An Update on Kaposi's Sarcoma: Epidemiology, Pathogenesis and Treatment

Anaplastic Kaposi Sarcoma: A Clinicopathologic and Molecular Genetic Analysis

Kaposi sarcoma (KS) is a human herpesvirus 8 (HHV8)-associated vascular proliferation that most often involves the skin. Rarely, KS shows marked nuclear atypia or pleomorphism; such examples are known as "anaplastic" KS. This poorly characterized variant often pursues an aggressive course; little is known of its genetic landscape. This study evaluated the clinicopathologic and genomic features of anaplastic KS. We identified 9 anaplastic KS cases from 7 patients and 8 conventional KS cases, including a matched conventional KS and primary metastasis anaplastic KS pair from a single patient (anaplastic KS diagnosed 9 years after conventional KS). All patients with anaplastic KS were men, aged 51 to 82 years, who had locally aggressive tumors predominantly affecting the soft tissue and bone of the lower extremities (5/7 patients). Four patients were known to be HIV positive (all on antiretrovirals), 2 were HIV negative, and 1 was of unknown HIV status. The tumors showed angiosarcoma-like or pleomorphic spindle cell sarcoma morphology. Plasma cell-rich chronic inflammation and hemosiderin deposition were commonly present. Single-nucleotide polymorphism-based chromosomal microarray analysis showed the anaplastic KS cohort to demonstrate highly recurrent whole chromosome (chr) gains of chr 7, 11, 19, and 21, which primarily affected olfactory and G protein-coupled receptor signaling and losses of chr6_q and chrY. Compared with conventional KS, anaplastic KS cases showed significantly more total copy number alterations and more frequent gains of chr7 and chr11_q13.1 (MARK2, RELA, and ESRRA, including high copy number gain in 1 case). Pathway analysis demonstrated that these gains preferentially affected genes that facilitate cyclin-dependent cell signaling. Furthermore, anaplastic KS cases were phylogenetically distinct from conventional KS cases, including the patient-matched primary metastasis anaplastic KS pair and conventional KS. Our study is the first to demonstrate that a more complex genome and distinct copy number alterations distinguish anaplastic KS from conventional KS. Gains of chr7 and chr11_q13.1 appear central to biological transformation.

Comparison of 18F-FDG and 68Ga-FAPI PET/CT in Gastric Kaposi Sarcoma

ABSTRACT

Herein, we present the results of 18F-FDG PET/CT and 68Ga-FAPI-4 PET/CT of a patient with metastatic Kaposi sarcoma. A 47-year-old man with suspected gastric cancer was referred to 18F-FDG PET/CT for diagnosis and staging. PET/CT detected increased 18F-FDG uptake in metastatic lymphadenopathies and liver lesions. 68Ga-FAPI-4 PET/CT was performed for ongoing clinical trial. Although 68Ga-FAPI-4 PET/CT may be a better alternative than 18F-FDG for the imaging of primary tumoral infiltrations in the stomach, 18F-FDG seems to be a more useful agent for the Kaposi sarcoma in determining the extent of the disease and the localization of metastatic lesions.

Kaposi Sarcoma, a Trifecta of Pathogenic Mechanisms

Kaposi’s sarcoma is a rare disease with four known variants: classic, epidemic, endemic and iatrogenic (transplant-related), all caused by an oncogenic virus named Human Herpes Virus 8. The viral infection in itself, along with the oncogenic properties of HHV8 and with immune system dysfunction, forms the grounds on which Kaposi’s Sarcoma may develop. Infection with HHV8 occurs through saliva via close contacts, blood, blood products, solid organ donation and, rarely, vertical transmission. Chronic inflammation and oncogenesis are promoted by a mix of viral genes that directly promote cell survival and transformation or interfere with the regular cell cycle and cell signaling (of particular note: LANA-1, v-IL6, vBCL-2, vIAP, vIRF3, vGPCR, gB, K1, K8.1, K15). The most common development sites for Kaposi’s sarcoma are the skin, mucocutaneous zones, lymph nodes and visceral organs, but it can also rarely appear in the musculoskeletal system, urinary system, endocrine organs, heart or eye. Histopathologically, spindle cell proliferation with slit-like vascular spaces, plasma cell and lymphocyte infiltrate are characteristic. The clinical presentation is heterogenic depending on the variant; some patients have indolent disease and others have aggressive disease. The treatment options include highly active antiretroviral therapy, surgery, radiation therapy, chemotherapy, and immunotherapy. A literature search was carried out using the MEDLINE/PubMed, SCOPUS and Google Scholar databases with a combination of keywords with the aim to provide critical, concise, and comprehensive insights into advances in the pathogenic mechanism of Kaposi’s sarcoma.

