Cancer and AIDS are perhaps the two most terrible diagnoses a person can hear. Both are incurable, cause a lot of suffering and require gigantic efforts to even slightly prolong life. Needless to say, the situation is deplorable when a malignant neoplasm and HIV are detected together in one patient.

HIV infection provokes the development of malignant neoplasms - a weakened immune system “does not see” and cannot fight bad cells that begin to divide uncontrollably, turning into a tumor. There are a number of pathologies that are classified as AIDS-associated:

• Kaposi's sarcoma (hemorrhagic sarcomatosis);
• cervical cancer (caused primarily by infection with papillomavirus in HIV patients);
• non-Hodgkin's lymphomas;
• lymphoma of the central nervous system.

The presence of these diagnoses in an HIV-infected patient indicates the terminal stage of immunodeficiency - AIDS. There are also groups of diseases, the incidence of which is higher in HIV-positive patients, regardless of the degree of immunosuppression:

• rectal cancer;
• cancer of the oral cavity and pharynx;
• skin neoplasms;
• lungs' cancer.

According to statistics, up to 40% of HIV patients have some kind of malignant neoplasm.

Cancer risk and HIV infection

Large scientific studies have shown that the risk of developing cancer in HIV for specific nosologies is several, and sometimes several tens of times, higher than in HIV-negative patients. For example, the risk of a rectal tumor is 55 times higher, and Kaposi's sarcoma is 200 times higher. Scientists note that HIV and cancer, as a secondary concomitant disease, are more common in drug addicts, alcoholics or people who have refused antiretroviral therapy. Smoking with HIV increases the risk of developing cancer of the lip, pharynx or lungs several hundred times.

Features of HIV therapy for cancer

If an HIV-positive cancer patient receives chemotherapy or radiation therapy, this primarily affects the immune system - the toxic effect of the treatment affects the composition of the blood, cell renewal and the level of lymphocytes. This may reduce the effectiveness of antiretroviral therapy. On the other hand, patients with HIV have low tolerance to chemotherapy - more and more severe complications, less therapeutic effect. When taking ART and drugs for the treatment of oncology simultaneously (immunotherapy, biotherapy, chemotherapy, antibacterial agents), their chemical interaction is possible, which leads to:

• increased load on the liver and kidneys;
• decreased effectiveness of drugs;
• possible formation of toxic compounds.

Oncological surgeries for HIV

A blood test for HIV antibodies is mandatory before any surgery. But the patient’s HIV-positive status is not a contraindication to surgery, but simply requires additional safety measures for medical personnel. Surgical treatment of cancer in HIV is carried out according to the same standards as in HIV-negative patients, but has some features:

• assessment of the level of CD4 lymphocytes to determine the stage of immunodeficiency and the body’s ability to recover after surgery;
• mandatory control of concomitant infections - if the disease is in the acute phase, then antibacterial (antiviral, antifungal - depending on the pathogen) therapy is necessary before surgery and stabilization of the process;
• assessment of the severity of the patient’s condition and the presence of concomitant chronic pathologies of the cardiovascular and excretory systems.

Recovery after surgery for immunodeficiency is somewhat more difficult - incisions take longer to heal, often fester and become inflamed, and functional indicators return to normal more slowly. But surgical treatment of cancer for HIV, as far as possible, prolongs the patient’s life and improves the quality of life.

His name is AIDS Vyacheslav Zalmanovich Tarantul

Cancer is a product of AIDS

Cancer is a product of AIDS

The causes of all the above-described diseases accompanying AIDS are more or less clear: the immune system is impaired and all pathogenic microorganisms around us multiply freely in a sick body; The shield has disappeared - and numerous, previously hidden enemies are now triumphant! After all, it is known: leonem mortuum etiam catuli mordent (even puppies bite a dead lion). The situation is more complicated with another type of concomitant disease, which is no less terrible than AIDS - cancer.

Almost immediately after the first diagnosis of AIDS, it became clear that this disease is closely associated with the development of certain types of malignant transformations. Further statistics showed that quite often people infected with HIV get cancer. It also became clear that HIV provokes its appearance. True, not all of the numerous types of cancer known today affect AIDS patients, but only some of them. These, called indicator tumors, characteristic of AIDS, include primarily Kaposi's sarcoma (affects the skin and internal organs) and primary non-Hodgkin's lymphomas of the brain or other localization. They can even be considered as a diagnostic sign: if a patient has them, then this most likely indicates the presence of HIV. Before we talk about these cancers, let's make one more small digression.

