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Aversa SM, Cattelan AM, Salvagno L, Meneghetti F, Francavilla E, Sattin L, Sasset L, Cadrobbi P. Chemo-Immunotherapy of Advanced Aids-Related Kaposi'S Sarcoma. TUMORI JOURNAL 2018; 85:54-9. [PMID: 10228499 DOI: 10.1177/030089169908500112] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Aims and background Kaposi's sarcoma (KS) is the most common neoplastic complication of HIV infection and AIDS. Multiple cytotoxic chemotherapy regimens have been used with various response rates. We have evaluated the efficacy and toxicity of low-dose chemotherapy in patients with poor-prognosis AIDS-related KS and the role of interferon alpha (IFN-α) in complete responders. Methods Twenty-five previously untreated patients with advanced KS received bleomycin (BL) 10 mg/m2 and vinblastine (VB) 6 mg/m2 on days 1 and 15 every two weeks. After six cycles, patients in complete remission received IFN-alpha (3 million U s.c. 3 times/week) combined with antiretroviral therapy. All patients were evaluated for toxicity using the World Health Organization (WHO) toxicity schedule. Both Eastern Cooperative Oncology Group (ECOG) and AIDS Clinical Trials Group (ACTG) response criteria were used to evaluate response and survival. Results The overall response rate was 84% (95% confidence interval, 51–117%) with six complete remissions (24%) and 15 partial remissions (60%) by ECOG criteria, and 92% (95% confidence interval: 58–128%) with 17 partial remissions (68%) by ACTG criteria. The median duration of response on IFN-alpha treatment was 4.5 months (range, 2–10). The overall median survival duration for all 25 patients was 9 months (range, 2–39). Grade 3–4 anemia was observed in five patients and grade 3–4 neutropenia in two patients. No other clinically significant (> grade 3) toxicities were observed. Conclusions Combination of BL and VB is effective and well tolerated, even if new therapeutic options are developing. This disease remains a challenging problem, so larger studies using the combination of chemotherapy and/or IFN-alpha with antiretroviral treatment are warranted.
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Affiliation(s)
- S M Aversa
- Division of Medical Oncology, Padua General Hospital, Italy
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Kang H, Song J, Choi K, Kim H, Choi M, Lee SY, Kim C, Lee SJ, Song MJ, Kang H, Back SH, Han SB, Cho S. Efficient lytic induction of Kaposi's sarcoma-associated herpesvirus (KSHV) by the anthracyclines. Oncotarget 2015; 5:8515-27. [PMID: 25237786 PMCID: PMC4226701 DOI: 10.18632/oncotarget.2335] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Lytic induction of latent Kaposi's sarcoma-associated herpesvirus (KSHV) has been considered as a therapeutic option for efficient treatment of several KSHV-associated malignancies. Here, we developed a robust high-throughput screening system that allows an easy and quantitative measurement of lytic induction of latent KSHV and discovered three anthracyclines as potent inducers from screen of FDA-approved drugs. Lytic induction of latent KSHV by three compounds was verified by the significant induction of lytic genes and subsequent production of infectious KSHV. Importantly, lytic induction by three compounds was much more efficient than that by sodium butyrate, a well-characterized inducer of KSHV lytic cycle. Mechanistically, the anthracyclines caused lytic induction of KSHV through apoptosis induced by their DNA intercalation rather than topoisomerase II inhibition. Consequently, our results clearly demonstrated a role of anthracyclines as effective lytic inducers of KSHV and also provided a molecular basis of their use for efficient treatment of diseases associated with KSHV infection.
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Affiliation(s)
- Hyunju Kang
- Targeted Medicine Research Center, Korea Research Institute of Bioscience and Biotechnology, Cheongwon, Chungbuk, Republic of Korea. College of Pharmacy, Chungbuk National University, Cheongju, Chungbuk, Republic of Korea
| | - Jaehyung Song
- College of Pharmacy, Kangwon National University, Chuncheon, Republic of Korea
| | - Kwangman Choi
- Targeted Medicine Research Center, Korea Research Institute of Bioscience and Biotechnology, Cheongwon, Chungbuk, Republic of Korea. Department of Medical Biotechnology, Soonchunhyang University, Asan, Republic of Korea
| | - Hyeongki Kim
- Targeted Medicine Research Center, Korea Research Institute of Bioscience and Biotechnology, Cheongwon, Chungbuk, Republic of Korea. Department of Biomolecular Science, University of Science and Technology, Daejeon, Republic of Korea
| | - Miri Choi
- Targeted Medicine Research Center, Korea Research Institute of Bioscience and Biotechnology, Cheongwon, Chungbuk, Republic of Korea
| | - So-Young Lee
- International Cooperation Office, Ministry of Food and Drug Safety, Cheongwon, Chungbuk, Republic of Korea
| | - Chonsaeng Kim
- Virus Research and Testing Group, Korea Research Institute of Chemical Technology, Daejeon, Republic of Korea
| | - Sang Jun Lee
- Infection and Immunity Research Center, Korea Research Institute of Bioscience and Biotechnology, Daejeon, Korea
| | - Moon Jung Song
- Division of Biotechnology, College of Life Sciences and Biotechnology, Korea University, Seoul, Republic of Korea
| | - Hyojeung Kang
- College of Pharmacy, Research Institute of Pharmaceutical Sciences, and Institute for Microorganisms, Kyungpook National University, Daegu, Republic of Korea
| | - Sung Hoon Back
- School of Biological Sciences, University of Ulsan, Ulsan, Republic of Korea
| | - Sang-Bae Han
- College of Pharmacy, Chungbuk National University, Cheongju, Chungbuk, Republic of Korea
| | - Sungchan Cho
- Targeted Medicine Research Center, Korea Research Institute of Bioscience and Biotechnology, Cheongwon, Chungbuk, Republic of Korea. Department of Biomolecular Science, University of Science and Technology, Daejeon, Republic of Korea
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Affiliation(s)
- Yuanzeng Min
- Laboratory of Nano- and Translational Medicine, Carolina Institute of Nanomedicine, Department of Radiation Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina-Chapel Hill , Chapel Hill, North Carolina 27599, United States
| | - Joseph M Caster
- Laboratory of Nano- and Translational Medicine, Carolina Institute of Nanomedicine, Department of Radiation Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina-Chapel Hill , Chapel Hill, North Carolina 27599, United States
| | - Michael J Eblan
- Laboratory of Nano- and Translational Medicine, Carolina Institute of Nanomedicine, Department of Radiation Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina-Chapel Hill , Chapel Hill, North Carolina 27599, United States
| | - Andrew Z Wang
- Laboratory of Nano- and Translational Medicine, Carolina Institute of Nanomedicine, Department of Radiation Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina-Chapel Hill , Chapel Hill, North Carolina 27599, United States
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Immune reconstitution inflammatory syndrome associated with Kaposi sarcoma: higher incidence and mortality in Africa than in the UK. AIDS 2013; 27:1603-13. [PMID: 23462220 DOI: 10.1097/qad.0b013e328360a5a1] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To assess the incidence, predictors, and outcomes of Kaposi sarcoma-associated paradoxical immune reconstitution inflammatory syndrome (KS-IRIS) in antiretroviral therapy (ART)-naive HIV-infected patients with Kaposi sarcoma initiating ART in both well resourced and limited-resourced settings. DESIGN Pooled analysis of three prospective cohorts of ART-naive HIV-infected patients with Kaposi sarcoma from sub-Saharan Africa (SSA) and one from the UK. METHODS KS-IRIS case definition was standardized across sites. Cox regression and Kaplan-Meier survival analysis were used to identify the incidence and predictors of KS-IRIS and Kaposi sarcoma-associated mortality. RESULTS Fifty-eight of 417 (13.9%) eligible individuals experienced KS-IRIS with an incidence 2.5 times higher in the African vs. European cohorts (P=0.001). ART alone as initial Kaposi sarcoma treatment (hazard ratio 2.97, 95% confidence interval (CI) 1.02-8.69); T1 Kaposi sarcoma stage (hazard ratio 2.96, 95% CI 1.26-6.94); and plasma HIV-1 RNA more than 5 log₁₀ copies/ml (hazard ratio 2.14, 95% CI 1.25-3.67) independently predicted KS-IRIS at baseline. Detectable plasma Kaposi sarcoma-associated herpes virus (KSHV) DNA additionally predicted KS-IRIS among the 259 patients with KSHV DNA assessed (hazard ratio 2.98, 95% CI 1.23-7.19). Nineteen KS-IRIS patients died, all in SSA. Kaposi sarcoma mortality was 3.3-fold higher in Africa, and was predicted by KS-IRIS (hazard ratio 19.24, CI 7.62-48.58), lack of chemotherapy (hazard ratio 2.35, 95% CI 1.09-5.05), pre-ART CD4 cell count less than 200 cells/μl (hazard ratio 2.04, 95% CI 0.99-4.2), and detectable baseline KSHV DNA (hazard ratio 2.12, 95% CI 0.94-4.77). CONCLUSION KS-IRIS incidence and mortality are higher in SSA than in the UK. This is largely explained by the more advanced Kaposi sarcoma disease and lower chemotherapy availability. KS-IRIS is a major contributor to Kaposi sarcoma-associated mortality in Africa. Our results support the need to increase awareness on KS-IRIS, encourage earlier presentation, referral and diagnosis of Kaposi sarcoma, and advocate on access to systemic chemotherapy in Africa.
