Kaposi sarcoma: a continuing conundrum

Kaposi's sarcoma: epidemiologic aspects, the immune reconstitution inflammatory syndrome, and more along the Silk Road of cognition

Kaposi's sarcoma remains enignmatic with many clinical and epidemiological patterns. We review them and describe the groove sign, an important association worthy of recognition. We also stress Kaposi's sarcoma (KS) without coexistent human immunodefiency virus infection, with recent data from China describing an extraordinarily high classical KS prevalence rate among Uygurs and Kazaks in the Xinjiang Uygur Autonomous Region in northwestern China, presumably derived from elderly men residing there. The possible travel of HHV-8 along the ancient silk road from Italy to the Xinjiang Uyghur region remains intriguing. If only one in 10,000 HHV-8-infected patients develops classical KS worldwide, then triggers for its overrepresentation in this population within China are of particular concern. The KS-related immune reconstitution inflammatory syndrome is also emphasized.

A retrospective study of Kaposi's sarcoma in Hotan region of Xinjiang, China

Kaposi sarcoma (KS) is the most common cancer in patients with human immunodeficiency virus/acquired immunodeficiency syndrome (AIDS). In 1994, Chang and Moore discovered Kaposi sarcoma associated herpesvirus for the first time in KS lesions in AIDS patients. KS is a low-grade mesenchymal neoplasm of blood and lymphatic vessels that primarily affects the skin, although the disease may become disseminated to the lymphatic system, lungs, airways, or abdominal viscera. In this research, clinical characteristics and treatment of patients of Kaposi sarcoma were retrospectively analyzed in Hotan District, Xinjiang China. We look into the clinical traits, prognosis, and therapy of Kaposi sarcoma. From May 2017 to August 2022, 32 patients were treated in the People's Hospital of Hotan District, Xinjiang Uygur Autonomous Region, China. Twenty-two of these were classic Kaposi sarcomas (cKS), and 10 of these were Kaposi sarcomas linked to AIDS (AIDS-KS). The majority of KS patients were Uyghur. In terms of age at onset, AIDS-KS patients were younger than cKS patients. cKS and AIDS-KS are most frequently manifested in the feet and lower limbs. Ten patients with AIDS-KS have treated with combination antiretroviral therapy (combination antiretroviral therapy) combination chemotherapy, 5 of 10 patients had a complete response, 2 patients achieved partial response, the overall effective rate was 70%, and CD4 + T cells were greater than before. For cKS and AIDS-KS, the median overall survival was 56 and 50.8 months, respectively (P > .05). As a result, antiviral combination chemotherapy can also improve the prognosis of AIDS-KS patients.

Cutaneous vascular tumors: an updated review

Cutaneous vascular tumors constitute a heterogeneous group of entities that share overlapping morphologic and immunohistochemical features, which can be diagnostically challenging for pathologists and dermatopathologists. Our understanding and knowledge of vascular neoplasms have improved over time, resulting in both a refinement of their classification by the International Society for the Study of Vascular Anomalies (ISSVA) and an improvement in the accurate diagnosis and clinical management of vascular neoplasms. This review article aims to summarize the updated clinical, histopathological, and immunohistochemical characteristics of cutaneous vascular tumors, as well as to highlight their associated genetic mutations. Such entities include infantile hemangioma, congenital hemangioma, tufted angioma, spindle cell hemangioma, epithelioid hemangioma, pyogenic granuloma, Kaposiform hemangioendothelioma, retiform hemangioendothelioma, pseudomyogenic hemangioendothelioma, Kaposi sarcoma, angiosarcoma, and epithelioid hemangioendothelioma.

A description of Kaposi sarcoma risk factors and outcomes in HIV-positive and HIV-negative patients at a tertiary care medical center from 2005 to 2020

Kaposi sarcoma (KS) is a low-grade vascular malignancy caused by human herpesvirus-8 (HHV-8), also known as Kaposi's sarcoma-associated herpesvirus (KSHV). There are four established subtypes of KS, which are described by unique risk factors, presentation, and disease course. A "non-epidemic" variant to describe HIV-negative men who have sex with men (MSM) is emerging as a fifth subtype. We retrospectively examined patients with KS at an academic medical center in central Ohio, USA. To our knowledge, this is the first US-based report to describe KS risk factors and outcomes in the context of HIV status. Data were extracted from patient charts including demographic information, history at time of KS diagnosis, and information about KS disease course. HIV-positive and HIV-negative patients were grouped into established categories. HIV-negative patients who did not fit an existing subtype were described as "Unclassified-KS-Type." Demographic characteristics for AIDS-KS patients in our cohort match established trends in this subtype, such as male, MSM, and younger age at diagnosis compared to HIV-negative patients. Most Unclassified-KS-Type patients fit well into the emerging "non-epidemic KS" subtype. These patients are described as healthy, middle-aged, HIV-negative MSM with lower extremity lesions. This descriptive report provides an updated view of KS risk factors and outcomes to improve detection and treatment in dermatology.

Kaposi's sarcoma in a patient with pemphigus vulgaris mimicking exacerbation of pemphigus

BACKGROUND

Kaposi's sarcoma (KS) is a rare multifocal angiogenic tumor often seen in immunocompromised setting such as acquired immunodeficiency syndrome (AIDS) or organ transplantation recipients. Pemphigus vulgaris (PV) is a rare blistering disorder with mucocutaneous involvement for which immunosuppressive therapy has long been the core of treatment. Iatrogenic form of KS has been reported infrequently in pemphigus patients as a result of long-term immunosuppressive therapy.

CASE

We describe a 39-year-old male patient with confirmed diagnosis of PV who developed KS after receiving immunosuppressive agents for his pemphigus. KS was initially localized to the oral cavity with features mimicking exacerbation of his pemphigus.

CONCLUSION

This interesting case of KS suggests that dermatologists visiting patients with pemphigus with discomfort in the oral cavity should have a high degree of awareness and consider other differential diagnoses along with merely an exacerbation of PV.

Oral-visceral iatrogenic Kaposi sarcoma following treatment for acute lymphoblastic leukemia: a case report and review of the literature

Background

There have hardly been any reported cases of children presenting with Kaposi sarcoma as a second malignancy following treatment for acute lymphoblastic leukemia outside a transplant setting.

