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constituyendo los TNDS la principal causa de muerte<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">El conjunto de las neoplasias que presentan los pacientes VIH se divide en 2 grupos&#58; las asociadas al VIH y las no asociadas al VIH &#40;algunas de las cuales se relacionan con otras enfermedades virales&#41;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">8-16</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; Dentro de las asociadas al VIH se incluyen&#58; 1&#41; el sarcoma de Kaposi&#44; relacionado con el virus herpes humano tipo<span class="elsevierStyleHsp" style=""></span>8 &#40;VHH-8&#41;&#59; 2&#41; los linfomas no Hodgkin&#44; relacionados con el virus de Epstein Barr &#40;VEB&#41;&#59; y 3&#41; el carcinoma de c&#233;rvix&#44; relacionado con el virus del papiloma humano &#40;VPH&#41;&#46; Entre las enfermedades tumorales independientes de la infecci&#243;n VIH y relacionadas con enfermedades virales destacan el linfoma de Hodgkin &#40;LH&#41;&#44; relacionado con el VEB&#59; el carcinoma del canal anal&#44; relacionado con el VPH&#59; y el hepatocarcinoma&#44; asociado con los virus de las hepatitis<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleSmallCaps">C</span> &#40;VHC&#41; y B &#40;VHB&#41;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">17</span></a>&#46; Shepherd et al&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">18</span></a> propusieron que la clasificaci&#243;n de las neoplasias se base en su relaci&#243;n o no con infecciones virales&#46; Las enfermedades tumorales sin implicaci&#243;n viral est&#225;n representadas fundamentalmente por el carcinoma de pulm&#243;n &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Recientemente&#44; hemos revisado las enfermedades tumorales en 4&#46;994 pacientes VIH atendidos en nuestro centro desde 1986 hasta 2016&#46; Se diagnostic&#243; al menos un tumor en 416 pacientes &#40;8&#44;3&#37;&#41;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">19&#44;20</span></a>&#46; En nuestra experiencia&#44; a medida que se ha generalizado el uso de tratamiento antirretroviral &#40;TAR&#41;&#44; la incidencia de los tumores diagn&#243;sticos de sida &#40;TDS&#41; ha ido disminuyendo&#44; mientras que la de los TNDS ha aumentado<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">19&#44;20</span></a>&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Etiopatogenia</span><p id="par0020" class="elsevierStylePara elsevierViewall">El origen de las enfermedades tumorales en los pacientes con infecci&#243;n por el VIH es multifactorial&#44; siendo los factores m&#225;s importantes el propio VIH&#44; la inmunodepresi&#243;n&#44; la coinfecci&#243;n con virus oncog&#233;nicos y la mayor supervivencia debida al uso de TAR<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">21-24</span></a>&#46; El VIH es una condici&#243;n necesaria&#44; pero no suficiente&#44; ya que no es un virus oncog&#233;nico&#46; Sin embargo&#44; su presencia condiciona una situaci&#243;n de inmunodepresi&#243;n cr&#243;nica que est&#225; relacionada con los TDS<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">21&#44;25</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">La alteraci&#243;n de la inmunidad y la viremia VIH no controlada aumentan el riesgo de desarrollar neoplasias&#44; de tal forma que una carga viral indetectable y unos linfocitos CD4&#43; superiores a 500&#47;mm<span class="elsevierStyleSup">3</span> son factores que protegen del desarrollo de algunos tumores&#44; fundamentalmente los TDS&#46; Sin embargo&#44; coincidiendo con la introducci&#243;n de pautas de TAR de alta eficacia se ha producido un aumento de los TNDS ya que&#44; aunque la situaci&#243;n inmunol&#243;gica mejora&#44; no se restaura completamente<a class="elsevierStyleCrossRefs" href="#bib0525"><span class="elsevierStyleSup">26-29</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">La influencia de la TAR en la aparici&#243;n de tumores es independiente del f&#225;rmaco utilizado&#44; 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particularmente el VPH&#44; relacionado con el carcinoma de c&#233;rvix&#44; del canal anal y del &#225;rea otorrinolaringol&#243;gica&#46; Otros virus oncog&#233;nicos son los ya mencionados virus hepatotropos&#44; el VEB y el VHH-8<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">18&#44;34&#44;35</span></a>&#46; Finalmente&#44; el incremento de la supervivencia es uno de los factores que m&#225;s ha influido en el aumento de las enfermedades neopl&#225;sicas de esta poblaci&#243;n<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">36&#44;37</span></a>&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Tumores no diagn&#243;sticos de sida</span><p id="par0040" class="elsevierStylePara elsevierViewall">Constituyen un grupo de neoplasias muy heterog&#233;neo que var&#237;a dependiendo del &#225;rea geogr&#225;fica considerada&#46; Generalmente aparecen en pacientes j&#243;venes y su presentaci&#243;n es at&#237;pica&#44; con grandes masas tumorales que pueden progresar r&#225;pidamente a pesar del tratamiento<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">38-42</span></a>&#46; Este no difiere del utilizado en la poblaci&#243;n general&#44; aunque su administraci&#243;n puede ser m&#225;s compleja por las interacciones medicamentosas y las comorbilidades asociadas<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">43</span></a>&#46; Estas caracter&#237;sticas determinan que la mortalidad sea siempre mayor en la poblaci&#243;n con infecci&#243;n por VIH<a class="elsevierStyleCrossRefs" href="#bib0615"><span class="elsevierStyleSup">44&#44;45</span></a>&#46; En el momento actual&#44; el pron&#243;stico global de los TNDS es peor que el de los TDS&#46; En un estudio multic&#233;ntrico italiano&#44; en el que se analizaba la mortalidad de los pacientes con infecci&#243;n por VIH diagnosticados de una neoplasia&#44; se observ&#243; que solo el 45&#37; de los que ten&#237;an un TNDS viv&#237;an a los 10 a&#241;os frente al 60&#37; de los que padec&#237;an un TDS<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">46</span></a>&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Los TNDS m&#225;s frecuentes relacionados con virus son el del canal anal&#44; el LH y el hepatocarcinoma&#59; mientras que en relaci&#243;n con el h&#225;bito tab&#225;quico destaca el carcinoma de pulm&#243;n&#46; Otros tumores frecuentes en la poblaci&#243;n general&#44; como los carcinomas de mama&#44; pr&#243;stata o colon&#44; no tienen una incidencia mayor en los pacientes VIH&#44; y su comportamiento evolutivo es similar<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">25&#44;47</span></a>&#46; No obstante&#44; el carcinoma de mama es incluso menos frecuente en las mujeres con VIH&#44; pero suele ser m&#225;s agresivo<a class="elsevierStyleCrossRefs" href="#bib0635"><span class="elsevierStyleSup">48&#44;49</span></a>&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Linfoma de Hodgkin</span><p id="par0050" class="elsevierStylePara elsevierViewall">El LH es uno de los TNDS m&#225;s frecuentes y tiene una incidencia entre 15 y 30 veces superior a la de la poblaci&#243;n general&#46; Los enfermos con LH no presentan una inmunodepresi&#243;n profunda&#44; y en algunas series su incidencia es mayor a medida que se incrementa el recuento de linfocitos CD4&#43;<a class="elsevierStyleCrossRefs" href="#bib0645"><span class="elsevierStyleSup">50&#44;51</span></a>&#46; Para explicar este