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Kaposi sarcoma: review and medical management update. Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 113:2-16. [DOI: 10.1016/j.tripleo.2011.05.011] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Revised: 05/11/2011] [Accepted: 05/15/2011] [Indexed: 12/21/2022]
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Zhong DT, Shi CM, Chen Q, Huang JZ, Liang JG, Lin D. Etoposide, vincristine, doxorubicin and dexamethasone (EVAD) combination chemotherapy as second-line treatment for advanced AIDS-related Kaposi's sarcoma. J Cancer Res Clin Oncol 2011; 138:425-30. [PMID: 22160130 DOI: 10.1007/s00432-011-1109-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Accepted: 11/24/2011] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To evaluate through retrospective analysis the efficacy and toxicity of combination chemotherapy with etoposide, vincristine, doxorubin and dexamethasone (EVAD) as second-line therapy in patients with advanced AIDS-related Kaposi's sarcoma (AIDS-KS) after failure of first-line chemotherapy. METHODS Eighty-eight patients with poor-risk AIDS-KS were treated intravenously with combination chemotherapy with EVAD; etoposide at a dose of 100 mg/m(2) on three consecutive days, vincristine 1.4 mg/m(2) with a maximum single dosage of 2.0 mg on day one, doxorubicin 30 mg/m(2) on day one and dexamethasone 40 mg on three consecutive days, with a three week cycle. All eligible patients had relapsed or progressed after prior two to six cycles of combination chemotherapy with doxorubicin, bleomycin and vincristine (ABV) or bleomycin and vincristine (BV). RESULTS Assessment of the response of all the patients was made. The overall objective response rate was 59.1% (95% CI 48.83-69.37%), with five complete responses and 47 partial responses. Twenty-six cases of stable disease and 10 of progressive disease were observed in the remaining patients. The median follow-up period was 27 months (range 8-52 months). The median time to progression was 6.80 months (95% CI 2.04-11.56 months), and the median overall survival was 14.24 months (95% CI 10.26-18.22 months). Leucopenia was seen in 92.0% of patients, of which 20 patients had grade 3 and 12 had grade 4. Conclusions Combination chemotherapy with EVAD offers a new, active and safe therapeutic approach for the treatment of advanced AIDS-related KS.
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Affiliation(s)
- Dong Ta Zhong
- Department of Medical Oncology, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou 350001, Fujian, People's Republic of China
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Potent antiviral activity of topoisomerase I and II inhibitors against Kaposi's sarcoma-associated herpesvirus. Antimicrob Agents Chemother 2011; 56:893-902. [PMID: 22106228 DOI: 10.1128/aac.05274-11] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The lytic DNA replication of Kaposi's sarcoma-associated herpesvirus (KSHV) initiates at an origin (ori-Lyt) and requires trans-acting elements, both viral and cellular. We recently demonstrated that several host cellular proteins, including topoisomerases I and II (Topo I and II), are involved in KSHV lytic DNA replication (Y. Wang, H. Li, Q. Tang, G. G. Maul, and Y. Yuan. J. Virol. 82: 2867-2882, 2008). To assess the importance of these topoisomerases in viral lytic replication, shRNA-mediated gene silencing was used. Depletion of Topo I and II severely inhibited viral lytic DNA replication as well as virion production, suggesting essential roles of these cellular proteins in viral DNA replication. The discovery of Topo I and II as enzymes indispensable for KSHV DNA replication raises a possibility that these cellular proteins could be new targets of therapeutic approaches to halt KSHV replication and treat KSHV-associated diseases. In this report, we examined one Topo I inhibitor and several Topo II inhibitors (inclusive of Topo II poison and catalytic inhibitors) as potential therapeutic agents for blocking KSHV replication. The Topo II catalytic inhibitors in general exhibited marked inhibition on KSHV replication and minimal cytotoxicity. In particular, novobiocin, with the best selectivity index (SI = 31.62) among the inhibitors tested in this study, is effective in inhibiting KSHV DNA replication and virion production but shows little adverse effect on cell proliferation and cycle progression in its therapeutic concentration, suggesting its potential to become an effective and safe drug for the treatment of human diseases associated with KSHV infection.
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Malfitano A, Barbaro G, Barbarini G. Ongoing change in the treatment of HIV-associated malignancies in the HAART era. Expert Rev Clin Pharmacol 2009; 2:283-93. [PMID: 24410706 DOI: 10.1586/ecp.09.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Implementation of highly active antiretroviral therapy (HAART) has changed the epidemiology, clinical outcome and therapeutic approach of HIV-associated malignancies. Whereas Kaposi sarcoma and primary CNS non-Hodgkin lymphoma have decreased dramatically, systemic non-Hodgkin lymphoma incidence seems unchanged, perhaps increasing as with other tumor incidence. Owing to HAART-induced immune function preservation, response rates to chemotherapy and survival times in patients with HIV-associated malignancies have neared those observed in their HIV-negative counterparts. Hence, intensive regimens have been more and more extensively used with promising results. This may also apply to other therapeutic options, such as biotherapy, and procedures, such as stem cell rescue following high-dose chemotherapy or heterologous stem cell transplant, which have so far been precluded to HIV-infected subjects as a matter of fact. A trend toward a full assimilation of HIV-infected people with cancer and the general population with the same pathology is ongoing.
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Affiliation(s)
- Antonello Malfitano
- Department of Infectious and Tropical Diseases Foundation IRCCS San Matteo, University of Pavia, Pizzale Golgi 2, 27100 Pavia, Italy.