Case presentation

We report a case of a 5-year-old boy of Bantu origin, which, to our knowledge, could be only the second reported case of oral–visceral Kaposi sarcoma after acute lymphoblastic leukemia treatment. The patient presented with a 1-month history of progressive, non-painful, soft tissue oral mass, 1 month after completing treatment for high-risk acute lymphoblastic leukemia. He was successfully treated for Kaposi sarcoma on a two-drug regimen (bleomycin and vincristine) with good clinical response.

Conclusion

Visceral Kaposi sarcoma as a second malignancy may occur after pediatric acute lymphoblastic leukemia treatment, but its rarity makes it unlikely to raise suspicion among clinicians, thus precluding early diagnosis and treatment. We recommend routine evaluation for Kaposi sarcoma lesions in children undergoing long-term surveillance following treatment for childhood acute leukemia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13256-022-03620-3.

Imaging More than Skin-Deep: Radiologic and Dermatologic Presentations of Systemic Disorders

Background: Cutaneous manifestations of systemic diseases are diverse and sometimes precede more serious diseases and symptomatology. Similarly, radiologic imaging plays a key role in early diagnosis and determination of the extent of systemic involvement. Simultaneous awareness of skin and imaging manifestations can help the radiologist to narrow down differential diagnosis even if imaging findings are nonspecific. Aims: To improve diagnostic accuracy and patient care, it is important that clinicians and radiologists be familiar with both cutaneous and radiologic features of various systemic disorders. This article reviews cutaneous manifestations and imaging findings of commonly encountered systemic diseases. Conclusions: Familiarity with the most disease-specific skin lesions help the radiologist pinpoint a specific diagnosis and consequently, in preventing unnecessary invasive workups and contributing to improved patient care.

Kaposi's Sarcoma Management from a Plastic Surgery Perspective

Kaposi's Sarcoma (KS) is a low-grade angioproliferative tumor arising from endothelial cells and associated with Human Herpes Virus 8 infection. Although KS cases are not rare and there are considerable number of patients referred for surgical excision, the plastic surgery literature on KS is exceptionally scarce. Thirty patients who were operated with the diagnosis of KS between March 2015 and January 2020 were included. Preoperative HIV tests and detailed whole-body examinations of the patients were performed. As a surgical method, for lesions with sizes ranging from 0.5 * 1 cm to 2 * 3 cm, excisions were made over the deep skin fascia by placing a margin between 0.5-1 cm, considering the anatomical location and elasticity of the skin. Primary repair was performed in 40 lesions and 12 lesions of 8 patients were repaired with a skin graft. In four patients the repair was performed with local skin flaps. Higher upper extremity involvement, less systemic involvement and less pronounced male predominance have been important results in our study that we have found different from the literature data. Compared to the therapies such as radiotherapy, laser, or chemotherapy which require several administrations; one-stage surgical excision of the lesions provides remarkable advantages.

Kaposi Sarcoma with Mucocutaneous Involvement in French Guiana: An Epidemiological Study between 1969 and 2019

Data on Kaposi sarcoma in French Guiana are scarce and out of date. This territory presents unique epidemiological features. The objectives of this retrospective study were to analyse the clinical features, outcome and incidence of the different forms of Kaposi sarcoma in patients diagnosed between 1969 and 2019. The study population comprised a total of 52 patients. Clinical forms included epidemic Kaposi sarcoma (n=30), endemic (n=18), iatrogenic (n=2), classic (n=1) and unclassified Kaposi sarcoma (n=1). The mean annual incidence rate of epidemic Kaposi reached a peak in the 1990s (0.93/100,000) then decreased in the 2000s (0.33/100,000), while the incidence of endemic Kaposi sarcoma reached a peak in the 1980s (0.82/100,000) before decreasing in the 2000s (0.12/100,000). Factors associated with the epidemic form were: sexual intercourse between men (p=0.0054) and Haitian origin (p=0.035). The presence of nodules and/or tumour, lesions limited to the lower limbs, and age >65 years were associated with the endemic form. While Creole populations seem to be as affected by endemic Kaposi sarcoma as their African counterparts, the dynamics of Kaposi sarcoma in French Guiana are now dominated by the epidemic form.

Reflectance confocal microscopy for Kaposi's sarcoma treatment monitoring after intralesional vincristine chemotherapy

Kaposi's sarcoma (KS) is a multifocal systemic disease, originating from endothelial cells mainly affecting elderly men. Intralesional chemotherapy with vinblastine or vincristine is an effective and well‐tolerated treatment in patients presenting single nodules on the skin. Despite reflectance confocal microscopy represents a useful diagnostic method for many dermatological diseases, to date, there are few data regarding the use of RCM in mucocutaneous KS. Objective of this study was to evaluate the use of RCM for therapeutic follow‐up in KS patients treated with intralesional vincristine. An observational retrospective study involving patients with a histological diagnosis of classic KS was conducted. All patients were treated with intralesional vincristine; reflectance confocal microscopy images were taken for each patient at baseline (T0) and 1 month after vincristine injection. Four male patients with a median age of 76.8 years were included in the study and four nodules (one for each patient) were evaluated with RCM examination before and after vincristine injections. At 1 month from intralesional vincristine treatment, therapeutic response was confirmed at RCM examination; a reduction of inflammatory cell at the stratum spinosum level in all evaluated lesions was observed; at papillary dermis levels, black luminal structures were decreased in diameter and superficial linear canalicular structures were not represented. Aggregates of inflammatory cells and of hemosiderin deposition, at the dermal level, were reduced in number. Reflectance confocal microscopy showed to be a promising method to evaluate vincristine therapeutic response in patients with KS; further studies evaluating RCM use in KS patients in order to monitor treatment efficacy are still required.

Yield of FDG PET/CT for Defining the Extent of Disease in Patients with Kaposi Sarcoma

Simple Summary

The potential role of positron emission tomography/computed tomography with fluorodeoxyglucose (FDG PET/CT) for assessing the extent of Kaposi sarcoma is not well studied. We analyzed FDG PET/CTs performed on 75 patients referred to our department for Kaposi sarcoma staging or restaging. FDG PET/CTs detected most lymph nodes, bone, and muscle lesions, whereas digestive and mucous lesions could be missed. Most cutaneous lesions can be identified when whole-body FDG PET/CT (including lower limbs) is performed. Thus, a true whole-body FDG PET/CT can be recommended for staging purposes in patients with active Kaposi sarcoma and, if positive, be useful for therapeutic evaluation and follow-up.