A little history

The problem of cancer has plagued humanity since time immemorial. The legend connects the appearance of the word “cancer” to denote a certain group of diseases with the ancient ideas about the cause of this pathology: when a person drinks water from a river, the pathogen enters his body and then eats it away from the inside (Latin cancer - river crayfish). For a long time, it remained unclear what causes cancer to develop. In 1910, I. I. Mechnikov was one of the first to suggest that there are two causes of malignant degeneration, “one of which is in the body itself, but the other enters it in the form of an exogenous source, most likely a virus.” That some cancers in animals are caused by viruses became apparent a year later when Routh showed that the virus that would later be named after him, Rous' sarcoma virus, causes a form of cancer, sarcoma, in chickens. Many years passed until Routh received the Nobel Prize for his epoch-making discovery (1966). The main thing is that he lived to see it. After Routh's discovery, rabbit papillomavirus (R. Shoup, 1932) and mouse mammary gland tumor virus (J. Bitner, 1936) were isolated. Thus, it gradually became clear that at least some viruses could cause cancer. In the mid-40s. last century, the famous Soviet microbiologist L. Zilbert proposed a virogenetic theory of cancer, according to which “the role of the virus in the development of the tumor process is that it changes the hereditary properties of the cell, turning it from normal to tumor, and the tumor cell thus formed serves as a source of growth tumors; the virus that caused this transformation is either eliminated from the tumor due to the fact that the changed cell is an unsuitable environment for its development, or loses its pathogenicity and therefore cannot be detected during further tumor growth.”

Since then, using various viruses, hundreds of types of tumors have been reproduced in animals. However, the role of viruses as one of the main causes of certain forms of cancer in humans was finally confirmed only in the mid-70s - early 80s. The main evidence for the integration of viral and cellular genomes was the discovery of reverse transcriptase by G. Temin and D. Baltimore, the experiments of Renato Dulbecco in identifying viral DNA as an integral part of cellular DNA in tumors, and the establishment by D. Bishop and G. Varmus of the fact that special genes (oncogenes) ), contained in some viruses, are cellular genes that viruses pick up from higher organisms during reproduction in cells. All these scientists subsequently became Nobel laureates in physiology and medicine (R. Dulbecco, H. Temin and D. Daltimore in 1975, and D. Bishop and G. Varmus in 1989).

Although it is now clear that not all types of tumors are caused by viruses, the viral nature of a number of them is beyond doubt. Recently, a possible close relationship has been observed even between the malignant degeneration of cells and infection by bacteria. We are talking about the bacterium Helicobacter pulori. According to some researchers, this bacterium, “responsible” for the development of stomach and gastrointestinal cancer, has existed for almost 11 thousand years. According to some scientists, the “longevity” of this bacterium in the human body is determined by the fact that it has a positive effect on the body.

In general, today it is believed that at least 15% of all cancer cases in the world are the result of various chronic infectious diseases. Let us list the main viruses that are currently associated in one way or another with various forms of cancer:

Hepatitis B virus;

Hepatitis C virus;

Human papillomavirus;

Human T-cell leukemia virus;

Epstein-Barr virus;

Human herpesvirus-8;

AIDS virus.

Note that the hepatitis C virus, T-cell leukemia virus and HIV are RNA-containing viruses, while the genetic apparatus of other viruses, like most other living organisms, consists of DNA. This list cannot yet be considered completely exhausted. It cannot be ruled out (and most likely this will be the case) that in the future we will still face the discovery of other DNA and RNA viruses that, as scientists say, have oncogenic potential, i.e., capable of causing cancer. In all cases, currently known viruses do not directly cause cancer in humans, but their very presence makes cells more prone to malignant transformation, or the viruses damage or change the functioning of normal human genes, which leads to an acceleration of this process.

It is now quite clearly established that the main cause of primary liver cancer throughout the world is chronic infection with hepatitis B and C viruses. The presence of a specific enzyme in the hepatitis B virus - DNA polymerase, which has the function of reverse transcriptase, allows us to call it a “hidden” retrovirus. Hepatitis B virus is the most variable DNA virus, which is similar to the highly variable HIV. Doctors attribute about 80% of all cases of liver cancer in the world to the hepatitis B virus. This disease affects about a quarter of a million people every year (especially in several countries in Africa and Asia).

The hepatitis C virus, like the hepatitis B virus, can cause some cancers, such as malignant diseases of the immune system and thyroid gland, but mainly liver cancer. Scientists have called the hepatitis C virus the “silent killer” for its hidden, slowly progressive course, difficulty of detection and virtual lack of self-healing. When infected with the hepatitis C virus, the traditional sequence of changes in the liver is clearly observed: acute viral hepatitis - chronic hepatitis - cirrhosis - liver cancer. It is believed that the mechanism of destructive action of hepatitis C and B viruses is different, although patients do not need to delve into these subtleties. For them, the main thing is the result, and it is disappointing: long-term chronic viral hepatitis, which has already passed into the last stage, the stage of liver cirrhosis, is fraught with further development of cancer. The prevalence of hepatitis C is extremely high, especially among drug addicts and people who have undergone blood transfusions.

Another virus, the human papillomavirus, is considered one of the main causes of cervical cancer, as well as some other types of mucosal and skin cancer. Infection with this virus is one of the most common sexually transmitted diseases and is estimated to cause cancer in over 10% of women.