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Persistent Kaposi sarcoma in the era of highly active antiretroviral therapy: characterizing the predictors of clinical response. AIDS 2008; 22:937-45. [PMID: 18453853 DOI: 10.1097/qad.0b013e3282ff6275] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To evaluate the role of highly active antiretroviral therapy and chemotherapy on tumor response among persons with AIDS-related Kaposi sarcoma and identify factors associated with response in a clinic setting. DESIGN Retrospective cohort. METHODS One hundred and fourteen patients from two HIV clinics with a diagnosis of Kaposi sarcoma were identified via a clinical database. Records were reviewed to confirm Kaposi sarcoma diagnosis and abstract clinical and chemotherapy information. Demographics, laboratory values, and highly active antiretroviral therapy use were abstracted electronically. Cox's proportional hazards models identified predictors of Kaposi sarcoma improvement and resolution. RESULTS Thirty-six months following Kaposi sarcoma diagnosis, the rate of improvement among 64 patients with confirmed Kaposi sarcoma was 77% and that of complete resolution was 51%. In univariate analyses, recent chemotherapy was associated with Kaposi sarcoma improvement, and recent HIV viral load and highly active antiretroviral therapy were associated with both improvement and resolution. No measured baseline characteristics (tumor stage, diagnosis year, CD4 T-cell count, HIV viral load, or prior highly active antiretroviral therapy history) or recent CD4 T-cell counts predicted improvement or resolution. In multivariate analyses, recent chemotherapy (hazard ratio 5.5, 95% confidence interval: 2.7-11.2, P < 0.001) and highly active antiretroviral therapy (hazard ratio 4.1, 95% confidence interval: 1.4-12.6, P = 0.01) were predictors of improvement; only recent highly active antiretroviral therapy was associated with resolution (hazard ratio 6.2, 95% confidence interval: 1.5-26.4, P = 0.01). Response was not associated with type of highly active antiretroviral therapy regimen (non nucleoside reverse transcriptase inhibitor based, protease inhibitor based, or ritonavir-boosted protease inhibitor based). CONCLUSION Highly active antiretroviral therapy and chemotherapy are important in clinical Kaposi sarcoma response. Despite widespread availability of these therapies, Kaposi sarcoma continues to be a clinical problem; only half the patients achieved complete resolution of disease. New therapeutic approaches are needed.
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Bihl F, Mosam A, Henry LN, Chisholm JV, Dollard S, Gumbi P, Cassol E, Page T, Mueller N, Kiepiela P, Martin JN, Coovadia HM, Scadden DT, Brander C. Kaposi's sarcoma-associated herpesvirus-specific immune reconstitution and antiviral effect of combined HAART/chemotherapy in HIV clade C-infected individuals with Kaposi's sarcoma. AIDS 2007; 21:1245-52. [PMID: 17545700 DOI: 10.1097/qad.0b013e328182df03] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Kaposi's sarcoma-associated herpesvirus (KSHV) is endemic in South Africa and the clinical manifestation of AIDS-associated Kaposi's sarcoma (KS) represents a significant clinical problem. Whereas the positive effects of HAART on the regression of KS have been well established, less is known about the role of herpesvirus-specific cellular immunity in disease improvement. DESIGN Thirty-three treatment-naive HIV clade C-infected individuals with KS were randomly assigned into two treatment arms (HAART plus systemic chemotherapy versus HAART alone). KSHV-specific cellular immune responses, viral loads and clinical outcome were evaluated. METHODS KSHV, Epstein-Barr virus and HIV-specific cellular immunity was measured using an IFN-gamma enzyme-linked immunospot assay in samples obtained at baseline and up to 11 months after treatment initiation. Cell-associated KSHV viremia was determined by real-time polymerase chain reaction. RESULTS Robust increases in CD4 cell counts and suppressed HIV viral loads were seen in parallel with significant increases in the KSHV-specific cellular immune responses over time. Although slowly increasing after 5 months, KSHV-specific T-cell responses were significantly elevated only after 11 months, with both lytic and latent antigens being more frequently targeted. A trend towards better clinical outcome with HAART plus chemotherapy treatment was observed compared with HAART alone, and was accompanied by a significant reduction in cellular KSHV viral load in the HAART plus chemotherapy-treated subjects but not those treated with HAART alone after 11 months of treatment. CONCLUSION The data show a temporal association between the clinical improvement of KS and the re-appearance of KSHV-specific cellular immunity, and demonstrate an effective suppression of KSHV viral replication using combination therapy.
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Affiliation(s)
- Florian Bihl
- Partners AIDS Research Center, Massachusetts General Hospital and Harvard Medical School, 13th Street, Charlestown, MA 02129, USA
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Vanni T, Sprinz E, Machado MW, Santana RDC, Fonseca BAL, Schwartsmann G. Systemic treatment of AIDS-related Kaposi sarcoma: current status and perspectives. Cancer Treat Rev 2006; 32:445-55. [PMID: 16860939 DOI: 10.1016/j.ctrv.2006.06.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2006] [Revised: 06/01/2006] [Accepted: 06/07/2006] [Indexed: 12/16/2022]
Abstract
Kaposi's sarcoma (KS) is the most frequent type of cancer in patients with Acquired Immune Deficiency Syndrome (AIDS). In the western world, its incidence decreased dramatically in the era of highly active anti-retroviral therapy (HAART). In contrast, the incidence of KS has been steadily climbing in parallel with the AIDS epidemic in Africa over the past 10-15 years, being the most common cancer in adult men in countries like Uganda and Zimbabwe. AIDS-KS can be diagnosed at any stage of HIV infection, although it more commonly occurs in the setting of severe immune suppression, especially with an elevated viral load. Up to now, AIDS-KS is still an incurable disease. Its clinical course is variable, ranging from very indolent cases, requiring no or minimal therapy, to a rapidly progressive disease. Various local therapies are available to control small and asymptomatic lesions, while cytotoxic, immunological and biological therapies can be considered for more aggressive disease. The primary goal of therapy in most of the cases is to provide safe and effective palliation, in order to quality of life. Optimal anti-retroviral therapy is a key component of AIDS-KS management. There are still many questions to be answered in the management of patients with AIDS-KS, such as (1) What are the therapeutic agents that should be used in this disease, and in which sequence? and (2) What are the benefits and risks expected with each treatment option? The aim of this review is to discuss the systemic management of AIDS-KS, with special focus on the above mentioned questions.
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Affiliation(s)
- Tazio Vanni
- Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
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Sissolak G, Mayaud P. AIDS-related Kaposi's sarcoma: epidemiological, diagnostic, treatment and control aspects in sub-Saharan Africa. Trop Med Int Health 2005; 10:981-92. [PMID: 16185232 DOI: 10.1111/j.1365-3156.2005.01491.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Until the 1980s, little attention had been accorded to endemic Kaposi's sarcoma (KS), a neoplasm noted in several parts of Southern Europe and the African continent but with relatively slow progression, except in children and young adults. Furthermore, therapeutic approaches based on surgery, radiation and topical treatment were of limited efficacy, mostly used to overcome the disabling and stigmatizing effects of the disease. With the emergence of the HIV/AIDS epidemic, and the profound impact of KS on AIDS-related mortality, the pathogenesis of KS has been better studied, and the realisation that a virus (KS-associated Herpesvirus or Human Herpesvirus 8, or KSHV/HHV-8), combined with immunosuppression and cytokine-induced growth, was responsible for the development of this disease has led to novel therapeutic approaches. These are unfortunately still highly toxic, require careful monitoring, and are expensive, thus limiting their use in most parts of Africa. However, the use of highly active antiretroviral therapy (HAART), which has led to a considerable decline in KS incidence in populations of industrialized countries, constitutes the best hope for the control of this stigmatizing and lethal disease in Africa. Trials comparing different regimens of antiretroviral drugs in combination with systemic chemotherapeutic agents are urgently needed.