Clonality, Mutation and Kaposi Sarcoma: A Systematic Review

BACKGROUND

It remains uncertain whether Kaposi sarcoma (KS) is a true neoplasm, in that it regresses after removal of the stimulus to growth (as HHV8) when immunosuppression is reduced. We aimed to summarize the available evidence on somatic mutations and clonality within KS to assess whether KS is a neoplasm or not.

METHODS

Medline and Web of Science were searched until September 2020 for articles on clonality or mutation in KS. Search strings were supervised by expert librarians, and two researchers independently performed study selection and data extraction. An adapted version of the QUADAS2 tool was used for methodological quality appraisal.

RESULTS

Of 3077 identified records, 20 publications reported on relevant outcomes and were eligible for qualitative synthesis. Five studies reported on clonality, 10 studies reported on various mutations, and 5 studies reported on chromosomal aberrations in KS. All studies were descriptive and were judged to have a high risk of bias. There was considerable heterogeneity of results with respect to clonality, mutation and cytogenetic abnormalities as well as in terms of types of lesions and patient characteristics.

CONCLUSIONS

While KS certainly produces tumours, the knowledge is currently insufficient to determine whether KS is a clonal neoplasm (sarcoma), or simply an aggressive reactive virus-driven lesion.

Cancer immunotherapy from biology to nanomedicine

With the significant drawbacks of conventional cancer chemotherapeutics, cancer immunotherapy has demonstrated the ability to eradicate cancer cells and circumvent multidrug resistance (MDR) with fewer side effects than traditional cytotoxic therapies. Various immunotherapeutic agents have been investigated for that purpose including checkpoint inhibitors, cytokines, monoclonal antibodies and cancer vaccines. All these agents aid immune cells to recognize and engage tumor cells by acting on tumor-specific pathways, antigens or cellular targets. However, immunotherapeutics are still associated with some concerns such as off-target side effects and poor pharmacokinetics. Nanomedicine may resolve some limitations of current immunotherapeutics such as localizing delivery, controlling release and enhancing the pharmacokinetic profile. Herein, we discuss recent advances of immunotherapeutic agents with respect to their development and biological mechanisms of action, along with the advantages that nanomedicine strategies lend to immunotherapeutics by possibly improving therapeutic outcomes and minimizing side effects.

Clinicopathologic Correlation of Kaposi Sarcoma Involving the Ocular Adnexa: Immunophenotyping of Diagnostic and Therapeutic Targets

PURPOSE

To describe the clinicopathologic characteristics and the expression of diagnostic/treatment targets in ocular adnexal Kaposi Sarcoma.

METHODS

We conducted a clinical-pathologic retrospective case series. Immunohistochemical staining for cluster of differentiation 31 (CD31), human herpesvirus-8 (HHV8), platelet-derived growth factor receptor alpha (PDGFR-A), vascular endothelial growth factor receptor-1 (VEGF), tyrosine-protein kinase Kit (c-Kit), and programmed cell death protein 1 (PD-1) were performed. Percentage of positive tumor cells was recorded for PD-1; staining intensity and distribution (H-score) were determined for the remaining stains. A Friedman non-parametric ANOVA analysis evaluated the staining.

RESULTS

The study cohort included 13 patients (age 25 to 95 years; mean 46): 7 lesions were in the eyelid, 5 in the conjunctiva, and 1 in the cornea. Nine of 11 lesions (82%) were in human immunodeficiency syndrome-positive patients (human immunodeficiency syndrome status was unknown in 2 cases). Staging included 6 plaques and 7 nodules. The mean H-scores of CD31, HHV8, c-Kit, VEGF, and PDGF-A were 8.00, 8.23, 2.77, 11.54, and 10.31, respectively. Mean PD-1 staining was 6.46%. The Friedman non-parametric ANOVA analysis showed VEGF, PDGF-A, CD31, and HHV8 differed significantly, and all differed significantly from c-Kit. Programmed cell death protein 1 staining was not significant with any clinical variable.

CONCLUSIONS

Cluster of differentiation 31 and HHV8 are helpful diagnostic adjuncts for ocular adnexal Kaposi Sarcoma. Platelet-derived growth factor receptor alpha and VEGF are promising treatment targets. Programmed cell death protein 1/PD-L1 and c-Kit are targets that are useful in several tumors; their roles in ocular adnexal Kaposi Sarcoma warrant further studies.

A Systematic Examination of Burden of Childhood Cancers in 183 Countries: Estimates from GLOBOCAN 2018

OBJECTIVE

Childhood cancers are a significant cause of child deaths worldwide. This study examines the burden of 33 childhood cancers in 183 countries.