Abstract

Background: Positron emission tomography/computed tomography with fluorodeoxyglucose (F-18) (FDG PET/CT) is increasingly used in Kaposi sarcoma (KS), but its value has not been assessed. Objectives: In this study, we aimed to evaluate the diagnostic accuracy of FDG PET/CT to define the extent of disease in KS. Methods: Consecutive patients with KS referred to our department for FDG PET/CT were included. The diagnostic accuracy of FDG PET/CT for cutaneous and extra-cutaneous KS staging was assessed on a per lesion basis compared to staging obtained from clinical examination, standard imaging, endoscopy, histological analyses, and follow-up. Results: From 2007 to 2017, 75 patients with FDG PET/CT were analyzed. The sensitivity and specificity of FDG PET/CT for the overall detection of KS lesions were 71 and 98%, respectively. Sensitivity and specificity were 100 and 85% for lymph nodes, 87 and 98% for bone, 87 and 100% for lungs, and 100 and 100% for muscle involvement, whereas sensitivity was only 17% to detect KS digestive involvement. The sensitivity of the diagnostic for KS cutaneous involvement increased from 73 to 88% when using a whole-body examination. Conclusion: FDG PET/CT showed good sensitivity and specificity for KS staging (digestive involvement excepted) and could be used for staging patients with active KS.

Kaposi's sarcoma, biologics and small molecules: Navigating the complex interplay between host immunity and viral biology. A case series with focused review of the literature

The consequences of cytokine-specific immune modulation in the development and course of Kaposi's sarcoma (KS) are poorly understood. A retrospective chart review of patients treated with biologic/small molecule drugs and followed at the dedicated KS outpatient service of our Dermatology Unit was performed. The literature on biologic and small molecule drug use in KS patients was also reviewed. Data concerning 12 KS patients treated with biologic/small molecule drugs were collected. After a median delay of 6 months following biologic or small molecule drug introduction, nine patients experienced either KS onset or reactivation. Drugs associated with KS onset or flaring were: rituximab, infliximab, ruxolitinib apremilast (1), mirikizumab, abatacept (1). After a median follow-up of 25 months, all cases achieved persistent complete response through culprit drug discontinuation or drug withdrawal plus treatment. No effect on KS course was recorded with tocilizumab and vedolizumab. Based on our experience with the largest case series reported to date as well as the available literature, tocilizumab and ustekinumab seem to exert an overall neutral effect on KS. On the other hand, rituximab, infliximab, and ruxolitinib have been associated with the development or worsening of pre-existing KS and should be carefully pondered before use. Due to limited and partly controversial evidence, no definitive conclusions can be drawn on vedolizumab, apremilast, mirikizumab, abatacept.

Dissecting the Role of Circular RNAs in Sarcomas with Emphasis on Osteosarcomas

Circular RNAs (circRNAs) are single-stranded RNAs generated from exons back-splicing from a single pre-mRNA, forming covalently closed loop structures which lack 5'-3'-polarity or polyadenylated tail. Ongoing research depicts that circRNAs play a pivotal role in tumorigenesis, tumor progression, metastatic potential and chemoresistance by regulating transcription, microRNA (miRNA) sponging, RNA-binding protein interactions, alternative splicing and to a lesser degree, protein coding. Sarcomas are rare malignant tumors stemming from mesenchymal cells. Due to their clinically insidious onset, they often present at advanced stage and their treatment may require aggressive chemotherapeutic or surgical options. This review is mainly focused on the regulatory functions of circRNAs on osteosarcoma progression and their potential role as biomarkers, an area which has prompted lately extensive research. The attributed oncogenic role of circRNAs on other mesenchymal tumors such as Kaposi Sarcoma (KS), Rhabdomyosarcoma (RMS) or Gastrointestinal Stromal Tumors (GISTs) is also described. The involvement of circRNAs on sarcoma oncogenesis and relevant emerging diagnostic, prognostic and therapeutic applications are expected to gain more research interest in the future.

Splenic Kaposi’s sarcoma in a human immunodeficiency virus-negative patient: A case report

BACKGROUND

Kaposi’s sarcoma (KS) is a malignancy that usually affects the skin of the lower extremities, and may involve internal organs. It originates from the vascular endothelium. It is well known that the development of KS is associated with human herpes virus 8 (i.e. HHV8) infections. Sporadic KS cases have mainly been found in Africa. Isolated splenic KS in Asia has rarely been reported. We present here a case of KS primarily involving the spleen in a human immunodeficiency virus (HIV)-negative Chinese patient.

CASE SUMMARY

A 50-year-old male patient was admitted to hospital due to abdominal distension and discomfort, reduced food intake and weight loss. Medical examination revealed that the patient had moderate anemia, a low platelet count, slight fatty liver and a huge mass in the spleen. Spleen lymphoma was considered. An anti-HIV test was negative. The whole spleen was surgically excised. The final pathological diagnosis was nodular stage spleen KS, and the patient underwent total splenectomy. He recovered well and was discharged from hospital 12 d after surgery. Two weeks later, the patient developed liver metastasis and died within 1 mo after surgery.

CONCLUSION

KS is difficult to diagnose and pathological examination is necessary. KS has a poor prognosis and should be diagnosed and treated early to improve survival.

KDM2B Overexpression Facilitates Lytic De Novo KSHV Infection by Inducing AP-1 Activity Through Interaction with the SCF E3 Ubiquitin Ligase Complex