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Affiliation(s)
- Gerhard Sissolak
- Department of Internal Medicine, Tygerberg Academic Hospital, Tygerberg, South Africa.
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Cattelan AM, Trevenzoli M, Aversa SML. Novel pharmacological therapies for the treatment of AIDS-related Kaposi’s sarcoma. Expert Opin Investig Drugs 2005; 13:501-13. [PMID: 15155125 DOI: 10.1517/13543784.13.5.501] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Kaposi's sarcoma (KS) is the most common cancer associated with AIDS. KS aetiology and pathogenesis are still poorly defined and no definitive treatment has yet been identified. However, the introduction in 1996 of highly active antiretroviral therapy as a standard of care for those infected with HIV-1 determined a strong protection against the development of opportunistic infections, as well as a remission of pre-existing complications, including KS. Under highly active antiretroviral therapy, KS in particular has shown the highest clinical response rate reported to date among AIDS patients. Furthermore, recent insights into the pathogenetic mechanisms involved in KS development have provided new hope for a response and improved survival in patients with AIDS-related KS. This paper presents an overview of the current knowledge concerning pharmacological approaches to treating this disease. Newer treatments such as PEGylated liposomal anthracyclin, paclitaxel and pathogenesis-based strategies are also discussed.
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Affiliation(s)
- Anna Maria Cattelan
- Department of Infectious Diseases, University of Padua, Via Giustiniani 2, 35128 Padua, Italy.
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Aversa SML, Cattelan AM, Salvagno L, Crivellari G, Banna G, Trevenzoli M, Chiarion-Sileni V, Monfardini S. Treatments of AIDS-related Kaposi's sarcoma. Crit Rev Oncol Hematol 2005; 53:253-65. [PMID: 15718150 DOI: 10.1016/j.critrevonc.2004.10.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2004] [Indexed: 11/19/2022] Open
Abstract
Although Kaposi's sarcoma (KS) has decreased in countries where the highly active antiretroviral therapy (HAART) regimen is available, however it remains, after non-Hodgkin's lymphomas, the most common malignancy in HIV+ patients. Advances in the treatment of AIDS-KS have been achieved, even though a gold standard therapy has not been yet defined. With the availability of HAART, a dramatic KS clinical response has been documented, making HAART essential in all patients. In case of aggressive and/or life threatening KS, more complex therapeutic schedules have to be taken into account, including chemotherapy and/or immunotherapy. Liposomal anthracyclines and paclitaxel have been approved by FDA as first line and second line mono-therapy, respectively. Interferon-alpha (INF-alpha) is the only immunomodulant agent to have shown a therapeutic effect. Among the new drugs, many antiangiogenetic agents have produced encouraging responses. Finally, the identification of the HHV-8 as a causative agent and new metalloproteinase inhibitors may offer promising targets for the KS treatment.
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Cheung TW. AIDS-related cancer in the era of highly active antiretroviral therapy (HAART): a model of the interplay of the immune system, virus, and cancer. "On the offensive--the Trojan Horse is being destroyed"--Part A: Kaposi's sarcoma. Cancer Invest 2004; 22:774-86. [PMID: 15581058 DOI: 10.1081/cnv-200032788] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The introduction of highly active antiretroviral therapy (HAART), aimed at controlling human immunodeficiency virus (HIV), has been associated with a dramatic decrease in the incidence of acquired immunodeficiency syndrome-Kaposi's sarcoma (AIDS-KS) and the clinical manifestations of KS appear to be less aggressive. The pathogenesis of AIDS-related KS is related to a system of cytokines (e.g., interleukin-6) driven by autocrine and paracrine loops. More recently, human herpesvirus 8 (HHV-8), was discovered to be the putative etiological agent of this disease. This virus encodes several unique open reading frames that are homologs of human cellular proteins involved in cellular regulations, cell proliferation, apoptosis, and immune regulation. The treatment of this disease depends on whether it is "limited" disease or "extensive" disease. For "limited" disease, local therapy or non-bone marrow suppressive agents should be used. For "extensive" disease, new chemotherapeutic agents, such as liposomal anthracycline, which are active and have little adverse reactions, are indicated. The control of HIV infection continues to be essential. Knowledge of the pathogenesis of the disease has led to the development of novel treatment strategies, aimed at the inflammatory or angiogenesis cytokines necessary for growth or at HHV-8 as the target of therapy.
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Affiliation(s)
- Tony W Cheung
- University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA
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Abstract
Conventional chemotherapy regimens for the treatment of advanced Kaposi's sarcoma (KS) show limited efficacy and considerable toxicity. Liposomal anthracyclines with potential utility in KS include pegylated liposomal doxorubicin (Doxil/Caelyx [PLD]), daunorubicin citrate liposome (DaunoXome [DNX]), and nonpegylated liposomal doxorubicin (Myocet [NPLD]). Preclinical data showed that pegylated liposomes accumulate preferentially in highly vascularized KS lesions. In randomized clinical trials, PLD induced higher response rates than did the conventional combination chemotherapy regimens, bleomycin + vincristine (BV) and BV + conventional doxorubicin (ABV); DNX produced a response rate comparable to that of ABV. NPLD has not been compared with conventional chemotherapy for KS. PLD and DNX were associated with less toxicity compared with BV or ABV, including less alopecia and fewer gastrointestinal and neurologic side effects. Grade 3/4 myelosuppression was common with both PLD and DNX; stomatitis and infusion reactions occurred with PLD treatment, but hand-foot syndrome was relatively infrequent in the dose schedules used for KS. Health-related quality of life was improved in several domains in patients treated with PLD or DNX compared with ABV.
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Affiliation(s)
- Susan E Krown
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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Stebbing J, Wildfire A, Portsmouth S, Powles T, Thirlwell C, Hewitt P, Nelson M, Patterson S, Mandalia S, Gotch F, Gazzard BG, Bower M. Paclitaxel for anthracycline-resistant AIDS-related Kaposi's sarcoma: clinical and angiogenic correlations. Ann Oncol 2004; 14:1660-6. [PMID: 14581275 DOI: 10.1093/annonc/mdg461] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Murine data indicate that angiogenesis is central to the aetiopathogenesis of Kaposi's sarcoma (KS). Therefore, we measured angiogenic cytokines and growth factors in patients with AIDS-related KS during treatment with both antiretrovirals and second-line paclitaxel chemotherapy. Cytokines measured included tumour necrosis factor-alpha (TNF-alpha), basic fibroblast growth factor (bFGF), vascular endothelial growth factor (VEGF) and the interleukins IL-2, -6 and -12. PATIENTS AND METHODS Enzyme-linked immunosorbent assays (ELISAs) were carried out to measure plasma cytokine levels in 17 patients with AIDS-related KS who had progressed within 6 months of receiving liposomal anthracyclines and were treated with paclitaxel 100 mg/m(2) every 2 weeks. Measurements were carried out before progression, at commencement and at the completion of paclitaxel. RESULTS The objective response rate to paclitaxel was 71% (95% confidence interval 60% to 81%). In 17 patients with AIDS-related KS, we observed eight partial responses and four complete responses. Patients with AIDS Clinical Trial Group stage T1 disease had higher plasma VEGF (P = 0.05) and lower plasma TNF-alpha levels (P = 0.05) than patients with earlier stage T0 KS. There were no correlations between plasma cytokines (bFGF, VEGF, TNF-alpha, and IL-2,-6 and -12) and the CD4 and CD8 cell counts or HIV-1 RNA viral load. Response to paclitaxel was associated with a fall in plasma IL-6 levels (P = 0.04) but no change in other cytokines. There were no significant changes in CD4, CD8, CD16/56, CD19 cell counts and HIV-1 viral loads during chemotherapy. CONCLUSIONS Angiogenic cytokines may correlate with KS disease extent but not with cellular immune function or HIV viraemia. Response to paclitaxel therapy correlates with a fall in plasma IL-6 levels and recent data indicate this may be a surrogate marker of KS-associated herpesvirus viral load. Overall, clinical response in KS correlates poorly with known angiogenic cytokines.
