Our retrospective review of HIV-positive patients receiving radiation therapy found no increased toxicity in patients receiving concurrent PIs. The number and severity of toxicities experienced per patient were not found to be different in patients who were concurrently taking PIs compared to those who were not. There were differences in the baseline characteristics and medication regimens of the two groups. First, there were no cases of AIDS-defining malignancies in the group treated with PIs. This difference coincided with a difference in all HIV treatment and CD4 count. Significantly more patients in the non-PI group did not receive any medication to manage HIV, and significantly more patients in the non-PI group had CD4 counts below 500. This difference may reflect the efficacy of PIs and ART in controlling HIV, and a resulting decrease in opportunistic malignancies that has been observed with progressive generations of ART. Although ART is typically initiated if the CD4 count is below 500, there are a number of other factors that contribute to the decision to initiate therapy, such as patient preference, adherence to prescriptions, and HIV strain. There was no association between CD4 count and adverse events.
There have been a number of case reports and small case series documenting seve re toxicities in HIV patients receiving radiation therapy. A meta-analysis of case reports and case series found severe toxicities in HIV patients receiving radiation therapy for Kaposi sarcoma and cervical carcinoma, but not in other malignancies. Our results are in accordance with the only published study evaluating toxicities from interaction between PIs and radiation therapy . Plastaras et al. reviewed 14 patients with concurrent PIs and 28 patients in the absence of PI, and found no difference in toxicity from radiation therapy. Although this group found no increase in toxicity from radiation therapy, the patient series was treated between 1993-2007 for the control group and 1997-2006 for the PI group. Inclusion of patients from this time period may have been reflected in the distribution of PIs and the distribution of malignancies treated. Nearly all patients in the Plastaras et al. study were treated with nelfinavir, three were treated with saquinavir (the oldest available PI), and one was treated with amprenavir (no longer available). 29 (69%) of 42 malignancies were AIDS-defining or strongly associated with HIV. These results may be limited by the baseline characteristics: AIDS-defining and HIV-associated malignancies are more heavily represented than in the current HIV+ population and PI regimens are evolving rapidly. Although not related to the years from which the patients were sampled, only 6 of the 14 patients from the PI group had documented CD4 count: one was <50, two were <200, and three <500. No association was observed between CD4 count and radiation toxicity, but the data is limited.
Our study characterizes the safety of radiation therapy combined with the newer generation of PIs in treatment of non-AIDS defining malignancies which are increasingly common in the era of improved ART. The series included only patients treated from January 1, 2009 onwards: of the 18 patients receiving PIs, 16 (89%) were receiving a dual-PI regimen; only two were taking a mono-PI regimen (one ritonavir and one nelfinavir). The case series included more malignancies not associated with HIV or AIDS (ductal carcinoma of the breast, renal cell carcinoma, cholangiocarcinoma, and meningioma), and two non-malignancies (dural AVM, and keloid scar) that were treated with radiation. Half of the patients in this case series received definitive or adjuvant radiation dose regimens (45-78 Gy). These patients were distributed equally in the group with PIs and in the group without PIs, and combination of definitive/adjuvant doses of radiation with PIs did not increase toxicities over definitive/adjuvant radiation doses alone. The present study more than doubles the reported number of patients treated with HIV PIs and radiation from 14 to 32.
The limitations of this study include the small size, short follow-up, heterogeneous nature of our cohort, and the differences between the control group and the PI treatment group. As discussed before, in addition to not taking PI, the control group also received less non-PI HIV medications and had a lower median CD4 count. The factors that underlie these two differences may confound the results. In addition, although we collected data on late toxicities, there was insufficient follow-up (21 weeks [IQR 10-38] with PIs, 13 [IQR 5-18] without PIs) to assess differences in late toxicities. Extended follow-up is necessary to determine the impact on long term toxicities. In addition, the majority of the cases received ritonavir combined with a second PI. Ritonavir does not inhibit Akt, which is a proposed mechanism of radiosensitization by PIs . However, there are no published studies evaluating the radiosensitizing effect of darunavir, atazanavir, or lopinavir, which were used in combination with ritonavir by the majority of the patients. Prior studies on radiosensitization by PIs have not found a defining structural characteristic which would predict whether a PI will increase radiosensitivity. In spite of these limitations, this retrospective review provides valuable information about the acute toxicity of combining radiation with current PI therapies. Review of this contemporary series of patients did not find an increase in acute toxicity from the combination of the newest generation of HIV PIs and radiation therapy to treat diverse pathologies.