hallazgo se ha especulado que existe una posible interrelaci&#243;n entre las c&#233;lulas de Reed-Sternberg y los linfocitos CD4&#43; que las rodean&#46; En este sentido las c&#233;lulas de Reed-Sternberg&#44; productoras de citocinas&#44; atraen CD4&#43; y otras c&#233;lulas inflamatorias a su alrededor&#46; Como consecuencia de ello&#44; estos CD4&#43; se activar&#237;an y proporcionar&#237;an las se&#241;ales necesarias para la proliferaci&#243;n y la supervivencia de las c&#233;lulas malignas&#44; que ser&#237;a m&#225;s acusada en los pacientes con un mayor recuento de linfocitos CD4&#43;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">52</span></a>&#46; En la mayor&#237;a de las ocasiones los LH en los pacientes VIH&#43; se presentan en estadio<span class="elsevierStyleHsp" style=""></span>IVB&#44; y el tratamiento no difiere del empleado en los pacientes VIH negativos&#46; Al igual que en cualquier otro tipo de tumor&#44; el uso de la TAR y la profilaxis de las infecciones oportunistas son parte esencial del tratamiento<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">3&#44;43&#44;53</span></a>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">En los pacientes con infecci&#243;n por VIH&#44; la supervivencia del LH est&#225; condicionada por los factores pron&#243;sticos asociados al tumor&#44; pero la TAR tiene tambi&#233;n una importancia primordial&#46; En un estudio multic&#233;ntrico espa&#241;ol<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">54</span></a>&#44; la supervivencia global de estos pacientes a los 10 a&#241;os fue del 60&#37;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Hepatocarcinoma</span><p id="par0060" class="elsevierStylePara elsevierViewall">Su incidencia en la poblaci&#243;n con infecci&#243;n por VIH es 8 veces mayor que la de la poblaci&#243;n general&#44; aunque su etiopatogenia y comportamiento evolutivo no difieren significativamente entre ambas poblaciones<a class="elsevierStyleCrossRefs" href="#bib0670"><span class="elsevierStyleSup">55-57</span></a>&#46; Los factores implicados en su desarrollo son la hepatitis cr&#243;nica viral &#40;sobre todo la hepatitis<span class="elsevierStyleHsp" style=""></span>C en nuestro medio&#41;&#44; la cirrosis de cualquier etiolog&#237;a y el consumo de alcohol&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">La principal y posiblemente &#250;nica medida de prevenci&#243;n es el tratamiento del VHC&#44; pero la reducci&#243;n del riesgo en los pacientes con respuesta sostenida al tratamiento antiviral no es absoluta&#44; por lo que hay que continuar con las estrategias de cribado aunque se haya curado la infecci&#243;n por VHC<a class="elsevierStyleCrossRef" href="#bib0685"><span class="elsevierStyleSup">58</span></a>&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Carcinoma del canal anal</span><p id="par0070" class="elsevierStylePara elsevierViewall">El carcinoma del canal anal est&#225; estrechamente relacionado con los genotipos oncog&#233;nicos del VPH&#44; que se detectan en m&#225;s del 90&#37; de los casos&#46; Mientras su incidencia en la poblaci&#243;n con infecci&#243;n por VIH es de 55-144&#47;100&#46;000 pacientes&#47;a&#241;o&#44; en la poblaci&#243;n general es tan solo de 1-1&#44;5&#47;100&#46;000 pacientes&#47;a&#241;o<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">59</span></a>&#46; El mayor riesgo lo tienen los varones homosexuales&#44; pero tambi&#233;n se diagnostica en mujeres que tienen sexo anal y en pacientes con verrugas genitales<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">59</span></a>&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Como medidas principales de prevenci&#243;n se recomiendan el uso de preservativo &#40;aunque no protege en el 100&#37; de los casos&#41; y de la vacuna&#44; cuya eficacia est&#225; ya contrastada en mujeres para prevenir el carcinoma de c&#233;rvix<a class="elsevierStyleCrossRefs" href="#bib0695"><span class="elsevierStyleSup">60&#44;61</span></a>&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Seg&#250;n las recomendaciones del grupo de estudio del sida &#40;GESIDA&#41; de la Sociedad Espa&#241;ola de Enfermedades Infecciosas y Microbiolog&#237;a Cl&#237;nica&#44; para el diagn&#243;stico precoz se debe realizar una citolog&#237;a anal a los pacientes de riesgo&#44; independientemente de la presencia o no del VPH<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">43</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Carcinoma pulmonar</span><p id="par0085" class="elsevierStylePara elsevierViewall">Es el tumor m&#225;s frecuente tanto en la poblaci&#243;n con infecci&#243;n por VIH como en la poblaci&#243;n general&#44; y tiene una estrecha relaci&#243;n con el consumo de tabaco&#46; Sin embargo&#44; en los pacientes con infecci&#243;n por VIH&#44; independientemente del h&#225;bito tab&#225;quico&#44; se ha observado que es 2-4 veces m&#225;s frecuente&#44; aparece en edades m&#225;s tempranas&#44; su comportamiento es m&#225;s agresivo y su pron&#243;stico&#44; peor<a class="elsevierStyleCrossRefs" href="#bib0705"><span class="elsevierStyleSup">62-65</span></a>&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">El c&#225;ncer de pulm&#243;n es una de las principales causas de muerte&#44; pero hasta hace poco no ha habido un m&#233;todo de despistaje que permitiera realizar un diagn&#243;stico precoz&#46; En la actualidad&#44; a ra&#237;z de la publicaci&#243;n de los datos del <span class="elsevierStyleItalic">National Lung Screening Trial</span> en 2013<a class="elsevierStyleCrossRef" href="#bib0725"><span class="elsevierStyleSup">66</span></a>&#44; se propone el uso de la tomograf&#237;a computarizada de baja radiaci&#243;n&#44; en la poblaci&#243;n de riesgo no VIH&#44; ya que ha demostrado ser &#250;til en el diagn&#243;stico precoz de este tumor&#44; aunque a&#250;n se est&#225; evaluando su coste-efectividad&#46; En la poblaci&#243;n con infecci&#243;n por VIH este aspecto est&#225; poco estudiado y por ello GESIDA est&#225; llevando a cabo un estudio multic&#233;ntrico para valorar la eficacia de esta medida &#40;GESIDA 8815&#41;<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">67</span></a>&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Tratamiento de los tumores no diagn&#243;sticos de sida</span><p id="par0095" class="elsevierStylePara elsevierViewall">El tratamiento de los TNDS&#44; al igual que el de los TDS&#44; est&#225; basado en 3 pilares fundamentales<a class="elsevierStyleCrossRefs" href="#bib0615"><span class="elsevierStyleSup">44&#44;68-70</span></a>&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0100" class="elsevierStylePara elsevierViewall">El tratamiento antineopl&#225;sico debe ser igual al empleado en los pacientes VIH negativos&#46; Si no se tiene en cuenta esta premisa&#44; la mortalidad se puede incrementar ya que se realizar&#237;an terapias inadecuadas<a class="elsevierStyleCrossRef" href="#bib0750"><span class="elsevierStyleSup">71</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Se debe iniciar precozmente el tratamiento de la infecci&#243;n por VIH con una TAR eficaz&#44; segura y con pocas interacciones medicamentosas<a class="elsevierStyleCrossRefs" href="#bib0755"><span class="elsevierStyleSup">72-74</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall">La profilaxis y tratamiento de las infecciones oportunistas constituye una medida esencial&#46; Se realizar&#225; tanto en aquellas infecciones directamente relacionadas con la inmunodepresi&#243;n como en aquellas