METHODS

The estimates of age-, sex- and country-wise incidence and deaths due to 33 childhood cancers (below the age 15) for 183 countries were retrieved from GLOBOCAN 2018. The socioeconomic status of a country was measured by human development index (HDI).

RESULTS

Globally, an estimated 200 166 cases and 74 956 deaths were attributed to childhood cancers in 2018. The age-standardised incidence rate (ASIR) was 103 per million, whereas the age-standardised mortality rate (ASMR) stood at 38 per million. ASIR was highest in high-income regions (e.g. North America: 182 per million); ASMR, however, was elevated in low- and medium-income countries (e.g. south-east Asia: 62 per million; North Africa: 51 per million). Leukaemia and brain cancers were dominant cancer groups accounting for 45% of cases and 57% of deaths. The ASIRs exhibited a positive gradient with HDI ( R 2 = 0.46 ) .

CONCLUSION

The high burden of childhood cancers (>80% of total incidence) in low- and middle-income countries (LMICs) calls for increased cancer awareness, improvement in oncologic infrastructure, international collaborations and twinning programmes, equitable access to multi-modal treatment and financial coverage of treatment expenses.

Association of Viral Infections With Oral Cavity Lesions: Role of SARS-CoV-2 Infection

Different viral agents, such as herpesviruses, human papillomavirus, and Coxsackie virus, are responsible for primary oral lesions, while other viruses, such as human immunodeficiency virus, affect the oral cavity due to immune system weakness. Interestingly, it has been reported that coronavirus disease 2019 (COVID-19) patients can show cutaneous manifestations, including the oral cavity. However, the association between oral injuries and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is still unclear. This narrative review aimed to summarize the available literature and provide an overview of oral lesions associated with COVID-19. An online literature search was conducted to select relevant studies published up to November 2020. The results of 17 studies showed variability in oral lesions associated with COVID-19, including ulcerations, aphthous-like lesions, and macules. The tongue, lips, and palate were the most frequent anatomical locations. According to current knowledge, the etiopathogenesis of multiple COVID-19-associated lesions seems to be multifactorial. The appearance of such lesions could be related to the direct or indirect action of SARS-CoV-2 over the oral mucosa cells, coinfections, immunity impairment, and adverse drug reactions. Nevertheless, COVID-19-associated oral lesions may be underreported, mainly due to lockdown periods and the lack of mandatory dispositive protection. Consequently, further research is necessary to determine the diagnostic and pathological significance of oral manifestations of COVID-19. All medical doctors, dentists, and dermatologists are encouraged to perform an accurate and thorough oral examination of all suspected and confirmed COVID-19 cases to recognize the disease's possible early manifestations.

The course of Kaposi's sarcoma, a marker disease for the initial diagnosis of AIDS, under ongoing cART

While Kaposi's sarcoma (KS) was common in the 1980s and early 1990s in HIV-positive patients and one of the most common AIDS-defining diseases, its prevalence today has decreased significantly due to the early and widespread use of chimeric antigen receptor T-cell (cART) therapy. The rapid initiation of cART or, if occurring during ongoing cART, an optimization of antiretroviral therapy leads to a healing of this tumour disease in most patients. The aim of the therapy is immune reconstitution, as the immunodeficiency resulting from the HIV disease (reduced CD4+-T helper cells) promotes the development and spread of KS. This case report describes the course of KS in the first diagnosis of AIDS in a 36-year-old patient. The HIV copy count was below the detection limit and the CD3+/CD4+ T-helper cell count was only slightly below the normal value in the six-month follow-up after initial diagnosis and initiation of cART therapy. However, the clinical findings in the one-year follow-up showed only a partial response, whereby it was noted that new tumour lesions also developed focally in addition to individual progressive lesions. This was demonstrated clinically, dermatoscopically and by laser Doppler fluxmetry measurements of the lesions. Such a progression was observed in about one-third of the patients affected in various studies and is called Immune Reconstitution Inflammatory Syndrome. Other therapies in addition to cART are necessary here to suppress this immunological phenomenon (including cytostatic drugs). Promising studies are currently underway, including utilising checkpoint inhibitors. These are of great therapeutic interest due to the high immunological activity of KS itself and usually of systemic inflammatory response syndrome.

ETIOPATHOGENIC, EPIDEMIOLOGIC AND CLINICAL-THERAPEUTIC COMPARISON OF NON-HODGKIN'S LYMPHOMA AND KAPOSI'S SARCOMA

BACKGROUND

Non-Hodgkin's lymphomas (NHL) are primary neoplasms derived from lymphocytes, and Kaposi's sarcoma (SK) is a multicentric disease of viral etiology and is associated with HIV.