It is still largely unknown what host factors are involved in controlling the expression of the lytic viral gene RTA during primary infection, which determines if Kaposi's sarcoma-associated herpesvirus (KSHV) establishes latent or lytic infection. We have recently identified the histone demethylase KDM2B as a repressor of RTA expression during both de novo KSHV infection and latency based on an epigenetic factor siRNA screen. Here, we report that surprisingly, KDM2B overexpression can promote lytic de novo infection by using a mechanism that differs from what is needed for its repressor function. Our study revealed that while the DNA-binding and demethylase activities of KDM2B linked to its transcription repressive function are dispensable, its C-terminal F-box and LRR domains are required for the lytic infection-inducing function of KDM2B. We found that overexpressed KDM2B increases the half-life of the AP-1 subunit c-Jun protein and induces the AP-1 signaling pathway. This effect is dependent upon the binding of KDM2B to the SKP1-CUL1-F-box (SCF) E3 ubiquitin ligase complex via its F-box domain. Importantly, the inhibition of AP-1 reduces KDM2B-mediated lytic de novo KSHV infection. Overall, our findings indicate that KDM2B may induce the degradation of some host factors by using the SCF complex resulting in the enrichment of c-Jun. This leads to increased AP-1 transcriptional activity, which facilitates lytic gene expression following de novo infection interfering with the establishment of viral latency.SignificanceThe expression of epigenetic factors is often dysregulated in cancers or upon specific stress signals, which often results in a display of non-canonical functions of the epigenetic factors that are independent from their chromatin-modifying roles. We have previously demonstrated that KDM2B normally inhibits KSHV lytic cycle using its histone demethylase activity. Surprisingly, we found that KDM2B overexpression can promote lytic de novo infection, which does not require its histone demethylase or DNA-binding functions. Instead, KDM2B uses the SKP1-CUL1-F-box (SCF) E3 ubiquitin ligase complex to induce AP-1 transcriptional activity, which promotes lytic gene expression. This is the first report that demonstrates a functional link between SFC^KDM2B and AP-1 in the regulation of KSHV lytic cycle.

CircRNA ARFGEF1 functions as a ceRNA to promote oncogenic KSHV-encoded viral interferon regulatory factor induction of cell invasion and angiogenesis by upregulating glutaredoxin 3

Circular RNAs (circRNAs) are novel single-stranded noncoding RNAs that can decoy other RNAs to inhibit their functions. Kaposi’s sarcoma (KS), caused by oncogenic Kaposi’s sarcoma-associated herpesvirus (KSHV), is a highly angiogenic and invasive vascular tumor of endothelial origin commonly found in AIDS patients. We have recently shown that KSHV-encoded viral interferon regulatory factor 1 (vIRF1) induces cell invasion, angiogenesis and cellular transformation; however, the role of circRNAs is largely unknown in the context of KSHV vIRF1. Herein, transcriptome analysis identified 22 differentially expressed cellular circRNAs regulated by vIRF1 in an endothelial cell line. Among them, circARFGEF1 was the highest upregulated circRNA. Mechanistically, vIRF1 induced circARFGEF1 transcription by binding to transcription factor lymphoid enhancer binding factor 1 (Lef1). Importantly, upregulation of circARFGEF1 was required for vIRF1-induced cell motility, proliferation and in vivo angiogenesis. circARFGEF1 functioned as a competing endogenous RNAs (ceRNAs) by binding to and inducing degradation of miR-125a-3p. Mass spectrometry analysis demonstrated that glutaredoxin 3 (GLRX3) was a direct target of miR-125a-3p. Knockdown of GLRX3 impaired cell motility, proliferation and angiogenesis induced by vIRF1. Taken together, vIRF1 transcriptionally activates circARFGEF1, potentially by binding to Lef1, to promote cell oncogenic phenotypes via inhibiting miR-125a-3p and inducing GLRX3. These findings define a novel mechanism responsible for vIRF1-induced oncogenesis and establish the scientific basis for targeting these molecules for treating KSHV-associated cancers.

Kaposi’s sarcoma-associated herpesvirus (KSHV) is the etiological agent of Kaposi’s sarcoma (KS), which frequently occurs in people with AIDS. We and others had proved that KSHV-encoded viral interferon regulatory factor 1 (vIRF1) was crucial in the pathogenesis of KSHV-induced cancers. KSHV genome transcribes viral circular RNAs (circRNAs), however, the role of cellular circRNAs in vIRF1-induced tumorigenesis remains unknown. CircRNAs serves as competitive endogenous RNAs (ceRNAs) of miRNAs, thus regulating miRNA-mRNA network to influence mRNA stability and protein expression. Here we found that vIRF1 binds to the promoter of the parental gene ARFGEF1 and activate circARFGEF1 transcription through interaction with transcription factor lymphoid enhancer binding factor 1 (Lef1). CircARFGEF1 functioned as a ceRNA by binding to and inducing degradation of miR-125a-3p, thereby abrogating the inhibition effect of this miRNA on its direct targeting of GLRX3. Significantly, circARFGEF1/miR-125a-3p/GLRX3 axis was required for vIRF1 induction of cell motility, proliferation and in vivo angiogenesis. In summary, our study describes a novel mechanism of KSHV-induced oncogenesis by hijacking host circRNAs through a viral oncogene.

A case of Kaposi’s sarcoma of tonsil with profuse bleeding in an HIV-positive patient

Kaposi’s sarcoma is the most common AIDS-associated malignancy. Kaposi’s sarcoma in the oral cavity and oropharynx present as a macular, papular, or nodular lesion on the palate, gingiva, or tongue which may look pink, reddish, or purplish. Kaposi’s sarcoma of the tonsils is relatively less common compared with other sites in the oral cavity and oropharynx. We report a case of Kaposi’s sarcoma of tonsil with profuse bleeding requiring emergency tracheostomy to protect the airway followed by tonsillectomy to control the bleeding. Our initial diagnosis was hemangioma or a pyogenic granuloma. The patient tested positive for a retroviral infection and the histopathology report was compatible with Kaposi’s sarcoma. Antiretroviral therapy and radiotherapy were given after stabilizing the patient. Kaposi’s sarcoma of tonsils is relatively uncommon and it is unusual to cause profuse bleeding. Various treatment options are available but there are no standard treatment protocols. Treatments options depend on the site, size, stage, and immune status of the patient.

Diagnosis and treatment of classic and iatrogenic Kaposi's sarcoma: Italian recommendations

Kaposi's sarcoma (KS) is a lymphangioproliferative disorder associated with Human herpesvirus 8 (HHV8) infection. Four clinical subtypes are recognized: classic, endemic, epidemic (HIV-related) and iatrogenic. KS diagnosis is based on clinical features, histopathological assessment, and HHV8 serology. Classic KS is usually skin-limited and has a chronic course, while the iatrogenic variant may show mucosal, nodal or visceral involvement. Clinical staging is fundamental to guide the management. Localized disease may be treated with different local therapies, even if there are no randomized trials comparing these different modalities. Aggressive, disseminated KS and cases with visceral involvement usually require systemic chemotherapy, most commonly vinblastine, bleomycin or paclitaxel. Iatrogenic KS needs immunosuppression tapering/withdrawal and, if possible, switch to m-TOR inhibitors in post-transplant KS. The present work by a panel of Italian experts provides guidelines on KS diagnosis and management based on a critical review of the literature and a long and extensive personal experience.