que&#44; como la tuberculosis&#44; tienen una incidencia elevada en nuestro medio&#46; Debe tenerse en cuenta que tras el empleo de quimio o radioterapia se produce un descenso de la cifra total de linfocitos CD4 en un 30-50&#37;&#44; con respecto a la basal&#44; no recuper&#225;ndose los niveles pretratamiento hasta pasados 6-12 meses<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">75</span></a>&#46; Por ello&#44; se recomienda realizar profilaxis con cotrimoxazol siempre&#44; aunque al inicio del tratamiento los linfocitos CD4&#43; sean superiores a 200&#47;mm<span class="elsevierStyleSup">3</span>&#46;</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Diagn&#243;stico precoz y prevenci&#243;n</span><p id="par0115" class="elsevierStylePara elsevierViewall">En lo que se refiere a las medidas destinadas al diagn&#243;stico precoz de las neoplasias&#44; en ninguna de las gu&#237;as de TAR&#44; excepto en las de la <span class="elsevierStyleItalic">European AIDS Clinical Society</span><a class="elsevierStyleCrossRef" href="#bib0775"><span class="elsevierStyleSup">76</span></a>&#44; se hace referencia expresa a este punto&#46; En nuestro pa&#237;s&#44; GESIDA ha elaborado un documento&#44; redactado de forma independiente de las gu&#237;as de TAR&#44; sobre el manejo de los TNDS en el que se contemplan tanto la prevenci&#243;n como el diagn&#243;stico precoz<span class="elsevierStyleBold">&#44;</span> que b&#225;sicamente no difieren de lo recomendado para la poblaci&#243;n general &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">43</span></a>&#46; De acuerdo con el mismo&#44; las medidas de prevenci&#243;n m&#225;s importantes y de eficacia contrastada son&#58; el desarrollo de h&#225;bitos de vida saludable &#40;disminuci&#243;n del consumo de alcohol y tabaco&#41;&#44; el tratamiento del VHC&#44; y el empleo de vacunas frente al VPH y&#44; en menor medida&#44; frente al VHB<a class="elsevierStyleCrossRefs" href="#bib0610"><span class="elsevierStyleSup">43&#44;57&#44;58&#44;60&#44;61&#44;77-79</span></a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusiones</span><p id="par0120" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">1&#46;</span><p id="par0125" class="elsevierStylePara elsevierViewall">La mayor&#237;a de las neoplasias&#44; tanto TDS como TNDS&#44; que aparecen en los pacientes con infecci&#243;n por VIH est&#225;n relacionadas con infecciones virales&#46; Los TNDS presentan una frecuencia y gravedad mayores que los TDS&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">2&#46;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Una carga viral &#40;VIH&#41; indetectable y unos linfocitos CD4&#43; superiores a 500&#47;mm<span class="elsevierStyleSup">3</span> son factores que protegen del desarrollo de algunos tumores&#44; fundamentalmente de TDS&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">3&#46;</span><p id="par0135" class="elsevierStylePara elsevierViewall">El tratamiento de las neoplasias en sujetos VIH se asemeja al empleado en la poblaci&#243;n general&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">4&#46;</span><p id="par0140" class="elsevierStylePara elsevierViewall">Se debe realizar profilaxis de las infecciones oportunistas mientras se administra quimioterapia&#44; aunque los CD4 sean superiores a 200&#47;mm<span class="elsevierStyleSup">3</span>&#46;</p></li></ul></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflicto de intereses</span><p id="par0145" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Desde los inicios de la epidemia del virus de la inmunodeficiencia humana &#40;VIH&#41;&#44; la patolog&#237;a tumoral ha sido muy importante&#46; El conjunto de las neoplasias se puede dividir b&#225;sicamente en 2 grupos&#58; las asociadas al VIH&#44; todas ellas relacionadas con enfermedades virales&#44; y las no asociadas al VIH&#44; entre las que algunas est&#225;n asociadas a enfermedades virales y otras no&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El origen es multifactorial y las principales causas que han llevado a que se produzca un aumento de la patolog&#237;a tumoral son la inmunodepresi&#243;n&#44; la coinfecci&#243;n con virus oncog&#233;nicos y la prolongaci&#243;n de la vida secundaria al uso de tratamiento antirretroviral&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Establecer las caracter&#237;sticas generales de los tumores no diagn&#243;sticos de sida es dif&#237;cil fundamentalmente porque son un grupo muy heterog&#233;neo formado por neoplasias de diversa &#237;ndole&#46; Los tratamientos no difieren de los empleados en la poblaci&#243;n general&#44; aunque el manejo puede ser m&#225;s dif&#237;cil por el diagn&#243;stico tard&#237;o&#44; las interacciones medicamentosas y las comorbilidades asociadas&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Since the start of the human immunodeficiency virus &#40;HIV&#41; epidemic&#44; tumour disease among patients has been significant&#46; The collection of malignancies can be divided primarily into 2 groups&#58; those associated with HIV &#40;all of which are related to viral diseases&#41; and those not associated with HIV &#40;only some of which are associated with viral diseases&#41;&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The origin of these malignancies is multifactorial&#44; and the main causes that have led to an increase in tumour disease are immunosuppression&#44; coinfection with oncogenic viruses and life prolongation secondary to the use of antiretroviral therapy&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Establishing the general characteristics of the undiagnosed AIDS tumours is difficult&#44; mainly because they are a highly heterogeneous group formed by malignancies of a diverse nature&#46; The treatments do not differ from those used in the general population&#44; although the management can be more difficult due to the late diagnosis&#44; drug interactions and associated comorbidities&#46;</p></span>"
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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Algoritmo para el diagn&#243;stico precoz del carcinoma del canal anal&#46;</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">ASCUS&#58; c&#233;lulas de significado incierto&#59; SIL&#58; lesi&#243;n intraepitelial&#46;</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Fuente&#58; adaptaci&#243;n de Santos&#44; Valencia y Panel de expertos de GeSIDA<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">43</span></a>&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">a</span> En estos 3 tumores las medidas recomendadas para el diagn&#243;stico precoz no difieren de las empleadas en la poblaci&#243;n general&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">HSH&#58; hombres que tienen sexo con hombres&#59; PSA&#58; ant&#237;geno prost&#225;tico espec&#237;fico&#59; TC&#58; tomograf&#237;a computarizada&#59; VHB&#58; virus de la hepatitis<span class="elsevierStyleHsp" style=""></span>B&#59; VHC&#58; virus de la hepatitis<span class="elsevierStyleHsp" style=""></span>C&#59; VPH&#58; virus del papiloma humano&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pacientes cirr&#243;ticos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pacientes fumadores mayores de 45 a&#241;os&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TC de t&#243;rax baja radiaci&#243;n sin administraci&#243;n de contraste&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Carcinoma de colon<span class="elsevierStyleSup">a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Personas entre 50 y 75 a&#241;os&#46; Antecedentes familiares de c&#225;ncer de colon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sangre oculta en heces anual &#177; colonoscopia cada 5 a&#241;os&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Carcinoma de pr&#243;stata<span class="elsevierStyleSup">a</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tacto rectal &#177; PSA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Carcinoma de mama<span class="elsevierStyleSup">a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mujeres entre 50 y 70 a&#241;os&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mamograf&#237;a&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                0 => array:2 [