Another oncogenic virus, human T-cell lymphotropic virus type I, infects T lymphocytes (a type of white blood cell that is part of the body's immune system) and causes some T-cell lymphomas. However, the incidence of such virus-related lymphomas in the general population is low.

With the discovery of HIV, it also began to be considered as one of the causes of cancer.

Long-term observations by doctors have revealed a clear relationship between HIV infection and certain types of malignant diseases. The most common types of cancer in HIV-infected patients are shown in Fig. 25. Their frequency in HIV carriers increases tens and thousands of times compared to the frequency of such diseases among uninfected people. Even at the beginning of the epidemic, it was noted that an increase in HIV infection leads to an increase in the incidence of cancers such as lymphoma and Kaposi's sarcoma. Kaposi's sarcoma got its name from the Austrian M. Kaposi, who described it for the first time in 1874. For many years, this disease was considered to be extremely rare. Kaposi's sarcoma was mainly found in elderly men living in the Mediterranean and Central Africa. After some time, it became clear that the increased incidence of this disease is closely related to immune deficiency. After the start of the HIV epidemic, this was finally confirmed. Starting from the first years of the epidemic, Kaposi's sarcoma began to be considered as one of the main indicators of the presence of HIV and began to be classified as an AIDS-associated disease. It is believed that it is not HIV that plays an important role in the development of this pathology, but other viruses, in particular one of the herpes viruses, called human herpes virus type 8 (HHV8). The growth of sarcoma causes large lesions located on the face, which greatly disfigures the person, and those located on the legs or in the joint area limit physical activity. But Kaposi's sarcoma itself rarely causes death in HIV-infected people. Initially, Kaposi's sarcoma occurred in almost a third of HIV-positive people. But then the incidence of Kaposi's sarcoma in people with HIV decreased significantly, and this decrease coincided with the widespread use of highly active antiretroviral therapy for gay/bisexual people to treat HIV infection (this therapy and its successes will be discussed later).

Rice. 25. Some malignant diseases are constant companions of HIV infection. The occurrence of some of them (lymphoma, Kaposi's sarcoma) serves as an indication to doctors that the patient may have HIV infection. In parentheses in the figure it is indicated how many times more often the corresponding malignant diseases develop in HIV-positive people compared to the population of uninfected people

Another oncological disease that is closely related to AIDS (i.e., is an indicator) is lymphoma, especially some of its varieties, the so-called non-Hodgkin lymphomas and primary lymphomas of the central nervous system (Fig. 25). Lymphoma is the second most common tumor after Kaposi's sarcoma in patients with HIV infection. Typically, this type of tumor occurs in later stages of the disease. Approximately 12–16% of AIDS patients die from lymphoma. Unlike Kaposi's sarcoma, lymphoma is not associated with any specific risk group. The prevalence of lymphomas in HIV-infected patients is estimated to range from 3 to 12%, which is approximately 100–200 times more common than in the general population. And one form of lymphoma, called Burkitt's lymphoma, occurs 1,000 to 2,000 times more often in HIV-infected people than in uninfected people. Symptoms of lymphomas are fever, sweating, weight loss, damage to the central nervous system, accompanied by epileptic seizures. Unlike Kaposi's sarcoma, lymphomas usually kill patients within one year of their onset.

As HIV infection progresses and spreads across different populations, other types of cancer begin to appear with increasing frequency. In addition to the two “main” types of cancer usually diagnosed in immunocompromised patients, malignancies such as small cell lung carcinoma, colon adenocarcinoma, testicular seminoma, and even basal cell carcinoma, the most common form of skin cancer in HIV-infected people, have begun to be discovered. There are also reports of an increase in the incidence of cervical cancer and melanoma in patients with HIV infection. In AIDS, cervical cancer, most likely associated with infection with the human papillomavirus, has become one of the significant causes of death in infected women.

The real mechanisms of malignant transformation under the influence of HIV still remain unknown. There is only a general understanding of the relationship between the development of cancer and the suppression of the normal function of the immune system by the virus. But perhaps individual HIV proteins also purposefully interfere with this process. In particular, transgenic animal models have shown that some HIV genes encode proteins with oncogenic potential. Transgenic are organisms in which all cells contain some additional gene, artificially introduced by scientists. Today there is a lot of talk and debate around transgenic products, i.e. food products obtained from transgenic organisms. But this is a special question. Molecular geneticists use transgenic animals for completely different purposes. By transferring individual HIV genes into the genetic apparatus of mice and analyzing the health status of transgenic animals, scientists can draw certain conclusions about their independent function in the body. Based on such experiments, it was concluded that one of the causes of cancer in HIV-infected people is a protein encoded by a viral regulatory gene called tat (already discussed above). This protein regulates the functioning of not only viral genes. It actively interferes with the metabolism of cells, not only those infected with the virus, but also those sometimes located at a fairly large distance from them. By disrupting the normal metabolism in the cell, it can itself cause malignant degeneration. These are the most likely causes of cancer development in HIV-infected patients.

