence in patients without AIDS. There has been little to no change in

May

1990

a. Figure 3. Case 5. Pleural-based mal mass (4 X 5 cm) (arrows) apex.

parenchyat the right

Volume

175

Number

#{149}

4. Case

distal

subsegmental

cm)

the prevalence of lung cancer among HIV-seropositive patients in all age groups at San Francisco General Hospital from 1979 to 1988 (6). The number of cases of lung carcinoma that we observed in our population of approximately 500 HIV-seropositive patients represents 1,200 cases per 100,000 population. This corresponds to a 14-fold increased risk compared with the overall risk for white male persons, which is 85 cases per 100,000 population. Our actual prevalence may be higher since our base population of 500 HIV-seropositive patients was identified from January 1982 to February 1989. The six lung cancer patients were identi-

2

b.

Figure with

6.

(a)

Left

hilar

atelectasis

aortopulmonic

mass

and

aortopulmonic

in the

left

upper

window

adenopathy

and

fied between April 1988 and March 1989. The precise explanation for this is uncertain, but this finding suggests that the frequency of lung cancer is increased in patients with HIV infection. This observation requires further study, since our series involves

such

tients.

U

a small

number

of

Garay

SM,

Leitman

BS,

et al.

4.

Moser cell

5.

LE,

carcinoma

quired

immunodeficiency

Intern

Med

1984;

MK,

Moore of the

TM. lung

syndrome.

Adenin the

in

1985;

small

Intern

Med

1985;

Monfardini

MF,

HIV

drug

abusers

Rideour

R.

in

G, et al.

intravenous

mainly

in rather

testicular, than

carcinomas (abstr). Oncol 1989;8:5.

D, Desmond at San Francisco the HIV epidemic

1989;

Proc

P. et al.

of malignancies General (abstr).

Conference

International

oral

In:

S. Volberding

prevalence

Centre,

acAnn

E, Pizzocaro

pulmonary

V International

Oat

associated

tumors

consist

anorectal Soc Clin

N

103:478.

related and

carciAIDS.

syndrome.

S. Vaccher

Rare

cell with

in transfusion

immunodeficiency

search

(3 X 7

312:1706.

quired

men ing

with

mass

a patient

RJ, Tenholder

Heyer

(arrows)

Hilar

Metastatic lung

carcinoma

Changing

manifestations of pulmonary the acquired immunodeficiency (AIDS). Semin Roentgenol 1987; Begandy

MJ. the

J Med

Engl

(b) atelectasis.

of

Ottawa:

osquamous

lobes.

Nusbaum noma

6. DP,

22: 14-30. Irwin

3.

and Am

Nadich

adenopathy

lower

cervical,

Radiographic disease in syndrome 2.

window

left

postobstructive

pa-

References 1.

and

in

Hospital durIn: Abstracts on

AIDS

Development

1989. Re-

206.

ac-

Ann

100:158.

Radiology

343

#{149}