AIM

To study the etiopathogenesis and clinical characteristics of NHL and KS, describing their mutual factors.

METHODS

This retrospective investigation was performed on 101 medical charts. The patients were studied according to their age, gender, and HIV-positivity, following the PRISMA guidelines. The characteristics of the tumors and comorbidities were analyzed according to their age and lymphatic metastasis.

RESULTS

The mean age of the patients ranged between 15-87 years for NHL and between 25-54 for KS, but the age of patients with NHL associated with HIV did not surpass 34 years. The ratio male: female was 1,8:1 for NHL, but only men presented KS. HIV-positivity was found in five patients with NHL and in 14 with KS. The stages of NHL were: I (21%), II (18,4%), III (26,3%), and IV (34,2%), but KS were found only at III (40%) and IV (60%) stages. The lymphatic metastases were positive in 62 patients NHL and in four with KS. HIV-positivity occurred in 60% of patients with NHL and in 50% with KS.

CONCLUSION

The HIV seropositivity was revealed for most of patients during the NHL and SK propaedeutic and none of them present clinical manifestations of AIDS. NHL associated with HIV was found only in young patients. NHL and KS patients have similar epidemiological, clinical, and therapeutic characteristics.

Admitted AIDS-associated Kaposi sarcoma patients: Indications for admission and predictors of mortality

Kaposi sarcoma (KS) is an AIDS-defining angioproliferative malignancy associated with high morbidity and mortality. Most KS patients in regions with high incidence such as sub-Saharan Africa present late with advanced stage disease. Admitted KS patients have high mortality rates. Factors associated with mortality of admitted KS patients are poorly defined.We conducted a retrospective file review to ascertain reasons for admission and identify factors associated with mortality of admitted HIV-associated (epidemic) KS patients in Zambia. Baseline study variables were collected, and patients were retrospectively followed from admission to time of discharge or death.Mortality rate for admitted epidemic KS patients was high at 20%. The most common reasons for admission included advanced KS disease, severe anemia, respiratory tract infections, and sepsis. The majority (48%) of admitted patients had advanced clinical stage with visceral involvement on admission. Clinical predictors of mortality on univariate analysis included visceral KS [odds ratio (OR) = 13.74; 95% confidence interval (95% CI) = 1.68-113; P = 0.02), fever (OR = 26; 95% CI = 4.85-139; P = .001), and sepsis (OR = 35.56; 95% CI = 6.05-209; P = .001). Baseline hemoglobin levels (5.6 vs 8.2 g/dL; P = .001) and baseline platelet counts (63 x 10^9/L vs 205 x 10^9/L; P = .01) were significantly lower in mortalities vs discharges. Baseline white cell counts were higher in mortalities vs discharges (13.78 x 10^9/L vs 5.58 x 10^9/L; P = .01), and HIV-1 viral loads at the time of admission were higher in mortalities vs discharges (47,607 vs 40 copies/μL; P = .02). However, only sepsis (or signs and symptoms of sepsis) were independently associated with mortality after controlling for confounders.In conclusion, common reasons for admission of epidemic KS patients include advanced disease, severe anemia, respiratory tract infections, and signs and symptoms of sepsis. Signs and symptoms of sepsis are independent predictors of mortality in these patients.

Kaposi's sarcoma-associated herpesvirus protein ORF75 among HIV-1 patients in Kenya

Background

Histology is used to identify Kaposi’s sarcoma (KS) in countries with low resources to fund healthcare costs. Approximately 95% of KS cases can be detected using a polymerase chain reaction.

Objective

To determine the presence of the open reading frame 75 (ORF75) gene associated with Kaposi’s sarcoma herpes virus among HIV-1/AIDS patients and to describe morphological presentations of KS.

Methods

This was a retrospective, descriptive study of archived tissue blocks collected from 2013 to 2016. Haematoxylin and eosin staining was used to identify KS. Deoxyribonucleic acid from archived tissue blocks was extracted and a nested polymerase chain reaction was used to detect the ORF75 gene.

Results

All 81 cases in this study had been diagnosed as HIV-1 positive, of which 68 had hallmark features of KS in the histology report and 13 had features suggestive of KS (‘KS-like’). Microscopic identification of KS by haematoxylin and eosin staining was considered a significant indicator of KS herpes virus ORF75 gene positivity (p = 0.002). The ORF75 gene was detected in 60.5% (49/81) of tissue blocks; 27.2% were men (22/81) and 33.3% were women (27/81). The ORF75 gene was observed to be present in up to 15.4% (2/13) of the cases reported to have KS-like features.