                  "contribucion" => array:1 [
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Neoplasias e infección por el virus de la inmunodeficiencia humana: ¿enfermedades emergentes?
Malignancies and infection due to the human immunodeficiency virus. Are these emerging diseases?
M.E. Valencia Ortega
Servicio de Medicina Interna-Unidad de VIH, Hospital Universitario La Paz, Madrid, España
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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Algoritmo para el diagn&#243;stico precoz del carcinoma del canal anal&#46;</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">ASCUS&#58; c&#233;lulas de significado incierto&#59; SIL&#58; lesi&#243;n intraepitelial&#46;</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Fuente&#58; adaptaci&#243;n de Santos&#44; Valencia y Panel de expertos de GeSIDA<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">43</span></a>&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">En los &#250;ltimos a&#241;os&#44; las enfermedades no relacionadas con el sida &#40;ENOS&#41; han aumentado de forma progresiva&#44; siendo una de las principales causas de morbimortalidad en los pacientes infectados por el virus de la inmunodeficiencia humana &#40;VIH&#41;&#46; Entre otros procesos&#44; destacan las enfermedades cardiovasculares y renales&#44; la osteoporosis&#44; el deterioro neurocognitivo y los tumores&#44; en especial aquellos que no son diagn&#243;sticos de sida &#40;TNDS&#41;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">1-6</span></a>&#46; Una publicaci&#243;n reciente muestra como a lo largo del tiempo ha disminuido la mortalidad debida al sida y ha aumentado la causada por ENOS&#44; constituyendo los TNDS la principal causa de muerte<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">El conjunto de las neoplasias que presentan los pacientes VIH se divide en 2 grupos&#58; las asociadas al VIH y las no asociadas al VIH &#40;algunas de las cuales se relacionan con otras enfermedades virales&#41;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">8-16</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; Dentro de las asociadas al VIH se incluyen&#58; 1&#41; el sarcoma de Kaposi&#44; relacionado con el virus herpes humano tipo<span class="elsevierStyleHsp" style=""></span>8 &#40;VHH-8&#41;&#59; 2&#41; los linfomas no Hodgkin&#44; relacionados con el virus de Epstein Barr &#40;VEB&#41;&#59; y 3&#41; el carcinoma de c&#233;rvix&#44; relacionado con el virus del papiloma humano &#40;VPH&#41;&#46; Entre las enfermedades tumorales independientes de la infecci&#243;n VIH y relacionadas con enfermedades virales destacan el linfoma de Hodgkin &#40;LH&#41;&#44; relacionado con el VEB&#59; el carcinoma del canal anal&#44; relacionado con el VPH&#59; y el hepatocarcinoma&#44; asociado con los virus de las hepatitis<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleSmallCaps">C</span> &#40;VHC&#41; y B &#40;VHB&#41;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">17</span></a>&#46; Shepherd et al&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">18</span></a> propusieron que la clasificaci&#243;n de las neoplasias se base en su relaci&#243;n o no con infecciones virales&#46; Las enfermedades tumorales sin implicaci&#243;n viral est&#225;n representadas fundamentalmente por el carcinoma de pulm&#243;n &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Recientemente&#44; hemos revisado las enfermedades tumorales en 4&#46;994 pacientes VIH atendidos en nuestro centro desde 1986 hasta 2016&#46; Se diagnostic&#243; al menos un tumor en 416 pacientes &#40;8&#44;3&#37;&#41;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">19&#44;20</span></a>&#46; En nuestra experiencia&#44; a medida que se ha generalizado el uso de tratamiento antirretroviral &#40;TAR&#41;&#44; la incidencia de los tumores diagn&#243;sticos de sida &#40;TDS&#41; ha ido disminuyendo&#44; mientras que la de los TNDS ha aumentado<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">19&#44;20</span></a>&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Etiopatogenia</span><p id="par0020" class="elsevierStylePara elsevierViewall">El origen de las enfermedades tumorales en los pacientes con infecci&#243;n por el VIH es multifactorial&#44; siendo los factores m&#225;s importantes el propio VIH&#44; la inmunodepresi&#243;n&#44; la coinfecci&#243;n con virus oncog&#233;nicos y la mayor supervivencia debida al uso de TAR<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">21-24</span></a>&#46; El VIH es una condici&#243;n necesaria&#44; pero no suficiente&#44; ya que no es un virus oncog&#233;nico&#46; Sin embargo&#44; su presencia condiciona una situaci&#243;n de inmunodepresi&#243;n cr&#243;nica que est&#225; relacionada con los TDS<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">21&#44;25</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">La alteraci&#243;n de la inmunidad y la viremia VIH no controlada aumentan el riesgo de desarrollar neoplasias&#44; de tal forma que una carga viral indetectable y unos linfocitos CD4&#43; superiores a 500&#47;mm<span class="elsevierStyleSup">3</span> son factores que protegen del desarrollo de algunos tumores&#44; fundamentalmente los TDS&#46; Sin embargo&#44; coincidiendo con la introducci&#243;n de pautas de TAR de alta eficacia se ha producido un aumento de los TNDS ya que&#44; aunque la situaci&#243;n inmunol&#243;gica mejora&#44; no se restaura completamente<a class="elsevierStyleCrossRefs" href="#bib0525"><span class="elsevierStyleSup">26-29</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">La influencia de la TAR en la aparici&#243;n de tumores es independiente del f&#225;rmaco utilizado&#44; no existiendo diferencias entre los pacientes tratados con reg&#237;menes basados en inhibidores de la transcriptasa inversa no an&#225;logos de nucle&#243;sidos&#44; inhibidores de la proteasa o inhibidores de la integrasa<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">19&#44;20&#44;27-32</span></a>&#46; Por otro lado&#44; las interrupciones de tratamiento&#44; que se realizaron en &#233;pocas previas&#44; condicionan un aumento de la incidencia de TNDS&#46; Esto qued&#243; establecido en el estudio SMART&#44; donde todas las ENOS&#44; incluidos los TNDS&#44; fueron significativamente m&#225;s frecuentes en los pacientes que realizaron interrupciones de tratamiento que en los que continuaron la terapia sin interrupciones<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">33</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Otro factor importante para el desarrollo de neoplasias en los pacientes con infecci&#243;n por VIH es la coinfecci&#243;n con otros virus&#44; particularmente el VPH&#44; relacionado con el carcinoma de c&#233;rvix&#44; del