Nervous system damage

Immune deficiency resulting from HIV infection is usually accompanied by the development of a number of concomitant pathologies: neuropathy, enteropathy, nephropathy, myopathy, impaired hematopoiesis, and tumor formation.

It has already been noted that HIV often affects the brain, and to the same extent as the immune system. Between one third and half of its victims suffer from various severe neurological diseases. Damage to brain tissue varies from minor changes to severe progressive ones. Since 1987, nervous system disorders have been officially recognized as another symptom of AIDS.

Neurological, and then mental disorders, are such formidable companions of AIDS that in these cases there is no need for an “army of hired killers,” i.e., causative agents of secondary infections. The virus itself has the ability to infect cells of the central nervous system, and the pathogen does this so skillfully and often that the brain form of AIDS can be safely placed in second place in terms of frequency. However, AIDS-associated infections may also play an important role in neurodevelopmental disorders in HIV-infected people. Most often, the pathological process is determined by infections such as cryptococci, toxoplasma, candida, cytomegalovirus, and tuberculosis complex bacteria.

Neurological lesions may be associated in some cases with disorders of the brain, in others - of the spinal cord, in others - of the membranes, and in others - of peripheral nerves and roots. Symptoms of the pathology depend on the location of the lesion. Neoplasms, such as, for example, primary lymphoma of the central nervous system, also make a certain contribution to the pathology of the nervous system.

Neurological patients are usually bothered by headaches, anxiety with depression, imbalance, decreased visual acuity, and memory impairment. They, as a rule, lose orientation in time and space, lose the ability to contact the external environment, and ultimately often die in a state of complete insanity and personality disintegration. In particular, the so-called AIDS dementia syndrome, which develops in approximately a quarter of patients affected by the virus, is considered one of the diagnostic signs of HIV infection. The name of this pathology comes from the word dementia - that is, a progressive decline in intelligence. At the same time, attention is impaired, memory deteriorates, and a manic state gradually develops. In a number of its symptoms, this syndrome resembles Parkinson's disease. Another neurological pathology often found in HIV-infected people is serous meningitis. Its typical syndromes are headache, photophobia.

For a long time, the cause of damage to the nervous system during HIV infection remained unclear. It was recently discovered that this effect may be due to HIV proteins. At least one of them (the already mentioned gp120 envelope protein), when acting on neurons, triggers the process of apoptosis in them, i.e., a special mechanism of cell death.

Lesions of the gastrointestinal tract

Another weak point in HIV infection is the gastrointestinal tract. It is constantly involved in the pathological process caused by HIV and can be affected at various stages of the disease. This is due to the fact that some cells of the gastrointestinal tract serve as a target for the virus. HIV is found in various cells not only of the rectal mucosa, especially in homosexuals, but also in all parts of the intestine, even in cells that do not have CD4 receptors. Obviously, the penetration of the virus into tissue occurs through intercellular exchange. The virus itself causes degenerative changes in the crypts and microvilli of the intestine, as a result of which parietal digestion and absorption of useful products are disrupted. Not only a purely structural disturbance of the intestinal wall occurs, but also a decrease in its stability (resistance) and the development of dysbiosis. The nature of the lesion can be either diffuse or local in the form of inflammation of different parts of the gastrointestinal tract: oral mucosa (stomatitis), esophagus (esophagitis), duodenum (duodenitis), small intestine (enteritis), colon (colitis), rectum intestines (proctitis), etc. One of the most characteristic clinical manifestations of damage to the gastrointestinal tract during HIV infection is diarrhea (in everyday life - diarrhea), which is observed in 70% of patients.

Doctors at the Cancer Center at Children's Hospital in Philadelphia (USA) have made a real breakthrough in medicine by learning to treat cancer with HIV.

Experts conducted research in the field of genetic engineering and were able to reprogram the deadly virus. Thus, in three weeks, HIV cured a girl who had two days to live, reports CBS.

Seven-year-old Emily Whitehead from New Jersey battled lymphoblastic leukemia for two years. Doctors prescribed her radiation and chemotherapy sessions, but there were no visible results. In the end, the girl felt a little better, but right before the difficult operation for a bone marrow transplant, she had a relapse. Then the doctors put an end to the possibility of recovery. Emily had only days left before her organs would fail.

Then the parents moved the girl to the children's hospital in Philadelphia, which is famous for one of the best cancer centers in the United States. The center's director, Stefan Grup, offered the parents an experimental but promising treatment called CTL019 therapy.

The essence of the method is that scientists modify the HIV virus. Its genetic code is altered so that the infected T cell attacks cancerous tissue while sparing healthy tissue.

Healthy lymphocytes do not participate in the fight at all. Infected T cells recognize cancer cells thanks to a specific protein called CD19. The treatment is incredibly dangerous: infection is accompanied by the final decline of an already weakened immune system, as well as terrible pain. Emily had little chance of surviving the first night after the operation, but without intervention the girl would not have survived two days.