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Affiliation(s)
- J Stebbing
- Departments of Oncology and HIV Medicine, Chelsea and Westminster Hospital, London, UK
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18
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Abstract
BACKGROUND Most patients infected with human immunodeficiency virus (HIV) experience skin disease at some stage of their illness, either as a presenting feature or as a later manifestation. Different dermatoses may coexist during the course of the infection, and the unusual nature of the skin lesions can make an accurate diagnosis difficult. Kaposi's sarcoma is one of the acquired immunodeficiency syndrome (AIDS)-defining skin diseases and may coexist with other lesions in AIDS patients. Kaposi's sarcoma is caused by human herpesvirus 8 (HHV8), which is mainly transmitted through male homosexual behavior, and is less common in women than in men. METHODS The clinical, histopathologic, and therapeutic aspects of AIDS-related Kaposi's sarcoma in three women (age, 18-34 years) who presented to the dermatology clinic of the University of Nigeria Teaching Hospital, Enugu, Nigeria, were studied over 18 months, beginning in August and September 1998. RESULTS At presentation, the condition of the three patients was generally poor, with severe anemia and extensive dark-brown papules, plaques, and nodules. Mucosal involvement was extensive. Generalized lymphadenopathy was found in two patients, one of whom had extensive coexisting dermatophytosis. All three women were in stage III/IV of the disease at the time of initial presentation. Death occurred within days in one and within 7-8 months in two. CONCLUSIONS Because these female patients with epidemic Kaposi's sarcoma lived in an almost entirely heterosexual population, the mode of contamination with HHV8 was obscure. The course of the disease was pervasive, aggressive, and devastating.
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Affiliation(s)
- Edith N Nnoruka
- Sub-Department of Dermatology, Department of Medicine, College of Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria.
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19
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20
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Von Roenn JH. Clinical presentations and standard therapy of AIDS-associated Kaposi's sarcoma. Hematol Oncol Clin North Am 2003; 17:747-62. [PMID: 12852654 DOI: 10.1016/s0889-8588(03)00043-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The treatment plan for a patient with AIDS-related KS should be based on tumor characteristics, control of HIV infection, comorbidities, and patient treatment goals (see Table 1). Institution of optimal antiretroviral therapy is an essential component of KS therapy. When available, enrollment in a clinical trial should be considered, except for patients who are naive to chemotherapy with symptomatic or life-threatening KS. For a patient with minimal, indolent cutaneous disease, after optimal control of HIV replication, local treatment, investigational treatment, or interferon are reasonable considerations. For the patient with rapidly progressive, cutaneous disease, tumor-related symptoms, or visceral disease, cytotoxic chemotherapy in combination with antiretroviral therapy is the first consideration. Future advances undoubtedly will include pathogenesis-based agents, either alone or in combination with currently available cytotoxic therapy.
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Affiliation(s)
- Jamie H Von Roenn
- Department of Medicine, Division of Hematology/Oncology, The Feinberg School of Medicine, The Robert H. Lurie Comprehensive Cancer Center, Northwestern University, 676 North St. Clair Street, Suite 850, Chicago, IL 60611, USA.
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21
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Cattelan AM, Trevenzoli M, Aversa SML. Recent advances in the treatment of AIDS-related Kaposi's sarcoma. Am J Clin Dermatol 2002; 3:451-62. [PMID: 12180893 DOI: 10.2165/00128071-200203070-00002] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Kaposi's sarcoma (KS) is the most common malignancy associated with HIV infection and is considered an AIDS defining condition by the US Centers of Disease Control Guidelines. Several advances in the treatment of AIDS-related KS have been achieved over the past few years, even though a gold standard therapy for KS has not yet been defined and treatment must be tailored to individual needs. Since the availability of highly active antiretroviral therapy (HAART), a dramatic clinical response has been documented in patients with KS, making HAART an essential approach in the management of KS in most, if not all, patients with AIDS-related KS. However, in case of aggressive, visceral, and/or life-threatening KS, more complex therapeutic schedules have to be taken into account, including chemotherapy, radiotherapy, and/or immunotherapy. In general, systemic treatment for KS is limited to widespread, symptomatic disease, whereas local interventions are indicated for minimal, cosmetically troublesome lesions. Among new cytotoxic agents, liposomal anthracyclines and paclitaxel are highly effective molecules for KS and have been approved by the US Food and Drug Administration (FDA) as first-line and second-line monotherapy, respectively, for advanced KS. Furthermore, a greater understanding of the pathogenesis of KS has lead to the development of an array of new experimental agents. Many antiangiogenic agents such as AGM 1470 (TNP 470), thalidomide, and glufanide disodium (IM 862) have produced encouraging responses in patients with KS and large clinical trials are in progress. Retinoic acids may also block neoangiogenesis as well as proliferation of KS cells in vitro, and they have been used either systemically or topically with a high response rate. Thus, a topical compound 0.1% alitretinoin gel was approved in 1999 by the FDA for the treatment of skin lesions associated with KS. Human chorionic gonadotropin, a hormonal agent, has shown a strong inhibitory activity in KS cells, but its role in the regression of KS lesions is not clear. Finally, the identification of a novel gamma-herpesvirus, human herpesvirus-8, as a causative agent for KS, together with novel antiangiogenic compounds, such as metalloproteinase inhibitors, may offer promising targets for the therapy of KS.
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Affiliation(s)
- Anna M Cattelan
- Infectious Diseases Division, General Hospital, University of Padua, Padua, Italy.
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22
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Evans SR, Krown SE, Testa MA, Cooley TP, Von Roenn JH. Phase II evaluation of low-dose oral etoposide for the treatment of relapsed or progressive AIDS-related Kaposi's sarcoma: an AIDS Clinical Trials Group clinical study. J Clin Oncol 2002; 20:3236-41. [PMID: 12149296 DOI: 10.1200/jco.2002.12.038] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Liposomal anthracyclines and paclitaxel are considered the best available cytotoxic therapies for Kaposi's sarcoma (KS), but relapse is common. To identify new interventions for relapsed or progressive KS, a phase II study of low-dose etoposide to assess its toxicity and efficacy was conducted. PATIENTS AND METHODS Thirty-six patients with high-risk KS were treated with oral etoposide 50 mg/d for 7 consecutive days of every 2-week cycle. All patients' disease had relapsed or progressed after prior combination chemotherapy or anthracycline therapy. For patients without a complete or partial response after two cycles of therapy and no toxicity greater than grade 2, the dose of etoposide was escalated to 100 mg/d orally on days 1 to 7 of each 14-day cycle. Treatment-related and disease-specific quality of life was evaluated using patient reports on the General Health Self-Assessment Form and a KS-specific measure. RESULTS One patient achieved a complete response, 12 patients had a partial response (overall response rate, 36.1%), and stable disease was observed in 12 patients (33.3%). Tumor responses were seen in all disease sites. Fourteen patients had their dose escalated, of whom five responded. The median time to response was 17.7 weeks; the median duration of response was 25 weeks. The most frequent hematologic abnormality was neutropenia, which was grade 4 in seven patients and grade 3 in six. Opportunistic infections occurred in eight patients during the treatment period. Both response to treatment and toxicity influenced patient-reported quality of life. CONCLUSION We conclude that low-dose oral etoposide at a dose of 50 mg/d is safe and effective for the treatment of refractory or progressed AIDS-related KS and has an overall positive effect on the quality of life of responding patients.