Conclusion

Following the initial diagnosis of KS by histology, the ORF75 gene was fur-ther detected from both cases that had hallmark features of KS as well as among cases with KS-like fea-tures.

A case of classic Kaposi sarcoma in an immunocompetent human immunodeficiency virus-negative Dominican man

Kaposi sarcoma is an uncommon tumor that primarily arises in the skin and mucosal surfaces, but may metastasize to the internal organs. Four main variants of Kaposi sarcoma are recognized as the following: classic Kaposi sarcoma, which occurs in middle-aged or elderly men; epidemic Kaposi sarcoma, associated with human immunodeficiency virus infection; iatrogenic Kaposi sarcoma seen in patients on immunosuppressive drug therapy; and endemic Kaposi sarcoma. This report is of a case of classic Kaposi sarcoma in 55-year-old immunocompetent and human immunodeficiency virus-negative Dominican man who had lived in the United States for 2 years, who presented with a 2-year history of skin lesions on his lower extremities and soft palate. Biopsy of the soft palate was consistent with Kaposi sarcoma. The patient was treated with paclitaxel with a good response. This case report demonstrates the importance of recognizing that classic Kaposi sarcoma, first described almost 150 years ago, can still present in immunocompetent middle-aged men of all ethnicities.

Targeted therapies for autoimmune/idiopathic nonmalignant diseases: risk and management of opportunistic infections

INTRODUCTION

The management of patients affected by autoimmune/idiopathic diseases has been revolutionized by the development of targeted therapies (TT). However, the use of TT is complicated by several adverse events, like opportunistic infections (OIs). The potential of TT to predispose to OIs mainly depends on the site of action; nevertheless, such associations are far from being deterministic, because many factors could increase the infection risk.

AREAS COVERED

The impact on the infective risk of different TT used for autoimmune/idiopathic diseases is far from being completely understood. Indeed, many post-marketing reports documented severe or unexpected infections in patients treated with TT that did not emerge during registrative trials. In this review, the authors attempt to provide an easy and practical update about the 'infectious' safety of TT and examine the management strategies of OIs and other infections more frequently observed in the course of treatment with TT.

EXPERT OPINION

The authors suggest to precisely schedule the clinical management of these subjects, both to prevent and eventually treat promptly the TT-related infectious complications. A coordinated approach should be implemented from different medical specialties to improve the overall understanding of safety of TT and, in general, the management of opportunistic infections in immune-compromised hosts.

Kaposi sarcoma among people living with HIV in the French DAT'AIDS cohort between 2010 and 2015

Background

Although antiretroviral therapy (ART) has reduced the risk of Kaposi sarcoma (KS), KS cases still occur in HIV‐infected people.

Objective

To describe all KS cases observed between 2010 and 2015 in a country with high ART coverage.

Methods

Retrospective study using longitudinal data from 44 642 patients in the French Dat’AIDS multicenter cohort. Patients’ characteristics were described at KS diagnosis according to ART exposure and to HIV‐plasma viral load (HIV‐pVL) (≤50 or >50) copies/mL.

Results

Among the 209 KS cases diagnosed during the study period, 33.2% occurred in ART naïve patients, 17.3% in ART‐experienced patients and 49.5% in patients on ART, of whom 23% for more than 6 months. Among these patients, 24 (11.5%) had HIV‐pVL ≤50 cp/mL, and 16 (66%) were treated with a boosted‐PI‐based regimen. The distribution of KS localization did not differ by ART status nor by year of diagnosis.

Limitations

Data on human herpesvirus 8, treatment modalities for KS and response rate were not collected.

Conclusion

Half of KS cases observed in the study period occurred in patients not on ART, reflecting the persistence of late HIV diagnosis. Factors associated with KS in patients on ART with HIV‐pVL ≤50 cp/mL remain to be explored.

Epidemic, Endemic, or Stewart-Bluefarb? When Several Forms of Kaposi Seem to Dispute Paternity

The role of human herpes virus 8 (HHV8) is demonstrated in the occurrence of Kaposi's disease, but the role of cofactors is still hardly known. We report a case of Kaposi's disease which occurred 10 years after a local trauma in an HIV-positive patient from Central Africa. A 38-year-old female, from and living in Central Africa, consulted for angiomatous papulo-nodules associated with purple-colored macules and painful lymphoedema of the right leg and foot that had been developing for 6 months. She reported a history of posttraumatic lymphoedema of the affected limb as a result of a road accident that occurred ten years earlier. The mucous were healthy. There was no sign of systemic lesions. The diagnosis of Kaposi's disease was evoked with, in differential, a Stewart–Bluefarb syndrome-type of pseudo-Kaposi and an epidemic Kaposi disease. Retroviral serology was positive to HIV1 with a CD4 count of 600 cells/mm³. Histopathology of the lesions and duplex ultrasonography could not be performed. The rest of the biological assessment was without particularity. The diagnosis of epidemic Kaposi's disease associated with cofactors involved in endemic Kaposi's disease and Stewart–Bluefarb syndrome was retained. An antiretroviral treatment (emtricitabine, tenofovir, and efavirenz) allowed to obtain after 6 months a noticeable improvement of the lesions and a disappearance of the pain with however the persistence of a residual lymphoedema. This is a special case of Kaposi's disease that seems to involve several factors. The role of cofactors in Kaposi's disease remains to be elucidated.

