Teaching Case

Middle-aged woman with long-standing HIV infection, currently on combined antiretroviral therapy with 191/mmc CD4+ cell count. Medical history also included chronic viral hepatitis, HIV encephalopathy, uterine cervix dysplasia, chronic anaemia, urolithiasis, previous bouts of urosepsis.
Currently hospitalized because of fever, haematuria, dull pelvic pain.

Initial multidetector CT (Fig. 1) showed that the urinary bladder was almost entirely replaced by a large solid mass with markedly heterogeneous contrast enhancement, which corresponded to necrotic carcinoma with squamocellular differentiation at endoscopic biopsy. Further investigation with pelvic MRI (Fig. 2) confirmed severe (over 3 cm) circumferential neoplastic mural thickening of the urinary bladder with initial infiltration of perivesical fat, which was deemed inoperable by urologic surgeons.
Hospitalization was complicated by low-grade small bowel obstruction (Fig. 3) caused by direct ileal infiltration by urinary bladder tumour. Chemotherapy (cisplatin plus paclitaxel) was interrupted because of toxicity, but there was a significant size reduction of the neoplastic bladder mass (Fig. 4), with appearance of mural calcifications and left-sided hydronephrosis.
Rapid disease progression occurred with development of lung metastases (Fig. 5a…c) and local recurrence (Fig. 5d…e), superimposition of intractable urinary infections and progressive worsening of renal function.

The classic AIDS-related tumours declined dramatically after the widespread use of effective antiretroviral therapy (ART). Currently, the long-living HIV-infected patients increasingly develop diseases associated with aging and long-term exposure to oncogenic risk factors, including oncoviruses: not surprisingly, cardiovascular problems and non-AIDS defining malignancies represent the leading causes of death [1-3].
Very common worldwide, up to a few years ago urinary bladder carcinoma (UBC) was considered exceptional in the setting of HIV. However, UBC ranks among the growing list of cancers which will be increasingly encountered in aging patients with controlled HIV disease, so that early urologic evaluation and appropriate imaging are warranted. Compared to the general population, the risk of UBC is 3-4 times higher, and common features include male sex predominance (9:2), high proportion of smokers, and usual presentation with painless gross or microscopic haematuria, voiding symptoms or pelvic pain. Conversely, HIV-positive patients develop UBC at a younger (at least 10 years) median age, most usually 8-14 years after HIV diagnosis and in good immunologic (280-500 CD4+ cells/mmc) status on ART. Human papillomavirus (HPV) infection (17-60% of cases) and history of recurrent urinary infections or urolithiasis are common. 80% of HIV-related UBCs are transitional cell carcinomas, often with high histologic grade (73%); necrotic changes, sarcomatoid histology and HPV-related squamous differentiation are not unusual. Furthermore, UBCs are more likely diagnosed at advanced stage disease than in immunocompetent patients, with muscle invasion in nearly 50% of cases, frequent perivesical extension, nodal and distant metastases – thus indicating that the immune function plays a role in controlling the neoplastic progression [4-7].
Similarly to the general population, cross-sectional imaging allows for tumour detection and staging, particularly in locally advanced UBC or metastatic disease, thus helping the appropriate therapeutic choice [7-10]. Largely adopted to investigate patients with haematuria, CT-urography has moderate sensitivity for early-stage UBC which tends to enhance in the nephrographic phase. MRI including high-resolution T2-weighted sequences has better contrast resolution for intramural and extravesical neoplastic invasion [9, 10]. The imaging differential diagnosis should consider other tumour-like disorders which appear as mural thickening or focal bladder masses [11].
In the context of HIV, the treatment options are the same and include transurethral resection, mitomycin-C instillation, radical cystectomy with or without adjuvant chemotherapy according to initial stage. However, compared to the general population the outcome is generally poorer with 71% relapse and 27% case-fatality rates, one-year survival of approximately 75% [4-8].