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Affiliation(s)
- Scott R Evans
- Center for Biostatistics in AIDS Research, Department of Biostatistics, Harvard School of Public Health, Boston, MA, USA
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23
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Affiliation(s)
- D M Aboulafia
- Division of Hematology/Oncology, Virginia Mason Clinic, Seattle, Washington 98111, USA.
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24
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Abstract
Kaposi's sarcoma, non-Hodgkin's lymphoma, Hodgkin's disease, and squamous cell carcinoma are among the malignancies seen with increased frequency in patients infected with HIV. The outlook for patients with these malignancies has improved significantly with the utilization of highly active antiretroviral therapy (HAART) and more aggressive cytotoxic therapies. Novel biologic therapies with lesser side effects are currently being evaluated. This article reviews the current knowledge about HIV malignancies, their epidemiology, pathogenesis, clinical manifestations, and treatment.
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Affiliation(s)
- P G O'Connor
- AIDS Research Center and MGH Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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25
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Ozer H, Armitage JO, Bennett CL, Crawford J, Demetri GD, Pizzo PA, Schiffer CA, Smith TJ, Somlo G, Wade JC, Wade JL, Winn RJ, Wozniak AJ, Somerfield MR. 2000 update of recommendations for the use of hematopoietic colony-stimulating factors: evidence-based, clinical practice guidelines. American Society of Clinical Oncology Growth Factors Expert Panel. J Clin Oncol 2000; 18:3558-85. [PMID: 11032599 DOI: 10.1200/jco.2000.18.20.3558] [Citation(s) in RCA: 568] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- H Ozer
- American Society of Clinical Oncology, Alexandria, VA 22314, USA
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26
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Arican A, Karakayali H, Bilgin N, Haberal M. Results of treatment in renal transplant patients with Kaposi sarcoma: one-center experience. Transplant Proc 2000; 32:626-8. [PMID: 10812144 DOI: 10.1016/s0041-1345(00)00922-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- A Arican
- Faculty of Medicine, Departments of Oncology and General Surgery, Başkent University, Ankara, Turkey.
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27
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Nasti G, Errante D, Talamini R, Rizzardini G, Fasan M, Landonio G, Zeroli C, Chichino G, Nigra E, Vaccher E, Tirelli U. Vinorelbine is an effective and safe drug for AIDS-related Kaposi's sarcoma: results of a phase II study. J Clin Oncol 2000; 18:1550-7. [PMID: 10735904 DOI: 10.1200/jco.2000.18.7.1550] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To assess the safety and efficacy of vinorelbine in patients with AIDS-related Kaposi's sarcoma (KS). PATIENTS AND METHODS From December 1994 to May 1997, within the Italian Cooperative Group on AIDS and Tumors, we enrolled 36 patients with AIDS-related KS who experienced disease progression after one or more regimens of systemic chemotherapy. Patients were treated with vinorelbine 30 mg/m(2) every 2 weeks by intravenous bolus. RESULTS Of 35 assessable patients, three (9%) had a clinical complete response and 12 (34%) had a partial remission, for an overall objective response rate of 43% (95% confidence interval, 26% to 61%). For the 15 patients with objective responses, the median duration of response from the beginning of therapy until the development of progression was 176 days, whereas the median progression-free survival and the median survival durations for 35 assessable patients were 151 days and 216 days, respectively. Vinorelbine also induced responses in patients who had become resistant to regimens that included other vinca alkaloids. Overall, vinorelbine was well tolerated. Toxicity, including neurologic toxicity, was mild and reversible. Neutropenia was the most frequent dose-limiting toxicity. CONCLUSION Vinorelbine is safe and effective in the treatment of patients with advanced KS who have been previously treated with one or more chemotherapy regimens.
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Affiliation(s)
- G Nasti
- Division of Medical Oncology A and Epidemiology Unit, Centro di Riferimento Oncologico, Aviano, Italy
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28
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Abel EA. Skin neoplasias including cutaneous lymphoma, melanoma, and others: unapproved treatments or indications. Clin Dermatol 2000; 18:201-10. [PMID: 10742630 DOI: 10.1016/s0738-081x(99)00112-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- E A Abel
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA
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29
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Tulpule A, Scadden DT, Espina BM, Cabriales S, Howard W, Shea K, Gill PS. Results of a randomized study of IM862 nasal solution in the treatment of AIDS-related Kaposi's sarcoma. J Clin Oncol 2000; 18:716-23. [PMID: 10673512 DOI: 10.1200/jco.2000.18.4.716] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Although advances have been made in the treatment of AIDS-related Kaposi's sarcoma (AIDS-KS) with systemic chemotherapy, less toxic therapies are needed. IM862 is a naturally occurring peptide with antiangiogenic properties and was thus studied in patients with AIDS-KS. PATIENTS AND METHODS IM862 was given as intranasal drops at a dose of 5 mg. Patients were randomized to two dosing schedules given in repeated cycles until disease progression or unacceptable toxicity: 5 days of therapy followed by 5 days off (n = 18) and every other day dosing (n = 26). RESULTS Forty-two male patients and two female patients with a median age of 38 years (range, 22 to 53 years) were accrued. Twenty-one patients (47%) had more than 50 mucocutaneous lesions, 14 (32%) had lymphedema, and none had visceral involvement. Thirty-three patients (75%) had received prior systemic chemotherapy. Twenty-four patients (55%) had CD4(+) lymphocyte count </= 200/mm(3). All but five patients were being treated with concurrent protease inhibitor(s), for a median of 10 months (range, 0 to 24 months). Major responses were documented in 36%, with five complete and 11 partial remissions, occurring after a median of 6 weeks (range, 3 to 26 weeks) and lasting a median of 33+ weeks (range, 12+ to 95+ weeks). Twenty-one patients had stable disease for periods of 7 to 72+ weeks. Adverse effects to IM862 were limited to mild and transient headache, fatigue, tingling, and nausea. No hematologic adverse effects attributed to treatment were reported. CONCLUSION IM862 given as intranasal drops is well tolerated and has antitumor activity in patients with AIDS-KS. A randomized double-blinded study to define the activity of IM862 in patients with AIDS-KS is in progress.
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Affiliation(s)
- A Tulpule
- Department of Medicine, Division of Hematology, Kenneth Norris Cancer Hospital and Research Institute, University of Southern California School of Medicine, Los Angeles, CA, USA
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30
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Gill PS, Tulpule A, Espina BM, Cabriales S, Bresnahan J, Ilaw M, Louie S, Gustafson NF, Brown MA, Orcutt C, Winograd B, Scadden DT. Paclitaxel is safe and effective in the treatment of advanced AIDS-related Kaposi's sarcoma. J Clin Oncol 1999; 17:1876-83. [PMID: 10561228 DOI: 10.1200/jco.1999.17.6.1876] [Citation(s) in RCA: 115] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Liposomal anthracyclines are the present standard treatment for advanced AIDS-related Kaposi's sarcoma (KS). No effective therapies have been defined for use after treatment failure of these agents. A phase II trial was thus conducted with paclitaxel in patients with advanced KS to assess safety and antitumor activity. MATERIALS AND METHODS A regimen of paclitaxel at a dose of 100 mg/m(2) was given every 2 weeks to patients with advanced AIDS-related KS. Patients were treated until complete remission, disease progression, or unacceptable toxicity occurred. RESULTS Fifty-six patients with advanced AIDS-related KS were accrued. Tumor-associated edema was present in 70% of patients and visceral involvement in 45%. Forty patients (71%) had received prior systemic therapy; 31 of these were resistant to an anthracycline. The median entry CD4(+) lymphocyte count was 20 cells/mm(3) (range, 0 to 358). A median of 10 cycles (range, 1 to 54+) of paclitaxel was administered. Fifty-nine percent of patients showed complete (n = 1) or partial response (n = 32) to paclitaxel. The median duration of response was 10.4 months (range, 2.8 to 26.7+ months) and the median survival was 15.4 months. The main side effects of therapy were grade 3 or 4 neutropenia in 61% of patients and mild-to-moderate alopecia in 87%. CONCLUSION Paclitaxel at 100 mg/m(2) given every 2 weeks is active and well tolerated in the treatment of advanced and previously treated AIDS-related KS. The median duration of response is among the longest observed for any regimen or single agent reported for AIDS-related KS. Paclitaxel at this dosage and schedule is a treatment option for patients with advanced AIDS-related KS, including those who have experienced treatment failure of prior systemic therapy.
