Kaposi sarcoma: Difference between revisions

Revision as of 08:20, 2 October 2022

Background

A tumour associated with HHV-8
Closely associated with advanced HIV, but may also present as classic, endemic, or transplant-related KS

ACTG Staging

Based on extent of tumour (T), immune status (I), and severity of systemic illness (S)

Criterion	Lower Risk (0)	Higher risk (1)
Tumour (T)	Confined to skin and/or lymph nodes and/or minimal oral disease (non-nodular KS confined to palate)	Tumor-associated edema or ulceration; extensive oral KS; gastrointestinal KS; or KS in other non-nodal viscera
Immune status (I)	CD4 cell count >200/µL	CD4 cell count <200/µL
Systemic illness (S)	No history of OI or thrush; no "B" symptoms; and Karnofsky performance status >70	History of OI or thrush; "B" symptoms present; Karnofsky performance status <70; or other HIV-related illness (eg, neurologic disease, lymphoma)

Clinical Manifestations

Non-tender, hyperpigmented skin lesions
May be macular or nodular
Oral lesions in about a third
May involve lymphatics, causing severe edema
May involve the viscera, which may be asymptomatic or cause dyspnea (lungs), hematochezia or melena (GI tract), or other signs and symptoms

Management

Treatment goals are symptom alleviation, prevention of disease progression, and shrinkage of tumour to alleviate edema, organ compromise, and psychological stress

HIV Patients

Combination antiretroviral therapy is the mainstay of treatment for all patients with HIV
Disease may worsen for 3 to 6 weeks following initiation of ART, due to immune reconstitution inflammatory syndrome
Try to decrease or stop any corticosteroids, if possible, since it appears to worsen KS

Transplant Patients

Try to include mTOR inhibitors, such as rapamycin and sirolimus, in the immunosuppression regimens

Local Treatments

Intralesional vinblastine 0.2 to 0.3 mg/mL solution with a volume of 0.1 mL per 0.5 cm2 of lesion
- May be repeated at 3 to 4 weeks
Radiation therapy
Topical alitretinoin

Systemic Chemotherapy

Used in cases of advanced or rapidly-progressive disease
Indications include:
- Symptomatic visceral involvement
- Widespread skin involvement (eg, more than 25 lesions)
- Extensive cutaneous KS that is unresponsive to local treatment
- Extensive edema
- Immune reconstitution inflammatory syndrome
- Progression of KS on ART alone

Options include pegylated liposomal doxorubicin or liposomal daunorubicin, paclitaxel, bleomycin, vinblastine, vincristine, or etoposide
- First-line: liposomal doxorubicin 20 mg/m² every three weeks
- Second-line: paclitaxel

Direct Antivirals

In vitro activity of ganciclovir, foscarnet, and cidofovir has not translated into clinical efficacy
Not recommended

@@ Line 23: / Line 23: @@
 |History of OI or thrush; "B" symptoms present; Karnofsky performance status <70; or other HIV-related illness (eg, neurologic disease, lymphoma)
 |}
+== Clinical Manifestations ==
+* Non-tender, hyperpigmented skin lesions
+* May be macular or nodular
+* Oral lesions in about a third
+* May involve lymphatics, causing severe edema
+* May involve the viscera, which may be asymptomatic or cause dyspnea (lungs), hematochezia or melena (GI tract), or other signs and symptoms
 == Management ==
-* Treatment goals are symptom alleviation, prevention of disease progression, and shrinkage of tumor to alleviate edema, organ compromise, and psychological stress
+* Treatment goals are symptom alleviation, prevention of disease progression, and shrinkage of tumour to alleviate edema, organ compromise, and psychological stress
+=== HIV Patients ===
 * [[HIV medications|Combination antiretroviral therapy]] is the mainstay of treatment for all patients with HIV
 * Disease may worsen for 3 to 6 weeks following initiation of ART, due to [[immune reconstitution inflammatory syndrome]]
+* Try to decrease or stop any corticosteroids, if possible, since it appears to worsen KS
+=== Transplant Patients ===
+* Try to include mTOR inhibitors, such as [[rapamycin]] and [[sirolimus]], in the immunosuppression regimens
 === Local Treatments ===
-* Intralesional vinblastine 0.2 to 0.3 mg/mL solution with a volume of 0.1 mL per 0.5 cm2 of lesion
+* Intralesional [[vinblastine]] 0.2 to 0.3 mg/mL solution with a volume of 0.1 mL per 0.5 cm2 of lesion
 ** May be repeated at 3 to 4 weeks
 * Radiation therapy
-* Topical alitretinoin
+* Topical [[alitretinoin]]
-== Systemic Chemotherapy ==
+=== Systemic Chemotherapy ===
 * Used in cases of advanced or rapidly-progressive disease
 * Indications include:
@@ Line 46: / Line 61: @@
 ** Progression of KS on ART alone
-* Options include pegylated liposomal doxorubicin or liposomal daunorubicin, paclitaxel, bleomycin, vinblastine, vincristine, or etoposide
+* Options include [[pegylated liposomal doxorubicin]] or [[liposomal daunorubicin]], [[paclitaxel]], [[bleomycin]], [[vinblastine]], [[vincristine]], or [[etoposide]]
-** Pegylated liposomal doxorubicin 20 mg/m2 every three weeks
+** First-line: [[liposomal doxorubicin]] 20 mg/m<sup>2</sup> every three weeks
+** Second-line: [[paclitaxel]]
+=== Direct Antivirals ===
+* ''In vitro'' activity of [[ganciclovir]], [[foscarnet]], and [[cidofovir]] has not translated into clinical efficacy
+* Not recommended
 [[Category:Oncology]]