canal anal y del &#225;rea otorrinolaringol&#243;gica&#46; Otros virus oncog&#233;nicos son los ya mencionados virus hepatotropos&#44; el VEB y el VHH-8<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">18&#44;34&#44;35</span></a>&#46; Finalmente&#44; el incremento de la supervivencia es uno de los factores que m&#225;s ha influido en el aumento de las enfermedades neopl&#225;sicas de esta poblaci&#243;n<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">36&#44;37</span></a>&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Tumores no diagn&#243;sticos de sida</span><p id="par0040" class="elsevierStylePara elsevierViewall">Constituyen un grupo de neoplasias muy heterog&#233;neo que var&#237;a dependiendo del &#225;rea geogr&#225;fica considerada&#46; Generalmente aparecen en pacientes j&#243;venes y su presentaci&#243;n es at&#237;pica&#44; con grandes masas tumorales que pueden progresar r&#225;pidamente a pesar del tratamiento<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">38-42</span></a>&#46; Este no difiere del utilizado en la poblaci&#243;n general&#44; aunque su administraci&#243;n puede ser m&#225;s compleja por las interacciones medicamentosas y las comorbilidades asociadas<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">43</span></a>&#46; Estas caracter&#237;sticas determinan que la mortalidad sea siempre mayor en la poblaci&#243;n con infecci&#243;n por VIH<a class="elsevierStyleCrossRefs" href="#bib0615"><span class="elsevierStyleSup">44&#44;45</span></a>&#46; En el momento actual&#44; el pron&#243;stico global de los TNDS es peor que el de los TDS&#46; En un estudio multic&#233;ntrico italiano&#44; en el que se analizaba la mortalidad de los pacientes con infecci&#243;n por VIH diagnosticados de una neoplasia&#44; se observ&#243; que solo el 45&#37; de los que ten&#237;an un TNDS viv&#237;an a los 10 a&#241;os frente al 60&#37; de los que padec&#237;an un TDS<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">46</span></a>&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Los TNDS m&#225;s frecuentes relacionados con virus son el del canal anal&#44; el LH y el hepatocarcinoma&#59; mientras que en relaci&#243;n con el h&#225;bito tab&#225;quico destaca el carcinoma de pulm&#243;n&#46; Otros tumores frecuentes en la poblaci&#243;n general&#44; como los carcinomas de mama&#44; pr&#243;stata o colon&#44; no tienen una incidencia mayor en los pacientes VIH&#44; y su comportamiento evolutivo es similar<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">25&#44;47</span></a>&#46; No obstante&#44; el carcinoma de mama es incluso menos frecuente en las mujeres con VIH&#44; pero suele ser m&#225;s agresivo<a class="elsevierStyleCrossRefs" href="#bib0635"><span class="elsevierStyleSup">48&#44;49</span></a>&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Linfoma de Hodgkin</span><p id="par0050" class="elsevierStylePara elsevierViewall">El LH es uno de los TNDS m&#225;s frecuentes y tiene una incidencia entre 15 y 30 veces superior a la de la poblaci&#243;n general&#46; Los enfermos con LH no presentan una inmunodepresi&#243;n profunda&#44; y en algunas series su incidencia es mayor a medida que se incrementa el recuento de linfocitos CD4&#43;<a class="elsevierStyleCrossRefs" href="#bib0645"><span class="elsevierStyleSup">50&#44;51</span></a>&#46; Para explicar este hallazgo se ha especulado que existe una posible interrelaci&#243;n entre las c&#233;lulas de Reed-Sternberg y los linfocitos CD4&#43; que las rodean&#46; En este sentido las c&#233;lulas de Reed-Sternberg&#44; productoras de citocinas&#44; atraen CD4&#43; y otras c&#233;lulas inflamatorias a su alrededor&#46; Como consecuencia de ello&#44; estos CD4&#43; se activar&#237;an y proporcionar&#237;an las se&#241;ales necesarias para la proliferaci&#243;n y la supervivencia de las c&#233;lulas malignas&#44; que ser&#237;a m&#225;s acusada en los pacientes con un mayor recuento de linfocitos CD4&#43;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">52</span></a>&#46; En la mayor&#237;a de las ocasiones los LH en los pacientes VIH&#43; se presentan en estadio<span class="elsevierStyleHsp" style=""></span>IVB&#44; y el tratamiento no difiere del empleado en los pacientes VIH negativos&#46; Al igual que en cualquier otro tipo de tumor&#44; el uso de la TAR y la profilaxis de las infecciones oportunistas son parte esencial del tratamiento<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">3&#44;43&#44;53</span></a>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">En los pacientes con infecci&#243;n por VIH&#44; la supervivencia del LH est&#225; condicionada por los factores pron&#243;sticos asociados al tumor&#44; pero la TAR tiene tambi&#233;n una importancia primordial&#46; En un estudio multic&#233;ntrico espa&#241;ol<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">54</span></a>&#44; la supervivencia global de estos pacientes a los 10 a&#241;os fue del 60&#37;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Hepatocarcinoma</span><p id="par0060" class="elsevierStylePara elsevierViewall">Su incidencia en la poblaci&#243;n con infecci&#243;n por VIH es 8 veces mayor que la de la poblaci&#243;n general&#44; aunque su etiopatogenia y comportamiento evolutivo no difieren significativamente entre ambas poblaciones<a class="elsevierStyleCrossRefs" href="#bib0670"><span class="elsevierStyleSup">55-57</span></a>&#46; Los factores implicados en su desarrollo son la hepatitis cr&#243;nica viral &#40;sobre todo la hepatitis<span class="elsevierStyleHsp" style=""></span>C en nuestro medio&#41;&#44; la cirrosis de cualquier etiolog&#237;a y el consumo de alcohol&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">La principal y posiblemente &#250;nica medida de prevenci&#243;n es el tratamiento del VHC&#44; pero la reducci&#243;n del riesgo en los pacientes con respuesta sostenida al tratamiento antiviral no es absoluta&#44; por lo que hay que continuar con las estrategias de cribado aunque se haya curado la infecci&#243;n por VHC<a class="elsevierStyleCrossRef" href="#bib0685"><span class="elsevierStyleSup">58</span></a>&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Carcinoma del canal anal</span><p id="par0070" class="elsevierStylePara elsevierViewall">El carcinoma del canal anal est&#225; estrechamente relacionado con los genotipos oncog&#233;nicos del VPH&#44; que se detectan en m&#225;s del 90&#37; de los casos&#46; Mientras su incidencia en la poblaci&#243;n con infecci&#243;n por VIH es de 55-144&#47;100&#46;000 pacientes&#47;a&#241;o&#44; en la poblaci&#243;n general es tan solo de 1-1&#44;5&#47;100&#46;000 pacientes&#47;a&#241;o<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">59</span></a>&#46; El mayor riesgo lo tienen los varones homosexuales&#44; pero tambi&#233;n se diagnostica en mujeres que tienen sexo anal y en pacientes con verrugas genitales<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">59</span></a>&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Como medidas principales de prevenci&#243;n se recomiendan el uso de preservativo &#40;aunque no protege en el 100&#37; de los casos&#41; y de la vacuna&#44; cuya eficacia est&#225; ya contrastada en mujeres para prevenir el carcinoma de c&#233;rvix<a class="elsevierStyleCrossRefs" href="#bib0695"><span class="elsevierStyleSup">60&#44;61</span></a>&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Seg&#250;n las recomendaciones del grupo de estudio del sida &#40;GESIDA&#41; de la Sociedad Espa&#241;ola de Enfermedades Infecciosas y