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.

Isolated limb perfusion is an effective treatment modality for locally advanced Kaposi sarcoma of the extremities

INTRODUCTION

Kaposi sarcoma (KS) is a rare soft tissue sarcoma. In case of locally advanced disease, mutilating surgery such as amputations or major reconstructive procedures are sometimes inevitable. The aim of this study was to evaluate the effectiveness of isolated limb perfusion (ILP) in patients with locally advanced KS of the extremities.

MATERIAL AND METHODS

All patients who underwent ILP for KS between 1996 and 2018 at Erasmus MC, Rotterdam were identified. Clinical data was obtained from either a prospectively maintained database or retrospective assessment of patient files.

RESULTS

A total of 14 primary ILP's were performed in 11 patients. Median follow-up from primary ILP was 30 months (range, 5-98). The overall response rate of primary ILP was 100%, with a complete response (CR) rate of 50%. Only minimal local toxicity (Wieberdink I-III) was observed. Local progressive disease occurred after eight primary ILP's (57%) with a median local progression free survival (PFS) of 18 months (95% confidence interval [CI]: 7.0-28.9). Subsequently, four (46%) patients received a total of 5 recurrent ILP's. After the recurrent ILP on the same leg, the overall response rate was 75% and a CR-rate of 50%. One patient needed amputation post-operatively resulting in a limb salvage rate of 91%. One (9%) patient developed metastases four months after ILP.

CONCLUSIONS

ILP is a highly effective treatment modality with very limited morbidity rates for patients with locally advanced KS of the extremity. ILP should be considered as a treatment modality for locally advanced KS of the extremities.

Nodular Classic Kaposi's Sarcoma Treated With Neodymium-Doped Yttrium Aluminum Garnet Laser Delivered Through a Tilted Angle: Outcome and 12-Month Follow Up

BACKGROUND AND OBJECTIVES

Classic Kaposi's sarcoma (KS) is a multifocal angioproliferative disorder with a long and indolent course typically affecting the lower extremities of elderly men. Multiple nodules with a rapid growth may sometimes develop, causing pain, bleeding, and discomfort on walking. In such cases, immediate intervention using different methods, including laser therapy, is advisable. We report our experience in classic KS patients with the use of neodymium-doped yttrium aluminum garnet (Nd:YAG) laser delivered through a tilted angle.

STUDY DESIGN/MATERIALS AND METHODS

A total of 81 KS nodules (0.5-3 cm size) located in the feet or lower limbs of nine patients (mean age: 78.8 years; age range: 64-86 years) were selected for treatment with Nd:YAG laser (5-7 mm spot, 140-200 J/cm² fluence, 5 ms triple pulse with 10 ms delay). The laser beam was delivered at the periphery of each nodule using a tilted angle of 30° to 60° according to lesion size in order to better target the feeding vessels located in the inner and basal depth of the lesion and minimize tissue damage. The treatment outcome was evaluated by clinical photograph, videodermatoscopy, and ultrasound scanning performed before and after treatment, and at each monthly follow-up visit.

RESULTS

All treated patients showed full recovery, with negligible scarring, no residual hyperpigmentation, and complete regression of pain. Treatment discomfort was minimal and use of topical anesthetics was not needed. No recurrences were observed at 12-month follow up.

CONCLUSIONS

Long-pulse Nd:YAG laser delivered using a tilted angle is a fast, easy, effective, comfortable, and safe treatment option available to promptly shrink bulky, painful, or bleeding nodules with minimal discomfort and gives excellent functional and cosmetic results. Lasers Surg. Med. © 2020 Wiley Periodicals, Inc.

Zebras in Foreskin Dermatopathology: A Review

OBJECTIVES

The aim of the study was to review uncommon foreskin dermatopathology conditions clinically and pathologically.

METHODS

A database search of PubMed and Google Scholar were extracted between March 1, 2009, and March 1, 2019, using the search terms "foreskin," "prepuce," "penis," "pathology," "dermatology," and "rare." The search was limited to "humans" and "dermatopathology." Full article texts were reviewed. Reference lists were screened for additional articles. Patient details (diagnosis, dermatopathology, treatment, and follow-up if available) were extracted. We excluded articles written in the non-English language, unusual variants of common conditions, and cases of common dermatologic conditions.

RESULTS

A list of 369 articles was identified and another screening identified 30 articles for rare foreskin pathologies. Those are divided into categories based on the following etiologies: (a) benign, including congenital (e.g., aposthia), infectious (graft versus host disease and histoplasma), autoimmune (Crohn's disease and pyoderma gangrenosum), and benign neoplasms (neurofibroma, apocrine hidrocystoma, verruciform xanthoma, porokeratosis, penile cutaneous horn, localized amyloidosis) and (b) malignancies, including primary (myeloid sarcoma, basal cell carcinoma, Kaposi's sarcoma, mucosal-associated lymphoid tissue lymphoma), and metastasis.

CONCLUSIONS

We reviewed and discussed unusual benign and malignant dermatopathology conditions that can affect the foreskin.

A case of mistaken identity: classic Kaposi sarcoma misdiagnosed as a diabetic foot ulcer in an atypical patient

Background

The presentation of Kaposi sarcoma is divided into four known clinical subtypes. In this case report we describe classic Kaposi sarcoma in an African-American heterosexual, diabetic, seronegative human immunodeficiency virus male. Classic Kaposi sarcoma is rare in this patient demographic and can be easily misdiagnosed.

Case presentation

The patient presented with a lesion between the fourth and fifth digits of his right foot which was initially diagnosed as a diabetic foot ulcer. Despite local wound care, the lesion did not resolve. A shave biopsy was performed and histopathology findings were consistent with classic Kaposi sarcoma.

Conclusions

The patient tolerated local radiotherapy well and had complete resolution of his pedal lesion. There have been emerging associations between diabetes and Kaposi sarcoma. As such, clinicians should have a low threshold when considering the biopsy of suspicious pedal lesions in patients with diabetes. The utilization of appropriate biopsy technique may lead to the diagnosis of classic KS tumors in populations outside of the current four widely accepted clinical subtypes.

Kaposi Sarcoma in HIV-positive Solid-Organ Transplant Recipients: A French Multicentric National Study and Literature Review

BACKGROUND

Kaposi sarcoma is a vascular tumor related to herpesvirus-8 and is promoted by immunosuppression. For the last 15 years, human immunodeficiency virus (HIV) patients have had access to organ transplantation. The dual immunosuppression of HIV and immunosuppressive treatments might increase the risk and severity of Kaposi sarcoma.

