Defining Characteristics of Nodal Disease on PET/CT Scans in Patients With HIV-Positive and -Negative Locally Advanced Cervical Cancer in South Africa

Abstract

Literature reports increased FDG nodal uptake in HIV-positive patients. Our aim is to identify differences in presentation and characteristics of FDG-avid lymph nodes between HIV-positive and HIV-negative locally advanced cervical cancer (LACC) patients in our clinical setting. We evaluated 250 pre-treatment 18F-FDG PET/CT imaging studies from women screened for a phase III randomised controlled trial investigating modulated electro-hyperthermia as a radiosensitiser (Ethics approval: M120477). The number of nodes; size; maximum standardised uptake value (SUVmax); symmetry; and relationship between nodal size and SUVmax uptake, were assessed by region and by HIV status. In total, 1314 nodes with a SUVmax ≥ 2.5 were visualised. Of 128(51%) HIV-positive participants, 82% were on antiretroviral therapy (ART) and 10 had a CD4 count <200 cells/µL. Overall pattern of presentation and nodal characteristics were similar between HIV-positive and -negative groups and the uniformity in presentation of the nodes draining the cervix strongly suggests these nodes may be attributed to malignancy rather than HIV infection. Novel findings: HIV infection is associated with: >four nodes visualised in the neck, symmetrical inguinal lymph nodes, increased rates of supraclavicular node visualisation; FDG-avid axillary nodes were more common, but not exclusive, in HIV-positive participants. 18F-FDG PET/CT is a reliable staging method for LACC in HIV-positive patients who are not in acute stages of HIV infection, have a CD4 count >200 cells/µL, and/or are on ART and there is a potential risk of underestimating metastatic spread by attributing increased nodal metabolic activity to HIV infection in these patients.

Gynecological radiotherapy in people living with human immunodeficiency virus: a semi-systematic literature review

“…Minnaar et al evaluated 250 pre-treatment PET-CT scans for patients with cervical cancer enrolling in a phase III trial; 128 of the participants were people living with HIV, of whom 82% were on antiretroviral therapy. The pattern of presentation and nodal characteristics did not differ based on HIV status; however, nodal biopsies were not performed or evaluated in this study 23…”

“…The pattern of presentation and nodal characteristics did not differ based on HIV status; however, nodal biopsies were not performed or evaluated in this study. 23 Treatment Disparities Suneja et al conducted a National Cancer Database analysis of 10 265 people living with HIV and 2 219 232 HIV-uninfected patients between 2003 and 2011 in the USA, which found that people living with HIV were less likely to receive cancer treatment compared with HIV-uninfected patients, even after adjusting for clinical and sociodemographic variables. For cervical cancer, people living with HIV were nearly three times as likely to be untreated for cancer (adjusted OR 2.81, 95% CI 1.77 to 4.45) compared with HIVuninfected controls.…”

The Clinical Validation of Modulated Electro-Hyperthermia (mEHT)

“…The cervix cancers were studied in a Phase III double-arm randomized prospective controlled trial involving two–two groups in both arms, patients ±HIV [ 67 , 68 ]. Metabolic response (MR) was measured by PET [ 69 ]. The advantages of mEHT appeared in the higher complete metabolic response (CMR) of the HIV groups compared to the control groups.…”