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Affiliation(s)
- P S Gill
- Departments of Medicine and Pharmacy, University of Southern California, Kenneth Norris Cancer Hospital and Research Institute, Los Angeles, CA, USA.
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Abstract
The appearance in 1981 of a usually rare malignancy, Kaposi's sarcoma, in homosexual men [1] was one of the first harbingers of an epidemic caused by a retrovirus, human immunodeficiency virus (HIV), which causes the acquired immunodeficiency syndrome (AIDS). Lymphoid and other malignancies were also increased, most strikingly non-Hodgkin's lymphoma and primary central nervous system (CNS) lymphoma. Advances in molecular biology, immunology, virology, and anti-viral therapy have combined to create unique research opportunities. One developing theme is the role of viral co-infection and malignancy. Human herpes virus 8 (HHV8), Epstein-Barr virus (EBV) and papilloma virus each may have a causal role in the development of HIV-associated malignancy. New antiretroviral therapies are able to substantially reverse or delay the profound immunosuppression of HIV infection. The changes in the epidemiology of malignancies, and understanding the mechanism of action of these new therapeutics provide research opportunities to understand the pathogenesis of these malignancies. The opportunities to discover the consequences of T-cell based immunodeficiency and the interactions with specific viral pathogens will likely lead to progress in HIV treatment and new strategies for other malignancies.
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Affiliation(s)
- E G Feigal
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD 20892, USA.
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32
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Schwartsmann G, Stefani S, Villarroel RU. The systemic treatment of AIDS-related Kaposi's sarcoma. Cancer Treat Rev 1998; 24:415-24. [PMID: 10189408 DOI: 10.1016/s0305-7372(98)90004-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- G Schwartsmann
- South-American Office for Anticancer Drug Development (SOAD), Medical Oncology Unit, Academic Hospital (HCPA), Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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Bennett CL, Golub RM, Stinson TJ, Aboulafia DM, von Roenn J, Bogner J, Goebel FD, Stewart S. Cost-effectiveness analysis comparing liposomal anthracyclines in the treatment of AIDS-related Kaposi's sarcoma. JOURNAL OF ACQUIRED IMMUNE DEFICIENCY SYNDROMES AND HUMAN RETROVIROLOGY : OFFICIAL PUBLICATION OF THE INTERNATIONAL RETROVIROLOGY ASSOCIATION 1998; 18:460-5. [PMID: 9715842 DOI: 10.1097/00042560-199808150-00007] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Liposomal formulations have been shown to alter the efficacy and toxicity profiles of anthracylines for patients with HIV-related advanced Kaposi's sarcoma (KS). Using decision-analysis models, the costs and cost-effectiveness of the two U.S. Food and Drug Administration (FDA)-approved liposomal formulations of these agents were estimated. Estimates of costs, effectiveness, and cost-effectiveness were derived from clinical trial data of separate, randomized phase III trials of pegylated liposomal doxorubicin (20 mg/m2 every 3 weeks) and liposomal daunorubicin (40 mg/m2 every 2 weeks). Clinical response rates were 59% for pegylated liposomal doxorubicin and 25% for liposomal daunorubicin. Despite higher acquisition costs for pegylated liposomal doxorubicin, total estimated costs of treatment for KS and chemotherapy-related hematologic toxicities were similar ($7,066 U.S. compared with $6,621 U.S. for liposomal daunorubicin). Cost-effectiveness profiles, defined as average costs per responder, favored pegylated liposomal doxorubicin ($11,976 U.S./responder versus $26,483 U.S./responder for liposomal daunorubicin), reflecting the higher reported response rate in the phase III trial. Sensitivity analyses suggested that the costs and cost-effectiveness results would not differ markedly when evaluated over a range of assumptions, including response rate, neutropenia rate, and dosage variations.
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Affiliation(s)
- C L Bennett
- Division of Hematology/Oncology, Northwestern University, and VA Chicago Health Care System, Illinois, USA
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35
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Abstract
In the US over one million persons are currently infected with the HIV, over half a million have had AIDS, and over 300,000 have died from AIDS. Worldwide, it is estimated that more than 17 million people are currently infected with HIV, and over 1,200,000 cases of AIDS have been reported to the World Health Organization. By some estimates, up to 40% of patients with AIDS will ultimately develop some form of cancer. Non-Hodgkin's lymphoma, Kaposi's sarcoma and invasive cervical cancer have a higher incidence in persons with HIV infection and all three are AIDS-defining illnesses. In addition, several reports suggest that a number of other malignancies may occur at an increased incidence in persons with HIV infection, including squamous-cell carcinoma of the head, neck and anus, plasmacytoma, melanoma, small-cell lung cancer, basal-cell cancer, and germ-cell tumours. Clinicians should become familiar with HIV-related malignancies as their incidence is expected to further increase as more effective therapies for HIV and associated opportunistic infections allow patients to live longer in an advanced state of immunodeficiency. In the current article, we will review the clinical and therapeutic aspects of the most common AIDS-related malignancies including non-Hodgkin's and Hodgkin's lymphomas, Kaposi's sarcoma and anogenital epithelial neoplasias.
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Affiliation(s)
- C Smith
- Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
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36
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Abstract
Neoplasms are a common complication of HIV-infected individuals. The increased survival rates of those with HIV infection may allow the emergence of an increased number of cancers. The new therapeutic regimens may slow the rate of progression by partially restoring the integrity of the immune system.
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Affiliation(s)
- A Tulpule
- Division of Hematology, University of Southern California, Norris Cancer Hosptal, Los Angeles, California 90033-1048, USA
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37
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38
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Abstract
Moriz Kaposi was the first who, in 1872, described five patients presenting with "sarcoma idiopathicum multiple hemorrhagicum". In 1912 Sternberg termed this disease Kaposi's sarcoma. Since then various forms of this rare disease have been observed. In 1914 Hallenberg described the first cases of African or endemic Kaposi's sarcoma. In the 1960s the first reports discussing Kaposi's sarcoma following organ transplantation and immunosuppressive therapy were published. After 1981, the epidemic form associated with the acquired immunodeficiency syndrome (AIDS) was described. All these forms, their history, treatment methods and the role of radiation therapy in the management of this rare malignancy are discussed, and the literature is reviewed.