Microbiolog&#237;a Cl&#237;nica&#44; para el diagn&#243;stico precoz se debe realizar una citolog&#237;a anal a los pacientes de riesgo&#44; independientemente de la presencia o no del VPH<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">43</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Carcinoma pulmonar</span><p id="par0085" class="elsevierStylePara elsevierViewall">Es el tumor m&#225;s frecuente tanto en la poblaci&#243;n con infecci&#243;n por VIH como en la poblaci&#243;n general&#44; y tiene una estrecha relaci&#243;n con el consumo de tabaco&#46; Sin embargo&#44; en los pacientes con infecci&#243;n por VIH&#44; independientemente del h&#225;bito tab&#225;quico&#44; se ha observado que es 2-4 veces m&#225;s frecuente&#44; aparece en edades m&#225;s tempranas&#44; su comportamiento es m&#225;s agresivo y su pron&#243;stico&#44; peor<a class="elsevierStyleCrossRefs" href="#bib0705"><span class="elsevierStyleSup">62-65</span></a>&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">El c&#225;ncer de pulm&#243;n es una de las principales causas de muerte&#44; pero hasta hace poco no ha habido un m&#233;todo de despistaje que permitiera realizar un diagn&#243;stico precoz&#46; En la actualidad&#44; a ra&#237;z de la publicaci&#243;n de los datos del <span class="elsevierStyleItalic">National Lung Screening Trial</span> en 2013<a class="elsevierStyleCrossRef" href="#bib0725"><span class="elsevierStyleSup">66</span></a>&#44; se propone el uso de la tomograf&#237;a computarizada de baja radiaci&#243;n&#44; en la poblaci&#243;n de riesgo no VIH&#44; ya que ha demostrado ser &#250;til en el diagn&#243;stico precoz de este tumor&#44; aunque a&#250;n se est&#225; evaluando su coste-efectividad&#46; En la poblaci&#243;n con infecci&#243;n por VIH este aspecto est&#225; poco estudiado y por ello GESIDA est&#225; llevando a cabo un estudio multic&#233;ntrico para valorar la eficacia de esta medida &#40;GESIDA 8815&#41;<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">67</span></a>&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Tratamiento de los tumores no diagn&#243;sticos de sida</span><p id="par0095" class="elsevierStylePara elsevierViewall">El tratamiento de los TNDS&#44; al igual que el de los TDS&#44; est&#225; basado en 3 pilares fundamentales<a class="elsevierStyleCrossRefs" href="#bib0615"><span class="elsevierStyleSup">44&#44;68-70</span></a>&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0100" class="elsevierStylePara elsevierViewall">El tratamiento antineopl&#225;sico debe ser igual al empleado en los pacientes VIH negativos&#46; Si no se tiene en cuenta esta premisa&#44; la mortalidad se puede incrementar ya que se realizar&#237;an terapias inadecuadas<a class="elsevierStyleCrossRef" href="#bib0750"><span class="elsevierStyleSup">71</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Se debe iniciar precozmente el tratamiento de la infecci&#243;n por VIH con una TAR eficaz&#44; segura y con pocas interacciones medicamentosas<a class="elsevierStyleCrossRefs" href="#bib0755"><span class="elsevierStyleSup">72-74</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall">La profilaxis y tratamiento de las infecciones oportunistas constituye una medida esencial&#46; Se realizar&#225; tanto en aquellas infecciones directamente relacionadas con la inmunodepresi&#243;n como en aquellas que&#44; como la tuberculosis&#44; tienen una incidencia elevada en nuestro medio&#46; Debe tenerse en cuenta que tras el empleo de quimio o radioterapia se produce un descenso de la cifra total de linfocitos CD4 en un 30-50&#37;&#44; con respecto a la basal&#44; no recuper&#225;ndose los niveles pretratamiento hasta pasados 6-12 meses<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">75</span></a>&#46; Por ello&#44; se recomienda realizar profilaxis con cotrimoxazol siempre&#44; aunque al inicio del tratamiento los linfocitos CD4&#43; sean superiores a 200&#47;mm<span class="elsevierStyleSup">3</span>&#46;</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Diagn&#243;stico precoz y prevenci&#243;n</span><p id="par0115" class="elsevierStylePara elsevierViewall">En lo que se refiere a las medidas destinadas al diagn&#243;stico precoz de las neoplasias&#44; en ninguna de las gu&#237;as de TAR&#44; excepto en las de la <span class="elsevierStyleItalic">European AIDS Clinical Society</span><a class="elsevierStyleCrossRef" href="#bib0775"><span class="elsevierStyleSup">76</span></a>&#44; se hace referencia expresa a este punto&#46; En nuestro pa&#237;s&#44; GESIDA ha elaborado un documento&#44; redactado de forma independiente de las gu&#237;as de TAR&#44; sobre el manejo de los TNDS en el que se contemplan tanto la prevenci&#243;n como el diagn&#243;stico precoz<span class="elsevierStyleBold">&#44;</span> que b&#225;sicamente no difieren de lo recomendado para la poblaci&#243;n general &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">43</span></a>&#46; De acuerdo con el mismo&#44; las medidas de prevenci&#243;n m&#225;s importantes y de eficacia contrastada son&#58; el desarrollo de h&#225;bitos de vida saludable &#40;disminuci&#243;n del consumo de alcohol y tabaco&#41;&#44; el tratamiento del VHC&#44; y el empleo de vacunas frente al VPH y&#44; en menor medida&#44; frente al VHB<a class="elsevierStyleCrossRefs" href="#bib0610"><span class="elsevierStyleSup">43&#44;57&#44;58&#44;60&#44;61&#44;77-79</span></a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusiones</span><p id="par0120" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">1&#46;</span><p id="par0125" class="elsevierStylePara elsevierViewall">La mayor&#237;a de las neoplasias&#44; tanto TDS como TNDS&#44; que aparecen en los pacientes con infecci&#243;n por VIH est&#225;n relacionadas con infecciones virales&#46; Los TNDS presentan una frecuencia y gravedad mayores que los TDS&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">2&#46;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Una carga viral &#40;VIH&#41; indetectable y unos linfocitos CD4&#43; superiores a 500&#47;mm<span class="elsevierStyleSup">3</span> son factores que protegen del desarrollo de algunos tumores&#44; fundamentalmente de TDS&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">3&#46;</span><p id="par0135" class="elsevierStylePara elsevierViewall">El tratamiento de las neoplasias en sujetos VIH se asemeja al empleado en la poblaci&#243;n general&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">4&#46;</span><p id="par0140" class="elsevierStylePara elsevierViewall">Se debe realizar profilaxis de las infecciones oportunistas mientras se administra quimioterapia&#44; aunque los CD4 sean superiores a 200&#47;mm<span class="elsevierStyleSup">3</span>&#46;</p></li></ul></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflicto de intereses</span><p id="par0145" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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          "identificador" => "xpalclavsec968756"
          "titulo" => "Keywords"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introducci&#243;n"
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          "identificador" => "sec0010"
          "titulo" => "Etiopatogenia"
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          "identificador" => "sec0015"
          "titulo" => "Tumores no diagn&#243;sticos de sida"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Linfoma de Hodgkin"
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            1 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Hepatocarcinoma"