METHODS

We conducted a multicentric retrospective study by collecting cases from French databases and society members of transplanted patients, among which 7 HIV-infected patients who subsequently developed Kaposi sarcoma were included.

RESULTS

In the CRISTAL database (114 511 patients) and the DIVAT (Données Informatisées et VAlidées en Transplantation) database (19 077 patients), the prevalence of Kaposi sarcoma was 0.18% and 0.46%, respectively, in transplanted patients; these values compare with 0.66% and 0.50%, respectively, in transplanted patients with HIV. The median time from HIV infection to Kaposi sarcoma was 20 years. Kaposi sarcoma occurred during the first year after transplantation in most cases, whereas HIV viral load was undetectable. Only 2 patients had visceral involvement. Five patients were treated with conversion of calcineurin inhibitor to mammalian target of rapamycin inhibitor, and 5 patients were managed by decreasing immunosuppressive therapies. At 1 year, 4 patients had a complete response, and 3 had a partial response.

CONCLUSIONS

In our study, Kaposi sarcoma in transplanted patients with HIV did not show any aggressive features and was treated with the usual posttransplant Kaposi sarcoma management protocol.

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.

Therapeutic Outcomes in AIDS-Associated Kaposi's Sarcoma Patients on Antiretroviral Therapy Treated with Chemotherapy at Two Tertiary Hospitals in Lusaka, Zambia

The incidence of HIV-associated Kaposi's sarcoma (KS) remains high in Zambia in the antiretroviral therapy era. The most efficacious treatment regimen for KS has yet to be established. In both developed and developing countries, treatment regimens have had limited efficacy. Late presentation in Africa affects therapeutic outcomes.

OBJECTIVE

The aim of this study was to determine therapeutic outcomes of epidemic KS patients on combination antiretroviral therapy (cART) after completion of six cycles of Adriamycin, Bleomycin, and Vincristine (ABV) chemotherapy.

METHODS

This was a descriptive cross-sectional study. Study participants were drawn from a study database of confirmed incident KS patients seen at the Skin Clinic of the University Teaching Hospitals (UTH) during the period between August, 2015 and September, 2016.

RESULTS

Of the 38 successfully recruited study participants, a complete response was documented in 18 (47%) after 6 cycles of ABV whereas 20 (53%) experienced a partial response. KS recurrence was observed in 8 (44%) of the individuals that experienced an initial complete response. At the time of the study, clinical assessment revealed that KS lesions had completely regressed in 21 (55%) of all the patients.

CONCLUSION

ABV chemotherapy appears ineffective in long-term resolution of epidemic KS patients on ART. Recurrence rates are high after chemotherapy in patients that experience initially favorable responses to treatment. There is a need to diagnose KS earlier, and to develop more efficacious treatment options in order to reduce recurrence rates for epidemic KS.

Role of iron in cancer development by viruses

Increased levels of iron in body are attributed to higher cancer risk. Given the fact that 16% of all human cancers are caused by viral infections, iron is suggested to play an important role in carcinogenesis particularly those induced by viral infections. The present study provides an updated summary of the literature and the plausible mechanisms of iron involvement in cancer development by viruses. Our understanding about the interplay between viral infections and iron in different settings particularly cancer development is yet to be improved as it may shed a new light in development of new therapeutic strategies.

Classical form of Kaposi sarcoma localized in penis

We present you a case of 43 year old man with classical form of Kaposi sarcoma (KS) localized to the Penis who was HIV negative. Detailed pathological and immunohistochemistry characteristic of the tumor was done. Pathology reported it as KS with nodular and polypoid form. Classical form of KS with localization in male genitalia is rare identity and serves as a diagnostic challenge.

Angiosarcoma complicating lower leg elephantiasis in a male patient: An unusual clinical complication, case report and literature review

Chronic lymphedema is rarely complicated by an angiosarcoma. Angiosarcoma superimposed on chronic lymphedema (Stewart-Treves syndrome) is usually seen post breast cancer surgery accompanied by lymph node resection of the axilla. This is a case report of a 59-year-old male patient with elephantiasis that developed an angiosarcoma of the lower leg. He died a month after the diagnostic biopsy was obtained. This is a rare multifocal tumor in a male with an unusual lower leg location. We reviewed the literature and the need to differentiate this often deadly lesion from a Kaposi's sarcoma.

HIV-related Malignancies and Mimics: Imaging Findings and Management

The risk of developing malignancy is higher in patients with human immunodeficiency virus (HIV) infection than in non-HIV-infected patients. Several factors including immunosuppression, viral coinfection, and high-risk lifestyle choices lead to higher rates of cancer in the HIV-infected population. A subset of HIV-related malignancies are considered to be acquired immunodeficiency syndrome (AIDS)-defining malignancies, as their presence confirms the diagnosis of AIDS in an HIV-infected patient. The introduction of highly active antiretroviral therapy (HAART) has led to a significant drop in the rate of AIDS-defining malignancies, including Kaposi sarcoma, non-Hodgkin lymphoma, and invasive cervical carcinoma. However, non-AIDS-defining malignancies (eg, Hodgkin lymphoma, lung cancer, hepatocellular carcinoma, and head and neck cancers) now account for an increasing number of cancer cases diagnosed in HIV-infected patients. Although the number has decreased, AIDS-defining malignancies account for 15%-19% of all deaths in HIV-infected patients in the post-HAART era. Most HIV-related malignancies in HIV-infected patients manifest at an earlier age with a more aggressive course than that of non-HIV-related malignancies. Understanding common HIV-related malignancies and their specific imaging features is crucial for making an accurate and early diagnosis, which impacts management. Owing to the weakened immune system of HIV-infected patients, other entities such as various infections, particularly opportunistic infections, are prevalent in these patients. These processes can have confounding clinical and imaging manifestations that mimic malignancy. This article reviews the most common AIDS-defining and non-AIDS-defining malignancies, the role of imaging in their diagnosis, and the imaging mimics of malignancies in HIV-infected patients. ^©RSNA, 2018.

Ultrasonographic intraoperative monitoring and follow-up of Kaposi's sarcoma nodules under treatment with intralesional vincristine

BACKGROUND

Intralesional vincristine is an effective treatment for Kaposi's sarcoma (KS) nodules on the skin, but there is little evidence of its action through imaging techniques. Ultrasonography can be an adjunctive tool in the diagnosis and management of KS skin lesions, but data in the literature are few.