Rare Laryngeal Kaposi’s Sarcoma: Case Report and Innovative Surgical Approach

Kaposi’s sarcoma is an angioproliferative neoplasm that usually appears on the skin, but can also involve all organs and anatomic locations. The atypical manifestations of Kaposi’s sarcoma can mislead the diagnosis, which can result in a poor case management. The authors present a HIV-negative patient with Kaposi’s sarcoma with both usual and unusual locations such as the larynx, eyelids and bones. In the pre-therapeutic balance, we used NBI, which showed an intensely vascularized tumor in the larynx. The chosen method for treatment consisted in subtotal epiglotectomy performed under TransOral UltraSonic Surgery (TOUSS) approach. The use of TOUSS endoscopic surgery helped reduce the time of hospitalization, the patient did not need a nasogastric tube and was orally fed from the first postoperative day, with a better and faster functional recovery.

Vascular lesions of the head and neck: an update on classification and imaging review

Vascular lesions have a varied appearance and can commonly occur in the head and neck. A majority of these lesions are cutaneous and congenital; however, some may be acquired and malignant. The presentation and clinical history of patients presenting with head and neck lesions can be used to guide further imaging, which can provide important diagnostic and therapeutic considerations. This review discusses the revised International Society for the Study of Vascular Anomalies (ISSVA) classification system for vascular tumors and malformations, as well as explores the most common vascular anomalies including their clinical presentations and imaging findings.

Systemic disease or periodontal disease? Distinguishing causes of gingival inflammation: a guide for dental practitioners. Part 2: cancer related, infective, and other causes of gingival pathology

Periodontitis and gingivitis are highly prevalent inflammatory diseases of the oral cavity, and typically are characterised by the presence of dental plaque. However, other causes of oral inflammation exist, which can resemble plaque-induced gingivitis and periodontitis, and may thus first be seen by a dental practitioner. This paper aims to provide dentists with an understanding of the manifestations of systemic diseases to the periodontium and highlights anamnestic and clinical clues important for distinguishing between plaque-induced and non plaque-induced lesions. In the first part of this series immune-mediated and hereditary conditions as causes of gingival lesions were discussed; this second part highlights cancer-related gingival lesions as well as those caused by specific pathogens, medication or malnutrition. A clear clinical, epidemiological and visual overview of the different conditions is provided. Early diagnosis of non plaque-related causes of gingival lesions can be vital for affected patients. Therefore, dental practitioners should be aware of the various manifestations of systemic diseases to the periodontium.

Gastric Ulcer as Presentation of HIV-Associated Kaposi Sarcoma and Resolution With HAART Therapy

Kaposi sarcoma (KS) is a neoplasm of endothelium-derived cells that are associated with human herpesvirus 8 infection. In the setting of HIV, extensive disease typically necessitates highly active antiretroviral therapy in conjunction with chemotherapy. We report a patient who presented with gastrointestinal symptoms and was found to have KS presenting only as cratered gastric ulcers. The patient declined chemotherapy and was treated with highly active antiretroviral therapy alone and had complete resolution of KS on endoscopy and imaging up to 3 years later.

Pyogenic granuloma and nodular Kaposi’s sarcoma: dermoscopic clues for the differential diagnosis

Background/aim

Pyogenic granuloma (PG)-like nodular Kaposi’s sarcoma (KS) has been previously demonstrated in several studies. However, to the best of our knowledge, no original study investigating the dermoscopic differential diagnosis of PG and KS exists in the relevant literature. In this study we aimed to identify dermoscopic findings providing useful clues to differential diagnosis between the two entities.

Materials and methods

Patients with histopathologically confirmed PG or nodular KS were included in the study. Demographic, clinical, dermoscopic, and histopathological findings of the cases were retrospectively reviewed.

Results

The most common finding observed in PG was red structureless areas (80.00%), followed by intersecting thick white lines (56.66%), ulceration (36.66%), and collarette scale (33.33%). The most common findings detected in nodular KS were polychromatic structures (56.66%) and red (46.66%) and white (13.33%) structureless areas, respectively.