            ]
            2 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Carcinoma del canal anal"
            ]
            3 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Carcinoma pulmonar"
            ]
          ]
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          "identificador" => "sec0040"
          "titulo" => "Tratamiento de los tumores no diagn&#243;sticos de sida"
        ]
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          "identificador" => "sec0045"
          "titulo" => "Diagn&#243;stico precoz y prevenci&#243;n"
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          "identificador" => "sec0050"
          "titulo" => "Conclusiones"
        ]
        10 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Conflicto de intereses"
        ]
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          "titulo" => "Bibliograf&#237;a"
        ]
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    "tienePdf" => true
    "fechaRecibido" => "2017-05-21"
    "fechaAceptado" => "2017-07-30"
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          "titulo" => "Palabras clave"
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          "palabras" => array:3 [
            0 => "Tumores no diagn&#243;sticos de sida"
            1 => "Neoplasias y VIH"
            2 => "Mortalidad"
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        ]
      ]
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec968756"
          "palabras" => array:3 [
            0 => "Undiagnosed AIDS tumours"
            1 => "Malignancies and HIV"
            2 => "Mortality"
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      ]
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    "resumen" => array:2 [
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Desde los inicios de la epidemia del virus de la inmunodeficiencia humana &#40;VIH&#41;&#44; la patolog&#237;a tumoral ha sido muy importante&#46; El conjunto de las neoplasias se puede dividir b&#225;sicamente en 2 grupos&#58; las asociadas al VIH&#44; todas ellas relacionadas con enfermedades virales&#44; y las no asociadas al VIH&#44; entre las que algunas est&#225;n asociadas a enfermedades virales y otras no&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El origen es multifactorial y las principales causas que han llevado a que se produzca un aumento de la patolog&#237;a tumoral son la inmunodepresi&#243;n&#44; la coinfecci&#243;n con virus oncog&#233;nicos y la prolongaci&#243;n de la vida secundaria al uso de tratamiento antirretroviral&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Establecer las caracter&#237;sticas generales de los tumores no diagn&#243;sticos de sida es dif&#237;cil fundamentalmente porque son un grupo muy heterog&#233;neo formado por neoplasias de diversa &#237;ndole&#46; Los tratamientos no difieren de los empleados en la poblaci&#243;n general&#44; aunque el manejo puede ser m&#225;s dif&#237;cil por el diagn&#243;stico tard&#237;o&#44; las interacciones medicamentosas y las comorbilidades asociadas&#46;</p></span>"
      ]
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Since the start of the human immunodeficiency virus &#40;HIV&#41; epidemic&#44; tumour disease among patients has been significant&#46; The collection of malignancies can be divided primarily into 2 groups&#58; those associated with HIV &#40;all of which are related to viral diseases&#41; and those not associated with HIV &#40;only some of which are associated with viral diseases&#41;&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The origin of these malignancies is multifactorial&#44; and the main causes that have led to an increase in tumour disease are immunosuppression&#44; coinfection with oncogenic viruses and life prolongation secondary to the use of antiretroviral therapy&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Establishing the general characteristics of the undiagnosed AIDS tumours is difficult&#44; mainly because they are a highly heterogeneous group formed by malignancies of a diverse nature&#46; The treatments do not differ from those used in the general population&#44; although the management can be more difficult due to the late diagnosis&#44; drug interactions and associated comorbidities&#46;</p></span>"
      ]
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          "es" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Clasificaci&#243;n de las principales neoplasias que presentan los pacientes con infecci&#243;n por el virus de la inmunodeficiencia humana&#46; Dentro del recuadro se observan las relacionadas con infecciones virales&#46;</p> <p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">VEB&#58; virus de Epstein Barr&#59; VHC&#58; virus de la hepatitis<span class="elsevierStyleHsp" style=""></span>C&#59; VHB&#58; virus de la hepatitis<span class="elsevierStyleHsp" style=""></span>B&#59; VIH&#58; virus de la inmunodeficiencia humana&#59; VPH&#58; virus del papiloma humano&#46;</p>"
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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Algoritmo para el diagn&#243;stico precoz del carcinoma del canal anal&#46;</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">ASCUS&#58; c&#233;lulas de significado incierto&#59; SIL&#58; lesi&#243;n intraepitelial&#46;</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Fuente&#58; adaptaci&#243;n de Santos&#44; Valencia y Panel de expertos de GeSIDA<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">43</span></a>&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">a</span> En estos 3 tumores las medidas recomendadas para el diagn&#243;stico precoz no difieren de las empleadas en la poblaci&#243;n general&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">HSH&#58; hombres que tienen sexo con hombres&#59; PSA&#58; ant&#237;geno prost&#225;tico espec&#237;fico&#59; TC&#58; tomograf&#237;a computarizada&#59; VHB&#58; virus de la hepatitis<span class="elsevierStyleHsp" style=""></span>B&#59; VHC&#58; virus de la hepatitis<span class="elsevierStyleHsp" style=""></span>C&#59; VPH&#58; virus del papiloma humano&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Tipo de neoplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Poblaci&#243;n susceptible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagn&#243;stico precoz&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Profilaxis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HSH&#44; mujeres que tienen sexo anal&#44; pacientes con verrugas genitales&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Citolog&#237;a anal anual&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vacunaci&#243;n frente al VPH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Carcinoma de c&#233;rvix&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mujeres sexualmente activas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Citolog&#237;a cervical anual&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vacunaci&#243;n frente al VPH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hepatocarcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pacientes cirr&#243;ticos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ecograf&#237;a abdominal semestral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vacunaci&#243;n frente a VHB<br>Tratamiento de hepatitis por VHC y VHB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Carcinoma de pulm&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pacientes