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Revista da Sociedade Br asileir a de Medicina Tr opical 3 7 ( 6 ) :4 9 6 -4 9 8 , nov-dez, 2 0 0 4
Highly aggr essive squamous cell car cinoma in an HIV-infected patient
Carcinoma de células escamosas altamente agressivo
em um paciente HIV-positivo
Roger io Neves-Motta
1, Fer nando Raphael de Almeida Fer r y
1, Car los Alber to
Basílio-de-Oliveir a
2, Ricar do de Souza Car valho
3, Car los José Mar tins
3,
Walter A. Eyer-Silva
1and
Car los Alber to Mor ais-de-Sá
1ABSTRACT
Un u su a lly a ggre ssive fo rm s o f c u ta n e o u s sq u a m o u s c e ll c a rc in o m a a re b e in g in c re a sin gly re c o gn ize d a s a c o m plic a tio n o f
HIV in fe c tio n . We re po rt the c a se o f a 59- ye a r- o ld m a le pa tie n t with a dva n c e d HIV in fe c tio n who pre se n te d with a highly
a ggre ssive SCC le sio n o ve r the sc a lp a re a with de struc tio n o f the unde rlying pa rie ta l b o ne a nd fulm ina nt c linic a l pro gre ssio n.
Ke y-words:
HIV i n f e c ti o n . Sq u a m o u s c e ll c a rc i n o m a .
RESUMO
Fo rm a s a lta m ente a gressiva s de ca rcino m a cutâ neo de célula s esca m o sa s vêm sendo reco nhecida s co m o um a im po rta nte co m plica çã o
da infecçã o pelo HIV. Descrevem o s o ca so de um pa ciente do sexo m a sculino , de 59 a no s, que se a presento u co m um a lesã o a lta m ente
a gressiva de SCC na regiã o do co uro ca beludo , co m destruiçã o do o sso pa rieta l subja cente e curso clínico fulm ina nte.
Pal avr as-chave s:
HIV/Ai d s. Ca rc i n o m a e sp i n o - c e lu la r. Ca rc i n o m a d e c é lu la s e sc a m o sa s.
1 . Se r viç o de Ale r gia e I m uno lo gia Clínic a do Ho s pita l Unive r s itá r io Ga ffr é e e Guinle da Unive r s ida de Fe de r a l do Es ta do do Rio de J a ne ir o , Rio de J a ne ir o , RJ . 2 . De par tame nto de Anato mia Pato ló gic a da Unive r sidade Fe de r al do Estado do Rio de Jane ir o , Rio de Jane ir o , RJ. 3 . De par tame nto de De r mato lo gia da Unive r sidade Fe de r al do Estado do Rio de J ane ir o , Rio de J ane ir o , RJ .
Addr e ss to: Pr o f. Ro gé r io Ne ve s- Mo tta. Ho spital Unive r sitár io Gaffr é e e Guinle /1 0a e nfe r mar ia. Rua Mar iz e B ar r o s, 7 7 5 , 2 0 2 7 0 -0 0 4 Rio de Jane ir o , RJ e - mail: r nmo tta@ ho tmail. c o m
Re c e b ido par a pub lic aç ão e m 2 6 /3 /2 0 0 4 Ac e ito e m 5 /8 /2 0 0 4
Cutaneous squamous cell carcinoma ( SCC) , also known as
epidermoid carcinoma, is a malignant neoplasm of the keratinizing
epidermal cells and accounts for around one-fifth of all cases of
nonmelanoma skin c anc er
1. Important etiologic fac tors to the
development of SCC are host characteristics, such as age and skin
pigmentation, and environmental elements, the most important of
which being long-term sunlight exposure
8. Actinic keratosis is known
to be a major precursor lesion of SCC
15. Other predisposing factors
include ionizing radiation, such as therapy with ultraviolet A, exposure
to chemical carcinogens, especially arsenic, and long-standing benign
der mato ses and sc ar s
1. We r epo r t o n the c ase o f a human
immunodeficiency virus ( HIV) -infected patient who developed a
rapidly growing SCC of the scalp with a fatal outcome.