Conclusion

Intersecting thick white lines seem to be the strongest dermoscopic clue to PG. Striate surface scaling (n = 6) was a novel finding identified for PG. Here we also described a new vascular pattern (widespread vessels composing a network) for nodular KS.

Clinical features of Kaposi's sarcoma: experience from a Taiwanese medical center

BACKGROUND

Most of the previous reports regarding the clinical features of Kaposi's sarcoma (KS) have been performed in Western and African countries. The clinical characteristics of KS have not been well defined in Han Chinese or Taiwanese patients. In this study, we analyzed the clinical features of KS patients in a Taiwanese medical center.

METHODS

Medical records from Kaohsiung Medical University Hospital over the past 20 years (1996-2016) were comprehensively reviewed.

RESULTS

There were 55 patients with KS (50 males and 5 females), including 37 patients (67%) with classic disease, 17 patients (31%) with AIDS-associated disease, and one patient (2%) with immunosuppressive medication-related disease. The average age was 58.7 years (range 20-87 years), and the average age was younger for AIDS patients (33.8 years) compared with non-AIDS patients (69.8 years). Among patients with classic KS, lesions were mostly localized to the lower extremities, whereas AIDS-associated KS patients were more likely to develop disseminated skin lesions, skin lesions on atypical sites (head and neck, trunk), and extracutaneous involvement (particularly oral cavity). The most common underlying diseases were diabetes mellitus (20% of patients) and hepatitis B (15% patients), and 38% of KS patients were smokers. Patients with AIDS-associated KS usually responded well to chemotherapy, whereas only 32% of patients with non-AIDS-associated KS showed complete response to radiotherapy.

CONCLUSIONS

The findings of the current study will serve as important references for clinicians in the diagnosis of KS and may form the basis for the implementation of KS clinical practice guidelines in Taiwan.

Designing a multi-epitope based vaccine to combat Kaposi Sarcoma utilizing immunoinformatics approach

Kaposi’s sarcoma-associated herpesvirus (KSHV) responsible for causing Kaposi sarcoma (KS), an opportunistic angioproliferative neoplasm is emerging rapidly. Despite this there is no permanent cure for this disease. The present study was aimed to design a multi-epitope based vaccine targeting the major glycoproteins of KSHV which plays an important role in the virus entry. After the application of rigorous immunoinformatics analysis and several immune filters, the multi-epitope vaccine was constructed, consisting of CD4, CD8 and IFN-γ inducing epitopes. Several physiochemical characteristics, allergenicity and antigenicity of the multi-epitope vaccine were analyzed in order to ensure its safety and immunogenicity. Further, the binding affinity and stability of the vaccine with Toll like receptor -9 (TLR-9) was analyzed by molecular docking and dynamics simulation studies. In addition, an in silico cloning was performed to ensure the expression and translation efficiency of the vaccine, utilizing pET-28a (+) vector. Such T-cell-based immunotherapies which leverage this mechanism could prove their potential against cancer. Further, the authors propose to test the present findings in the lab settings to ensure the safety, immunogenicity and efficacy of the presented vaccine which may help in controlling KSHV infection.

Regression of human immunodeficiency virus-associated oral Kaposi sarcoma with combined antiretroviral therapy: A case report and literature review

BACKGROUND

Kaposi's sarcoma (KS) is the most prevalent malignant neoplasia in human immunodeficiency virus positive (HIV+) patients for which the primary mode of management was chemotherapy.

METHODS

We have presented the case of a newly diagnosed HIV+ male patient who was diagnosed with a pedunculated nodule in the anterior region of the hard palate, measuring 3.5 cm in diameter and with 2 months of evolution.

RESULTS

Histopathological examination confirmed the clinical hypothesis of KS. Soon after the diagnosis, the patient started using combined antiretroviral therapy (Biovir and Kaletra), presenting a significant reduction of the lesion after 4 weeks. With 1.5 cm in diameter, the lesion was surgically removed. The patient was followed-up for 10 years without any recurrence.

CONCLUSION

In antiretroviral-naive patients with a well-preserved immune system, the use of cART may be efficient in reducing the progression of the KS lesions, thus avoiding the use of chemotherapeutic agents.