After the introduction of the modified virus, Emily's condition improved in just a few hours. Doctors noted that she began to breathe more smoothly, and her temperature and blood pressure returned to normal. To the surprise of the doctors, after three weeks there was no trace of cancer left. Six months have passed since the completion of the course, which was carried out in April, but there are still no traces of cancer in the baby’s body. Infected T cells protect the body and now this is another advantage of the new treatment method over traditional methods.

An additional 12 patients were treated with CTL019 therapy. Nine of these attempts ended positively. Two other children in the study also experienced complete remission.

Despite the fact that the cost of treatment is quite high (20 thousand dollars per session), scientists hope that this method will develop, become more accessible and help millions of people who have lost hope. It is likely that over time this procedure will eliminate the need for an expensive bone marrow transplant.

Emily's parents are extremely proud of their brave daughter, who seemed to be less afraid than others and fought her illness to the last. Now the girl leads a normal life - goes to school, plays, which her family is very happy about.

Cervical cancer

One of the greatest advances in cancer prevention was the invention of the smear test, or Pap test, which detects precancerous changes in cells in the cervix (lower part of the uterus). This is a simple, painless and relatively inexpensive method, thanks to which screening examinations have been widely implemented. Women can be screened at regular intervals so changes can be identified early and appropriate treatment can be given. Studies in a number of countries have shown that the incidence of cervical cancer can be reduced dramatically if screening programs are introduced and a large percentage of eligible women are offered screening. Early identification of abnormalities means that the necessary therapeutic measures can be taken long before there is a danger of their cancerous degeneration; Women with such anomalies can be closely monitored over many years to prevent further development of such disorders.

The need for measures aimed at reducing the incidence of cervical cancer is evidenced by the fact that cancer of this location is the eighth most common cancer among women in Western countries and the second most common type of cancer in the world (in developing countries it is the most common type of cancer) . Although mortality from it is declining overall, it is increasing among women aged 30 to 40 years.

In the USA, this examination is usually carried out annually. In the UK, government guidelines recommend that every woman aged 20 to 64 who has ever been sexually active should have a smear test every 5 years, with most doctors recommending an interval of 3 years.

When taking a smear, the doctor or nurse uses a specially shaped wooden spatula to carefully scrape a certain amount of cells from the cervix for examination under a microscope. Any changes or abnormalities of these cells are called cervical intraepithelial neoplasia (CIN), with codes CIN 1, 2, and 3, which correspond to early, moderate, and severe forms. These changes are not cancer and in many cases will never become cancerous, although some may develop into cancer if left untreated. In most types of cervical cancer, the progression of early abnormalities to malignancy occurs over many years.

The main difference between precancerous changes and cancer is that in the first case the changes affect only the superficial layers of the cervix (that is, they are precancerous), while in the second they penetrate into its deeper layers (then they are malignant). Pre-cancerous changes to the cervix can be treated very effectively using a number of different methods, which include cryotherapy (freezing cells), diathermy (burning cells), laser therapy (using laser beams to destroy cells) and cervical conization (surgical removal of the inside of the cervix ). All of these methods are equally effective and provide cure rates approaching 100%.

A number of factors contribute to the development of cervical cancer. There was an obvious connection between a woman’s sexual activity and the likelihood of her developing precancerous changes or developing cervical cancer: the more partners she had and the more partners her partners had (i.e., the wider the range of sexual contacts), the higher the risk. An increased risk was also noted in women who began sexual activity at a very young age. Apparently, there is some factor transmitted through sexual contact, which in many cases leads to the development of the disease. This is supported by the fact that the use of barrier contraceptives provides some degree of protection.

One possible contributing factor to cancer is infection with strains of a virus known as human papillomavirus (wart virus). However, most women affected by this virus do not develop cervical cancer, suggesting that there are many other unknown factors involved.

It was previously thought that the use of contraceptive pills may slightly increase the risk of developing cervical cancer. It is now believed that the pill itself is not a causative factor, but women taking them are less likely to use barrier contraceptives.

Smoking doubles the risk of cervical cancer, regardless of a woman's sex life. It is believed that a certain smoking product that enters the bloodstream from the lungs reduces immunity to other oncogenic factors.

Many women with cervical cancer blame themselves or their partners because the disease is linked to sexual activity. In reality, the latter is only one of many factors leading to cancer. A very small percentage of women with known risk factors develop this disease. Therefore, there is no reason to blame yourself or your partner for the disease.

Manifestations

Cervical cancer is often diagnosed through a routine smear test before a woman develops symptoms. The most common symptom is vaginal bleeding between periods or postmenopause, especially after sexual intercourse. Some women experience pain during sexual intercourse, although this is generally not a symptom of cervical cancer unless the disease is at an advanced stage. Some women experience foul-smelling vaginal discharge. However, all these symptoms are even more common in benign conditions, such as cervical erosion. However, if they appear, you should still consult a doctor and find out their causes.

Research

The doctor will usually examine the cervix by gently inserting a speculum into the vagina to spread the walls apart. It should be painless. Sometimes the affected area is visible to the naked eye. At the same time, the doctor takes a smear. If the smear test indicates minor abnormalities that are likely to resolve without treatment, the woman is advised to have another test after 6 months. If more serious changes are detected, the next step will likely be a colposcopy.