fumadores mayores de 45 a&#241;os&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TC de t&#243;rax baja radiaci&#243;n sin administraci&#243;n de contraste&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Abandono del h&#225;bito tab&#225;quico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Carcinoma de colon<span class="elsevierStyleSup">a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Personas entre 50 y 75 a&#241;os&#46; Antecedentes familiares de c&#225;ncer de colon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sangre oculta en heces anual &#177; colonoscopia cada 5 a&#241;os&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Carcinoma de pr&#243;stata<span class="elsevierStyleSup">a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hombres mayores de 50 a&#241;os&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tacto rectal &#177; PSA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Carcinoma de mama<span class="elsevierStyleSup">a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mujeres entre 50 y 70 a&#241;os&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mamograf&#237;a&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "es" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Medidas destinadas a la prevenci&#243;n y al diagn&#243;stico precoz de algunas de las neoplasias diagnosticadas en los pacientes con infecci&#243;n por el virus de la inmunodeficiencia humana</p>"
        ]
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    ]
    "bibliografia" => array:2 [
      "titulo" => "Bibliograf&#237;a"
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        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:79 [
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              "identificador" => "bib0400"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mortality&#44; causes of death and associated factors relate to a large HIV population-based cohort"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46; Garriga"
                            1 => "P&#46; Garc&#237;a de Olalla"
                            2 => "J&#46;M&#46; Mir&#243;"
                            3 => "I&#46; Oca&#241;a"
                            4 => "H&#46; Knobel"
                            5 => "M&#46;J&#46; Barber&#225;"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1371/journal.pone.0145701"
                      "Revista" => array:5 [
                        "tituloSerie" => "PLoS One&#46;"
                        "fecha" => "2015"
                        "volumen" => "10"
                        "paginaInicial" => "e0145701"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26716982"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0405"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mortalidad en personas infectadas por el virus de la inmunodeficiencia humana"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46; Berenguer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Enferm Infec Microbiol Clin&#46;"
                        "fecha" => "2016"
                        "volumen" => "34"
                        "paginaInicial" => "217"
                        "paginaFinal" => "218"
                      ]
                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0410"
              "etiqueta" => "3"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Trends in underlying causes of death in people with HIV from 1999 to 2011 &#40;D&#58;A&#58;D&#41;&#58; A multicohort collaboration"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46;J&#46; Smith"
                            1 => "L&#46; Ryom"
                            2 => "R&#46; Weber"
                            3 => "P&#46; Morlat"
                            4 => "C&#46; Pradier"
                            5 => "P&#46; Reiss"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(14)60604-8"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet&#46;"
                        "fecha" => "2014"
                        "volumen" => "384"
                        "paginaInicial" => "241"
                        "paginaFinal" => "248"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25042234"
                            "web" => "Medline"
                          ]
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                    ]
                  ]
                ]
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              "etiqueta" => "4"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cause-specific mortality in HIV-positive patients who survived ten years after starting antiretroviral therapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Trickey"
                            1 => "M&#46;T&#46; May"
                            2 => "J&#46; Vehreschild"
                            3 => "N&#46; Obel"
                            4 => "M&#46;J&#46; Gill"
                            5 => "H&#46; Crane"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1371/journal.pone.0160460"
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                        "tituloSerie" => "PLoS One&#46;"
                        "fecha" => "2016"
                        "volumen" => "11"
                        "paginaInicial" => "e0160460"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27525413"
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                          ]
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              "etiqueta" => "5"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Survival among HIV-infected and HIV-uninfected individuals with common non-AIDS-defining cancers"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;L&#46; Marcus"
                            1 => "Chao Ch"
                            2 => "W&#46;A&#46; Leyden"
                            3 => "L&#46; Xu"
                            4 => "J&#46; Yu"
                            5 => "M&#46;A&#46; Horberg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1158/1055-9965.EPI-14-1079"
                      "Revista" => array:6 [
                        "tituloSerie" => "Cancer Epidemiol Biomarkers Prev&#46;"
                        "fecha" => "2015"
                        "volumen" => "24"
                        "paginaInicial" => "1167"
                        "paginaFinal" => "1173"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25713023"
                            "web" => "Medline"
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                    ]
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              "identificador" => "bib0425"
              "etiqueta" => "6"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Malignancies in HIV-infected patients&#58; Descriptive study of 129 cases between 1993 and 2010"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46; Meijide"
                            1 => "A&#46; Mena"
                            2 => "B&#46; Pernas"
                            3 => "A&#46; Castro"
                            4 => "S&#46; L&#243;pez"
                            5 => "P&#46; V&#225;zquez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.4067/S0716-10182013000200006"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Chilena Infectol&#46;"
                        "fecha" => "2013"
                        "volumen" => "30"
                        "paginaInicial" => "156"
                        "paginaFinal" => "161"
                        "link" => array:1 [
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