Human oncoviruses: Mucocutaneous manifestations, pathogenesis, therapeutics, and prevention: Hepatitis viruses, human T-cell leukemia viruses, herpesviruses, and Epstein-Barr virus

In 1964, the first human oncovirus, Epstein-Barr virus, was identified in Burkitt lymphoma cells. Since then, 6 other human oncoviruses have been identified: human papillomavirus, Merkel cell polyomavirus, hepatitis B and C viruses, human T-cell lymphotropic virus-1, and human herpesvirus-8. These viruses are causally linked to 12% of all cancers, many of which have mucocutaneous manifestations. In addition, oncoviruses are associated with multiple benign mucocutaneous diseases. Research regarding the pathogenic mechanisms of oncoviruses and virus-specific treatment and prevention is rapidly evolving. Preventative vaccines for human papillomavirus and hepatitis B virus are already available. This review discusses the mucocutaneous manifestations, pathogenesis, diagnosis, treatment, and prevention of oncovirus-related diseases. The first article in this continuing medical education series focuses on diseases associated with human papillomavirus and Merkel cell polyomavirus, while the second article in the series focuses on diseases associated with hepatitis B and C viruses, human T-cell lymphotropic virus-1, human herpesvirus-8, and Epstein-Barr virus.

Endothelins in inflammatory neurological diseases

Endothelins were discovered more than thirty years ago as potent vasoactive compounds. Beyond their well-documented cardiovascular properties, however, the contributions of the endothelin pathway have been demonstrated in several neuroinflammatory processes and the peptides have been reported as clinically relevant biomarkers in neurodegenerative diseases. Several studies report that endothelin-1 significantly contributes to the progression of neuroinflammatory processes, particularly during infections in the central nervous system (CNS), and is associated with a loss of endothelial integrity at the blood brain barrier level. Because of the paucity of clinical trials with endothelin-1 antagonists in several infectious and non-infectious neuroinflammatory diseases, it remains an open question whether the 21 amino acid peptide is a mediator/modulator rather than a biomarker of the progression of neurodegeneration. This review focuses on the potential roles of endothelins in the pathology of neuroinflammatory processes, including infectious diseases of viral, bacterial or parasitic origin in which the synthesis of endothelins or its pharmacology have been investigated from the cell to the bedside in several cases, as well as in non-infectious inflammatory processes such as neurodegenerative disorders like Alzheimers Disease or central nervous system vasculitis.

Fatal Disseminated Kaposi's Sarcoma in Two Patients with Human Immunodeficiency Virus (HIV) Infection

Case series

Patient: Male, 25 • Male, 30

Final Diagnosis: Kaposi sarcoma

Symptoms: Oral lesions

Medication: —

Clinical Procedure: —

Specialty: Infectious Diseases

Three-Dimensional Patient-Derived In Vitro Sarcoma Models: Promising Tools for Improving Clinical Tumor Management

Over the past decade, the development of new targeted therapeutics directed against specific molecular pathways involved in tumor cell proliferation and survival has allowed an essential improvement in carcinoma treatment. Unfortunately, the scenario is different for sarcomas, a group of malignant neoplasms originating from mesenchymal cells, for which the main therapeutic approach still consists in the combination of surgery, chemotherapy, and radiation therapy. The lack of innovative approaches in sarcoma treatment stems from the high degree of heterogeneity of this tumor type, with more that 70 different histopathological subtypes, and the limited knowledge of the molecular drivers of tumor development and progression. Currently, molecular therapies are available mainly for the treatment of gastrointestinal stromal tumor, a soft-tissue malignancy characterized by an activating mutation of the tyrosine kinase KIT. Since the first application of this approach, a strong effort has been made to understand sarcoma molecular alterations that can be potential targets for therapy. The low incidence combined with the high level of histopathological heterogeneity makes the development of clinical trials for sarcomas very challenging. For this reason, preclinical studies are needed to better understand tumor biology with the aim to develop new targeted therapeutics. Currently, these studies are mainly based on in vitro testing, since cell lines, and in particular patient-derived models, represent a reliable and easy to handle tool for investigation. In the present review, we summarize the most important models currently available in the field, focusing in particular on the three-dimensional spheroid/organoid model. This innovative approach for studying tumor biology better represents tissue architecture and cell–cell as well as cell–microenvironment crosstalk, which are fundamental steps for tumor cell proliferation and survival.

Diagnosis and Treatment of Kaposi Sarcoma

Kaposi sarcoma (KS) is the most common neoplasm of people living with HIV today. In Sub-Saharan Africa, KS is among the most common cancers in men, overall. Not only HIV-positive individuals present with KS; any immune compromised person infected with KS-associated herpesvirus (KSHV) or human herpesvirus 8 is at risk: the elderly, children in KSHV-endemic areas, and transplant recipients. KS diagnosis is based on detection of the viral protein latency-associated nuclear antigen (LANA) in the biopsy, but not all cases of KS are the same or will respond to the same therapy. Standard KS therapy has not changed in 20 years, but newer modalities are on the horizon and will be discussed.