Colposcopy allows the doctor to examine the cervix more closely using an instrument called a colposcope, which also illuminates the cervix for better visibility. This procedure also requires a speculum to spread the vaginal walls. To view the affected areas more closely, a dye solution may be applied to the cervix and a sample of cells (biopsy) is taken for examination. This test is usually carried out in a hospital outpatient clinic. If it is not possible to examine the entire lesion with a colposcope, a surgical procedure known as conization is resorted to, which is performed under general anesthesia during a short hospitalization. The surgeon removes a small cone-shaped portion of the cervix for microscopic examination. This procedure allows the doctor to determine whether there are precancerous changes or whether cervical cancer can be accurately diagnosed.

If these tests confirm the diagnosis of cancer, further tests may be done to look for possible spread of cancer cells. A CT scan of the abdomen and pelvis can determine the size and location of the cancer, and whether local lymph glands are involved. Magnetic resonance imaging (MRI), a form of scanning, is currently being evaluated for its ability to provide a more accurate picture of the lesion.

The doctor may need to perform an examination under anesthesia to carefully look at the vagina and cervix and assess the extent of cancer cell growth without causing discomfort to the patient.

At the same time, cervical dilatation and curettage can be performed. To do this, a small probe is inserted into the uterus and a scraping of the mucous membrane is taken. Mucosal cells can also be examined under a microscope.

If surgical treatment is being considered, another intravenous urography study may be necessary. To do this, a dye is injected into a vein in the arm, which is visible under X-rays. The dye is delivered through the bloodstream to the kidneys, after which an X-ray examination is performed. Thanks to the dye, any changes or abnormalities in the kidneys or urinary tract are visible on the x-ray.

This section deals only with the treatment of cervical cancer. Precancerous changes in cervical cells are treated (if necessary) using the methods described in the last issue.

Surgical interventions
Surgery is the usual treatment for cervical cancer. The standard operation is a hysterectomy (removal of the uterus) along with nearby lymph nodes. There is usually no need to remove the ovaries, meaning that surgery will not cause menopause in younger, premenopausal women. If premenopausal women need to have their ovaries removed, they may be given hormone replacement therapy to prevent menopausal symptoms. In some cases, for young women who have very minor cervical lesions and who want to have children, conization can be performed as a therapeutic method.

A hysterectomy is a major surgery and it takes time to recover. You should avoid strenuous exercise or heavy lifting for several months after surgery. In order to heal scars, you should abstain from sexual intercourse for several weeks.

According to many women, they need more time to regain readiness for sexual activity after surgery. A hysterectomy can cause great distress, and many find it difficult to come to terms with the loss of the organ that they believe makes them a woman.

Moral support and counseling before and after surgery are necessary for every patient, so that no less attention is paid to emotional well-being than to physical recovery.

Radiotherapy
In the early stages of cervical cancer, radiotherapy is as effective as surgery, but the side effects are more severe, including loss of ovarian function. For this reason, at this stage of the disease, surgery is the treatment of choice.

However, if the cancer has spread beyond the cervix and is therefore incurable with surgery alone, radiotherapy is preferred. Radiotherapy can also be performed after surgery if the risk of relapse is high, for example, if the lymph glands are involved in the pathological process.

To ensure a good effect, external radiotherapy is usually combined with internal radiotherapy. Internal radiotherapy involves inserting one or more tampon-like applicators into the cervix under general anesthesia. A source of radioactive radiation, usually cesium-137, is placed in the applicators and left there for about 1-2 days. At this time, it is necessary to observe bed rest, for which it is better to place the patient in a separate room with protective screens around the bed to prevent exposure of medical personnel and visitors. Immediately after removal of the radioactive source and applicators, the radiation stops.

Side effects of radiotherapy include nausea, vomiting, tiredness, diarrhea and sometimes painful urination. However, they can be successfully combated and even prevented with the help of medications.

Radiation therapy sometimes causes the vagina to narrow, which can make sexual intercourse uncomfortable or painful. Estrogen ointments, use of dilators, or regular sexual intercourse may improve this condition. Women who have had internal radiotherapy are at increased risk of infection and should contact their doctor immediately if they experience heavy bleeding or a high fever after treatment.

The most serious long-term side effect is permanent damage to the ovaries, which in younger women leads to menopause. Hormone replacement therapy may be used to relieve symptoms such as hot flashes, anxiety and depression. A very small number of women experience a narrowing or contraction of the bowel as a result of pelvic radiotherapy.

Chemotherapy
Chemotherapy is used in a variety of situations to treat women with cervical cancer. For women who are okay with radiotherapy but who are at high risk of recurrence, chemotherapy is sometimes given before radiotherapy to shrink the cancer and increase the chance of cure. Another group of women who may benefit from chemotherapy are those whose disease cannot be treated with radiation therapy because either their cancer cells have spread to other parts of the body or they relapse after receiving maximum doses of radiation.