CASE REPORT
A 5 9 -ye ar-o ld white male r e tir e d dr ive r pr e se nte d with a
o ne -ye ar histo r y o f c hr o nic we ight lo ss, asthe nia, ane mia,
disseminated sc abies, herpes zoster and several rec ent episodes
o f bac terial pneumo nia. He gave a past histo ry o f multiple,
unprotected, sexual intercourse with male and female partners
and tested positive for HIV antibodies. He had a CD4 cell count of
1 3 0 /mm
3and an HIV plasma viral load of 4 .9 log/ml. A highly
a c tive a n tir e tr o vir a l r e gim e n a n d
Pn e u m o c ysti s c a ri n i i
prophylaxis were prescribed but the patient was soon lost to follow
up. One year later the patient sought our service with an indurated,
erythematous papule over the scalp area with a diameter of 3 cm.
The lesion was biopsied and histopathologic studies diagnosed
actinic keratosis and a well differentiated SCC ( Figure 1 D) . The
patient was again lost to follow up until six months later when he
presented with an extremely large infiltrating, vegetative mass over
the parietal area ( Figure 1 A and B) . Computed tomography scan
study showed extensive soft tissue involvement with destruction of
the underlying parietal bone ( Figure 1 C) . Magnetic resonanc e
imaging ( not shown) found no evidence of involvement of the
brain parenchyma and the superior sagittal sinus. The patient
was not c onsidered eligible for antineoplastic therapy due to
the parietal bone invasion and his dec lining general state. He
died of overwhelming se psis two mo nths late r.
4 9 7
Ne ve s- Mo tta R e t al
DISCUSSION
Cutaneous squamous cell carcinoma has long been associated
with conditions leading to immunosupression
2 1 3. Epidemiologic
investigations among subjec ts submitted to renal
4 5and heart
6transplantation found the risk of SCC to be several times higher than
in the general population. Patients prescribed immunosuppressant
agents to treat diverse conditions such as inflammatory bowel disease
and rheumatoid arthritis are also at an increased risk of developing
SCC
7. In face of these strikingly increased incidence rates of SCC
among immunosuppressed patients, Kwa and cols
8stated in a 1 9 9 2
review article that it was interesting that a similar increase had not
yet been found in patients with AIDS.
Highly aggressive forms of SCC are increasingly being recognized
among HIV-infected patients. Isolated case reports of aggressive SCC
in the context of HIV infection date back to the early years of the
epidemic
11 14. In fact, it is known that SCC can present in unusually
aggressive forms in association with immunodeficiency states such as
renal transplantation
4and lymphoma
3 16. Subsequent investigations
found that the major predisposing factors to the development of SCC
in association with HIV infection are a fair skin type, a positive family
history, a past history of excessive sun exposure, and advanced stages
of immunosuppression
9 1 0.
Nguyen and cols
12recently reported a case series of 1 0 patients
diagnosed with aggressive SCC based on rapid growth rate, a diameter
of over 1 .5 cm, a history of recurrence and/or evidence of metastasis.
A total of 4 1 SCC lesions were recorded from these 1 0 patients. The
head and neck were the most commonly involved sites ( 3 1 lesions) ,
followed by the trunk ( 7 lesions) and extremities ( 1 lesion) . Five
patients had well differentiated tumors, 4 had intermediately
differentiated lesions and 1 had a poorly differentiated SCC. The
authors also found that patients initially undergoing combination
surgery and radiation therapy or radical neck dissection had the best
outcomes
12.
Our patient’s fulminating c linic al c ourse, in c onjunc tion with
the reports c ited above, highlight the importanc e of a rapid
diagnosis and treatment of SCC lesions in HIV-infec ted patients if
devastating growth of the primary lesion and metastatic spread
are to be avoided. It is important to note that the development of
SCC in HIV-infec ted patients seems to be determined by similar
host and environmental predisposing fac tors as in the general
population. Physic ians c aring for HIV-infec ted patients need to
be aware of the possibility of an unusually aggressive behavior
of SCC in suc h a setting. Primary prevention should be regularly
instituted with sun avoidance and protection, as well as aggressive
treatment of prec anc erous lesions suc h as ac tinic keratosis.
A
B
C
D
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Revista da Sociedade Br asileir a de Medicina Tr opical 3 7 ( 6 ) :4 9 6 -4 9 8 ,nov-dez, 2 0 0 4
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