MATERIALS AND METHODS

Five patients with classic KS nodules were treated with intralesional vincristine. Ultrasonographic and color Doppler assessment were performed during vincristine injection and monitoring was repeated 1 and 3 months after the procedure. Partial response was defined as a reduction of more than 50% lesion volume and reduction of the vascular signal; complete response as a resolution of lesion associated with the absence of vascular signal.

RESULTS

Six KS nodules were included in the study. On ultrasonography examination, KS nodules appeared as oval or round, hypoechoic, homogeneous structures, with intralesional vascularization, more prominent in the deepest pole of the nodule. At month 1, 4 nodules achieved a complete response, while two nodules showed a partial response and were retreated with intralesional vincristine. At month 3, all lesions achieved a complete response.

CONCLUSION

Ultrasonography may be a valuable tool in assessing clinical response to intralesional vincristine therapy of cutaneous KS nodules.

Evolution of Kaposi sarcoma in the past 30 years in a tertiary hospital of the European Mediterranean basin

BACKGROUND

The incidence of Kaposi sarcoma (KS) has reduced as a result of the introduction of antiretroviral therapy. It is currently considered a rare disease in developed countries, and there has been a paucity of clinical papers on the subject in recent years in Europe.

AIM

To analyse the clinical features and evolution of the different clinical forms of KS in the past 30 years.

METHODS

Patients with cutaneous lesions of KS diagnosed during the period 1987-2016 at Bellvitge Hospital (an 800-bed university referral centre in Barcelona, Spain) were enrolled. Data recorded included age, sex, ethnicity, involved site, number of lesions, extracutaneous involvement, leg oedema, treatment, blood haemoglobin level, and blood cell (leucocyte, lymphocyte and CD4) counts.

RESULTS

Cutaneous lesions of KS were diagnosed in 191 patients (167 men, 24 women, mean ± SD age 51.95 ± 20.16 years). Clinical forms identified were classic KS (n = 53), acquired immunodeficiency syndrome (AIDS)-associated KS (n = 118), immunosuppression-associated KS (n = 18), and African endemic KS (n = 2). The number of patients diagnosed annually reached a maximum in the 1990s because of the AIDS epidemic, and has decreased since 2000. However, both classic KS and immunosuppression-associated KS doubled from the first to the second half of the analysed period. Cutaneous lesions involved the legs in 137 cases, and extracutaneous lesions were detected in 32 patients. In 46 of 118 patients with AIDS, the diagnosis of KS was simultaneous to the detection of human immunodeficiency virus infection.

CONCLUSION

After a decrease in incidence since the middle of the 1990s, AIDS-associated KS continues to occur in Europe, and the number of annual cases of classic KS and immunosuppression-associated KS is increasing.

Kaposi Sarcoma in the Era of Rapamycin Remains a Therapeutic Challenge in Organ Transplant Recipients

Solid-organ transplant recipients are at higher risk of developing Kaposi sarcoma, which is a multicentric vascular neoplasm of lymphatic endothelium-derived cells. Reducing doses of immunosuppressive drugs and switching from calcineurin inhibitors to the mammalian target of rapamycin inhibitor rapamycin have been suggested as an effective first-line treatment modality in most patients. Herein, we report a 64-year-old renal transplant recipient who developed multiple cutaneous and visceral Kaposi sarcoma lesions 2 months after transplant. The patient showed no improvement, with progression of the disease until month 15 of the suggested therapy of rapamycin.

Scrotal Kaposi's Sarcoma in HIV-negative patient: A case report and review of the literature

Kaposi's Sarcoma (KS) is a malignancy that generally effects the skin, and can be systemic with internal organ involvement. It originates from the vascular endothelium. KS's relationship with human immunodeficiency virus (HIV) infection is well known. Isolated scrotal KS in the urogenital system is quite rare and scrotal KS in an HIV-negative patient is limited to a few cases. In this case report, the biopsy result from the violescent nodular lesions on the scrotum of the HIV-negative 81-year-old patient was found compatible with KS and a pathology was not detected in the systemic screening. With a diagnosis of isolated scrotal KS, the patient underwent surgical excision aimed at the lesions on the scrotum. KS is rare in HIV-negative patients and it is associated with human herpes virus-8 infection.

High Prevalence of Distinct Human Herpesvirus 8 Contributes to the High Incidence of Non-acquired Immune Deficiency Syndrome-Associated Kaposi's Sarcoma in Isolated Japanese Islands

Background

Non-acquired immune deficiency syndrome (AIDS) Kaposi's sarcoma (KS) is extremely rare in Japan but highly endemic in Okinawa, especially in Miyako Islands. We aimed to elucidate the exact incidence and cause of this high prevalence.

Methods

Non-AIDS KS cases in Okinawa Prefecture over the past 31 years were reviewed, and human herpesvirus 8 (HHV8) seroprevalence in Miyako Islands was determined. We examined whole-genome sequences of 3 HHV8 strains and performed whole-exome sequencing of 4 male patients from Miyako Islands.

Results

Approximately half of the non-AIDS KS cases in Okinawa Prefecture were from Miyako Islands. The age-adjusted incidence rate was 0.87/105 per year for Miyako Islands and 0.056/105 per year for the rest of Okinawa. Human herpesvirus 8 seroprevalence was 15.4% in Miyako Islands. The 3 HHV8 genomes isolated from Miyako islanders formed a phylogenetically branch distinct from those of previously sequenced HHV8 strains and shared specific mutations in 9 proteins. These mutations were verified in Okinawan patients other than those from Miyako Islands. Whole-exome sequencing of the 4 male Miyako Islanders did not reveal shared pathogenic mutations.

Conclusions

Miyako Islands are an endemic area of non-AIDS KS. The high rate of a distinct HHV8 may contribute to the high incidence of KS in the region.

