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
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