Chemotherapy is given to shrink the tumor, control its growth, and relieve symptoms, but it cannot provide a cure.

Various combinations of chemotherapy agents are used to treat cervical cancer. Previously, nausea caused by these drugs was a very severe and difficult to tolerate side effect, but now modern antiemetic drugs are very effective in controlling nausea and vomiting.

When cervical cancer is detected at an early stage, the prognosis is very favorable and many women can be cured with surgical methods alone. If the cancer is at a sufficiently advanced stage to preclude surgery, but without the cancer spreading throughout the body, radiotherapy can cure a significant percentage of some women and maintain a good quality of life for others for a long time. If cancer is detected at a more advanced stage, chemotherapy plays a significant role in controlling the process, but it usually cannot lead to a cure.

The importance of detecting this type of cancer at an early stage is beyond doubt. In the UK, screening programs have already begun to have an impact on overall mortality rates. To improve the situation, more intensive efforts are needed to reach women who avoid screening, closer follow-up of those with poor results, and greater dissemination of health education materials on smoking and sexual behavior.

Cervical cancer in HIV-infected women

Popova M.Yu., Tantsurova K.S., Yakovleva Yu.A.

Federal State Budgetary Educational Institution of Higher Education South Ural State Medical University of the Ministry of Health of Russia

Department of Obstetrics and Gynecology

Cervical cancer in HIV-infected women

Popova M.Yu., Tantsurova K.S., Yakovleva Yu.A.

Federal State Budgetary Educational Institution of Higher Education South Ural State Medical University of the Ministry of Health of Russia

Department of Obstetrics and Gynecology

Relevance. Cervical cancer (CC) is one of the most common malignant tumors of the female reproductive system. Among cancers in young women, cervical cancer has the highest mortality rates. Cervical cancer originates from the normal cells that line the cervix. Every year this tumor is detected in more than 600 thousand patients. Human immunodeficiency virus (HIV) causes acquired immunodeficiency syndrome (AIDS) and is a risk factor for the development of squamous intraepithelial lesion (SIL), which occurs as a result of impaired immune control. Over time, SIL progresses to invasive cervical cancer.

Goal of the work. To study the features of the occurrence, course, diagnosis, and treatment of cervical cancer in HIV-infected women.

Research objectives. To establish the relationship between the progression of cervical cancer in women with HIV-positive status.

Materials and methods. According to the classification, LSIL, or Low grade SIL, or mild degree, and HSIL, or Hight grade SIL, or severe degree, are distinguished. SIL should be treated promptly (by removing or destroying the outer layers of cervical cells

uterus) to prevent it from developing into invasive cancer.

In HIV-infected women, the transition from SIL to cervical cancer occurs much faster than in healthy women, due to damage to the immune system. HIV affects human blood cells that have CD4 receptors on their surface, namely: T lymphocytes, macrophages and dendritic cells. Infected T lymphocytes die due to destruction by the virus, apoptosis, and killing by cytotoxic T lymphocytes. If the number of CD4+ T lymphocytes falls below 200 per microliter of blood, the cellular immune system ceases to protect the body. Studies have shown that untreated cervical neoplasia is more likely to develop into invasive cancer in HIV-infected women than in healthy women.

Neoplasia is diagnosed using methods such as cervical biopsy, which is a medical procedure that allows one to specifically take pathologically altered tissue of the cervix for the purpose of morphological examination. The diagnosis uses a Papanicolaou smear - this is scraping the tissue of the surface layer of the cervix and examining the resulting cells under a microscope after treatment with dyes. The liquid cytology method is a more modern and informative version of screening using the Papanicolaou test (PAP test), the “gold standard” for diagnosing neoplasia of the cervical mucosa, used when patients are suspected of having cancer or dysplasia. Due to the fact that absolutely all cellular matter enters the stabilizing solution, the quality of the material improves.

In liquid cytology, material is collected using cytobrushes, which are designed to take biological material from the surface of the cervix and from the cervical canal for cytological and bacteriological studies, while the sample is not immediately transferred to glass, but the cytobrush with the collected material is immersed in a special solution and then using The device prepares a sample for research. The cytobrush is easy to use and atraumatic for taking material. If necessary, the working part can be bent at any angle relative to the handle. This allows you to adapt the instrument depending on the anatomical features of the area from which the material is taken.