Prevalence of Kaposi's sarcoma-associated herpesvirus among intravenous drug users: a systematic review and meta-analysis

Intravenous drug users (IDUs) have been demonstrated to be highly vulnerable to HIV/AIDS. Nevertheless, the prevalence of Kaposi's sarcoma associated herpesvirus (KSHV), an important co-infected agent with HIV, among this population remained obscure. We conducted a systematic review on the epidemiological features of KSHV among IDUs worldwide. Eligible studies were retrieved from 6 electronic databases (PubMed, EMBASE, Web of Science, CBM, CNKI and Wanfang). We calculated the pooled prevalence and 95% confidence interval (CI) overall and among subgroups using either random-effects model or fixed-effects model depending on between-study heterogeneity. The potential publication bias was assessed by the Egger's test. A meta-regression analysis was performed to explore the sources of heterogeneity. Finally, twenty-two studies with a total sample of 7881 IDUs were included in the analysis. The pooled prevalence of KSHV was 14.71% (95% CI 11.12%-19.46%) among IDUs. Specifically, KSHV prevalence was 10.86% (95% CI 6.95%-16.96%) in HIV-negative IDUs, and 13.56% (95% CI 10.57%-17.38%) in HIV-positive IDUs. Moreover, prevalence among IDUs from the three continents involved in the current study was similar: 16.10% (95%CI 7.73%-33.54%) in Asia; 14.22% (95%CI 8.96%-22.57%) in Europe and 14.06% (95%CI 11.38%-17.37%) in America. Globally, IDUs are at higher risk of the KSHV infection when compared with the general population, regardless of geographical region or HIV-infection status.

Malignant skin tumors: Kids are not just little people

Skin tumors are a clinically heterogeneous group of dermatologic conditions that affect both children and adults. Although similar types of skin tumors can affect both children and adults, the epidemiology, pathogenesis, and treatment of these skin neoplasms can vary drastically in children compared with adults. Despite the clear need for literature elucidating the differences of skin tumors in children compared with adults, there is a serious dearth of scientific contributions addressing this area. This contribution highlights the types of differences that can occur between adults and children with skin neoplasms, as well as the special considerations that need to be recognized when managing skin tumors in children by providing a comparative analysis of basal cell carcinoma, squamous cell carcinoma, and Kaposi sarcoma occurring in adults with these same tumors occurring in children. Specifically, we examine the aforementioned tumors with a focus on (1) epidemiology, (2) etiology, (3) clinical presentation, (4) workup, and (5) treatment.

Effect of electrochemotherapy on human herpesvirus 8 kinetics in classic Kaposi sarcoma

BACKGROUND

Electrochemotherapy (ECT) has shown to be an effective treatment for cutaneous and subcutaneous Kaposi sarcoma (KS) lesions. However, no study has investigated the impact of ECT treatment on the kinetics of human herpesvirus type 8 (HHV8), which is considered the necessary causal agent of KS. We aimed to evaluate HHV8 viral load and expression levels in patients affected by classic KS who received one or more ECT treatments and have been followed semi annually for up to four years.

METHODS

A total of 27 classic KS patients were enrolled in this study. Tumour biopsies and blood samples were obtained before ECT treatment. Additional blood samples were collected at six month intervals for 12-48 months. HHV8 viral load and expression profiles of latent (ORF72 and ORF73) and lytic (K2, K8, K8.1, K10/K10.1, K10.5/K10.6 and ORF16) genes were assessed in all samples by real-time PCR. HHV8 ORF26 and K1 regions were amplified and subjected to direct nucleotide sequencing followed by phylogenetic analysis for variant identification.

RESULTS

All KS biopsies and 46.4% of peripheral blood mononuclear cells (PBMCs) collected before ECT treatment were positive for HHV8 DNA. Viral load ranged from 0.02 to 2.3 copies per cell in KS lesions and 3.0 × 10^-7 to 6.9 × 10^-4 copies per cell in PBMCs. Overall, latent ORF72 and ORF73 as well as lytic K2, K8 and K10/K10.1 were expressed in all KS biopsies. ORF16 mRNA was detected in 71.4% and both K8.1 and K10.5/K10.6 mRNAs in 57.1% of KS samples. The ORF72, ORF73 and K2 transcripts were amplified in 37.5%, 25% and 25% of PBMCs collected before ECT, respectively. After the first ECT session, complete response was achieved in 20 out of 27 (74.1%) patients and HHV8 DNA was detected in four out of 27 (14.8%) PBMC samples at six month follow up. Phylogenetic analysis of ORF26 amplimers showed that most viral variants belonged to A/C (82.3%), and few to C2 (5.9%) or C3 (11.8%) subtype. The K1/VR1 variants fell into A (33.3%) and C (66.7%) HHV8 clade. No correlation was found between HHV8 subtypes and ECT complete response.

CONCLUSIONS

ECT therapy has a significant effect on HHV8 kinetics in patients with classic KS. The complete remission of patients was accompanied by clearance of circulating virus.

Iatrogenic Kaposi's Sarcoma: a Retrospective Cohort Study in an Italian Tertiary Care Centre

AIMS

Kaposi's sarcoma (KS) is a lymphoangioproliferative multicentric disorder. Among its four distinct clinical variants, iatrogenic KS (iKS) typically affects patients who have received immunosuppressant regimens for organ transplants, proliferative disorders, or immune-mediated diseases. The aim of the current study was to examine the characteristics of a cohort of patients with iKS, evaluating the differences in terms of epidemiological and clinical features, management and outcomes between organ transplant recipients (OTR) and patients immunosuppressed for other medical conditions.

MATERIALS AND METHODS

This retrospective study included, out of 1389 KS patients, 143 patients suffering from iKS being followed in an Italian tertiary care centre from November 1995 to December 2016. Demographic data, clinical features, previous immunosuppressive therapies, management, and outcomes were recorded for each patient.

RESULTS

We detected iKS in 10.3% of the analysed KS population. The mean age was 71.9 years in non-OTR versus 51.4 years in OTR (P = 0.04). Staging at diagnosis showed a more severe disease in non-OTR than in OTR, with stage IA observed in 33.3% of OTR versus 11.8% of non-OTR (P < 0.001) and stage IVB in 29.1% of non-OTR versus 12.1% of OTR (P = 0.001). Corticosteroids represented the most frequent immunosuppressive drugs at diagnosis in both groups, in conjunction with cyclosporine A in OTR. Immunosuppressant reduction or withdrawal was carried out in 93.9% of OTR versus 63.6% of non-OTR (P < 0.001).

CONCLUSIONS

As corticosteroids and cyclosporine A are the most common iKS-inducing drugs, their reduction or withdrawal, wherever possible, is needed. Differences in disease severity at presentation between OTR and non-OTR may interfere with the choice of management strategy and the consequent outcome.