Studies have shown that untreated cervical neoplasia is more likely to develop into invasive cancer in HIV-infected women than in healthy women. To treat dysplasia in an HIV-positive patient at the LSIL stage, a laser is used (non-contact, bloodless, safe). This dysplasia responds well to treatment, since the laser destroys the damaged tissue, sealing the blood vessels and stopping the bleeding (simultaneously with the removal of the damaged tissue, their coagulation occurs, small blood vessels “close” at the vaporization site, which makes the intervention practically bloodless). The entire procedure takes place under the supervision of a colposcope, which magnifies the desired area up to fifteen times; a finely focused laser beam can be directed precisely, under the control of a video colposcope, to the desired location, which allows only the changed tissue to be removed. At the HSIL stage there should only be excision of pathologically changed tissue. The chances of relapse in HIV-infected women after treatment are quite high. Women with a CD4 cell count of less than 50 per microliter of blood are at higher risk of relapse. Recurrence of SIL in HIV-positive women is not associated with its stage, but is determined by the total number of T lymphocytes and CD4. Women who have been diagnosed with HIV must undergo cytological screening at least once every 6 months after treatment of identified genital infections, as well as testing for human papillomavirus (HPV), due to the risk of developing SIL, CC, and determining the CD4+ count. The only currently known method of increasing T-cell immunity and reducing the viral load in HIV-infected people is highly active antiretroviral therapy (HAART), which is used in the complex treatment of HIV-infected people. The method of therapy consists of taking three or four drugs, as opposed to the monotherapy (1 drug) that was used previously. The use of monotherapy is not advisable due to the high likelihood of developing viral resistance during the first 3 months of treatment. HAART includes three nucleoside reverse transcriptase inhibitors (NRTIs), two NRTIs + one or two protease inhibitors (PIs), two NRTIs + one non-nucleoside reverse transcriptase inhibitor (NNRTI), and NRTIs + NNRTIs + PIs.

Therapy requires strict adherence to the dosage schedule. It is unacceptable to skip doses of medications, as well as to take reduced or increased doses in case of skipping.

The appearance and development of cervical cancer is a multi-stage process. The stages of development of cervical cancer are presented as follows: normal cervical epithelium => epithelial dysplasia (mild, moderate, severe) => intraepithelial cancer (or stage 0 cancer, non-invasive cancer) => microinvasive cancer => invasive cancer. The earliest manifestations may be watery, copious discharge, bloody discharge, which in women of childbearing age is not associated with menstruation, and in postmenopausal women is observed constantly or periodically; the discharge may have an unpleasant odor. The discharge of urine and feces through the vagina is evidence of urinary and rectal-vaginal fistulas. At stage IV, metastatic inguinal and supraclavicular lymph nodes appear.

Cervical cancer is divided into four stages (I, II, III and IV), each stage is divided into two substages (A and B), and each of substages IA and IB into two more - IA1, IA2 and IB1, IB2. The choice of treatment for cervical cancer depends on the stage of the disease. Surgical treatment is used for stages IA1, IA2, IB and less commonly IIA. The extent of the operation depends on the depth of invasion, the presence of metastases in the pelvic and para-aortic lymph nodes. At stage IA1, it is possible to perform conization of the cervix (wedge biopsy, cone excision - amputation of a cone-shaped section of the cervix, which consists of removing part of the cervix in the form of a cone) or simple extirpation of the uterus with appendages: tubes and ovaries. At stages IA2, IB1, IB2 and IIA, radical hysterectomy with removal of the pelvic and sometimes para-aortic lymph nodes is indicated. During this operation, in addition to the uterus with appendages and lymph nodes, the upper third of the vagina, as well as parts of the uterine ligaments and fatty tissue of the parametrium and tissue surrounding the cervix are also removed. If metastases are detected in the lymph nodes, treatment after surgery is supplemented with radiation or simultaneous chemoradiotherapy. Usually combined treatment (surgery + radiation therapy) is carried out for stages IB and IIA. Sometimes, for invasive cervical cancer (stages IA2, IB1), a complex radical operation is performed, which allows preserving reproductive function, called trachelectomy. During surgery, only the cancerous cervical tissue and surrounding lymph nodes are removed. The effectiveness of surgical treatment and radiation therapy in the early stages of invasive cervical cancer is almost the same; radiation therapy is used in the form of external gammatherapy and brachytherapy. The duration of combined radiation therapy (external beam and brachytherapy) should not exceed 55 days. For stages IB2-IV, simultaneous chemoradiotherapy is recognized as the standard treatment worldwide (previously, only radiation therapy was performed for these stages). In stage IVB, only chemotherapy can be used. However, women with AIDS and cervical cancer at the same time are not cured of cancer as successfully as HIV-negative patients.

Research results. Thus, due to the high likelihood of cervical cancer in HIV-infected women and in order to detect it early, they need to have a PAP smear; if atypical cells are not detected, the test must be repeated six months later, and then, if the results are negative, 1 time per year. If all types of SIL are detected in the Pap smear, colposcopy is performed with targeted biopsy of altered areas of the uterine mucosa. This allows not only to detect cervical cancer in the initial stages, but also to prevent its development by diagnosing precancerous changes in the cervical epithelium, the treatment of which prevents the development of a tumor.

Conclusions. AIDS-associated cervical cancer develops more rapidly than cervical cancer in HIV-negative women and leads to numerous complications. Women who are HIV positive are more likely to develop precancerous cervical cancer into invasive cancer than HIV-negative women. Women with AIDS and HIV-infected women should be constantly monitored by the health care system, as they have a higher risk of developing cervical cancer.

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