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Affiliation(s)
- Y M Kirova
- Département de cancérologie, Hôpital Henri-Mondor, Créteil, France
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39
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Kirova YM, Belembaogo E, Frikha H, Haddad E, Calitchi E, Levy E, Piedbois P, Le Bourgeois JP. Radiotherapy in the management of epidemic Kaposi's sarcoma: a retrospective study of 643 cases. Radiother Oncol 1998; 46:19-22. [PMID: 9488122 DOI: 10.1016/s0167-8140(97)00147-3] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE To report to the literature the largest published series of epidemic Kaposi's sarcoma (EKS), treated with radiation therapy, to summarize and discuss our 10 years experience in the treatment of this malignancy. METHODS AND MATERIALS From June 1986 to December 1996, 643 patients with acquired immunodeficiency syndrome (AIDS)-related epidemic Kaposi's sarcoma were treated with radiation therapy (RT) at the Cancerology Department of Henri Mondor University Hospital. The patients, 640 men and 3 women had an average age of 38.5 years (range 20-68 years). Three hundred eighty-seven patients (60.1 %) had received previous treatment for their Kaposi's sarcoma (KS). In total, 6777 fields were irradiated, as follows: face 1342 (19.8%), eyelid and conjunctiva 362 (5.3%), trunk 1903 (28.1%), upper and lower limbs 2866 (42.3%), genitals 189 (2.8%). and oral cavity 115 fields (1.7%). Radiation therapy consisted of 4 MV or 45-70 kV X-rays, depending on tumor size and location. Doses ranged from 10 to 30 Gy, according to tumor response and toxicity. RESULTS Objective response (CR and PR) was observed in 92% (5947/6464) of all cases, treated for cutaneous form of EKS. All patients with irradiated oral lesions had an objective response. The overall tolerance was acceptable for the cutaneous lesions. By contrast, in oral lesions, mucosal reactions were often observed after relatively low doses of radiotherapy. CONCLUSIONS Doses of 15 Gy for oral lesions, 20 Gy for lesions involving eyelids, conjunctiva, and genitals, have been shown to be sufficient to produce shrinkage of the tumor and good palliation of the symptoms. For the cutaneous EKS, we propose 30 Gy given in a local field, using a fractionated scheme with small size applicators. Radiotherapy has its own place in the management of EKS, as an efficient treatment.
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MESH Headings
- Acquired Immunodeficiency Syndrome/complications
- Adult
- Aged
- Conjunctival Neoplasms/epidemiology
- Conjunctival Neoplasms/etiology
- Conjunctival Neoplasms/radiotherapy
- Dose-Response Relationship, Radiation
- Eyelid Neoplasms/epidemiology
- Eyelid Neoplasms/etiology
- Eyelid Neoplasms/radiotherapy
- Female
- Follow-Up Studies
- Genital Neoplasms, Female/epidemiology
- Genital Neoplasms, Female/etiology
- Genital Neoplasms, Female/radiotherapy
- Genital Neoplasms, Male/epidemiology
- Genital Neoplasms, Male/etiology
- Genital Neoplasms, Male/radiotherapy
- Humans
- Male
- Middle Aged
- Mouth Neoplasms/epidemiology
- Mouth Neoplasms/etiology
- Mouth Neoplasms/radiotherapy
- Recurrence
- Retrospective Studies
- Sarcoma, Kaposi/epidemiology
- Sarcoma, Kaposi/etiology
- Sarcoma, Kaposi/radiotherapy
- Skin Neoplasms/epidemiology
- Skin Neoplasms/etiology
- Skin Neoplasms/radiotherapy
- Treatment Outcome
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Affiliation(s)
- Y M Kirova
- University Hospital Henri Mondor, Department of Cancerology, Creteil, France
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40
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Haller JO. AIDS-RELATED MALIGNANCIES IN PEDIATRICS. Radiol Clin North Am 1997. [DOI: 10.1016/s0033-8389(22)00737-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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41
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Krown SE. Acquired immunodeficiency syndrome-associated Kaposi's sarcoma. Biology and management. Med Clin North Am 1997; 81:471-94. [PMID: 9093238 DOI: 10.1016/s0025-7125(05)70527-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Kaposi's Sarcoma (KS), the most common AIDS-associated malignancy, occurs with increased frequency in all HIV transmission groups, but at a particularly high rate in homosexual men. Recent studies suggest that KS pathogenesis involves exposure to an infectious agent, altered expression and response to cytokines, and modulation of growth by HIV gene products. KS varies in its clinical presentation from a relatively indolent process to a widely disseminated, aggressive disease. A variety of local and systemic treatments provide effective, but usually temporary, disease palliation. Insights into KS pathogenesis suggest a number of targeted therapeutic approaches that may eventually lead to improved disease management and disease cure.
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Affiliation(s)
- S E Krown
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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42
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Abstract
The AIDS epidemic has led to the emergence of several disease entities which in the pre-AIDS era were rare or seemingly innocuous. Experience of treating these diseases varies. In some instances, such as Pneumocystis carinii pneumonia, there is an abundance of published literature to direct our course of action. However, for many of these newly recognised diseases our treatment experience is limited. Furthermore, in many instances, well controlled trials evaluating treatment modalities in the AIDS population are lacking. We have identified 13 disease entities (P. carinii pneumonia, toxoplasmosis, cryptococcosis, histoplasmosis, Mycobacterium tuberculosis, Mycobacterium avium complex, cytomegalovirus, coccidioidomycosis, isosporiasis, candidosis, Kaposi's sarcoma, herpes simplex virus, and varicella zoster virus) and have reviewed the current literature with regard to their treatment.
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Affiliation(s)
- M E Klepser
- Division of Clinical and Administrative Pharmacy, College of Pharmacy, University of Iowa, Iowa City 52242-1112, USA.
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43
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Tulpule A, Joshi B, DeGuzman N, Espina BM, Mocharnuk R, Prakash O, Templeton D, Levine AM, Gill PS. Interleukin-4 in the treatment of AIDS-related Kaposi's sarcoma. Ann Oncol 1997; 8:79-83. [PMID: 9093711 DOI: 10.1023/a:1008205424763] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To define the safety and toxicity of interleukin-4 (IL-4) when administered subcutaneously in patients with AIDS-related Kaposi's sarcoma (AIDS-KS); to evaluate the effect of IL-4 on immunologic and virologic parameters; and to preliminarily assess the response rate of IL-4 in AIDS-KS. PATIENTS AND METHODS Eighteen patients with mucocutaneous, non-visceral AIDS-KS were treated with IL-4 at a dose of 1 mcg/kg subcutaneously, daily until unacceptable toxicity or for a maximum period of six months. Twelve (66%) patients had extensive mucocutaneous disease with over 25 lesions. Ten patients had received prior systemic chemotherapy. Seventeen had CD4+ lymphocyte counts less than 200/mm3. RESULTS The most common adverse effects included headache in 78%, fever in 56%, chills in 44%, and edema in 44%. Hematologic toxicities consisted of grade 4 neutropenia (less than 500/mm3) in 33%, mild anemia in 22%. Transient elevation of liver enzymes was noted in 17%. A transient elevation in CD4+ lymphocyte counts occurred during the first two weeks of therapy. Four of eleven patients tested showed marked decline in plasma HIV RNA after four weeks. Partial remission was observed in one patient, lasting six months. Three other patients (17%) had stable disease: 7 weeks in one patient, and 10 weeks in each of the two other patients. CONCLUSION Grade 4 neutropenia (absolute neutrophil count < 500/mm3) was the most common hematologic adverse effect with IL-4 in patients with AIDS-KS. In contrast to in vitro findings, there was a decrease in plasma HIV RNA after four weeks of IL-4 therapy in the majority of patients tested. IL-4 produced minimal anti-tumor effects in AIDS-KS with one partial remission in a patient with CD4 lymphocyte counts over 200/mm3. Further studies of IL-4 in AIDS-KS may be considered in patients with better immune status.
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Affiliation(s)
- A Tulpule
- Department of Internal Medicine, University of Southern California School of Medicine, Los Angeles, USA
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44
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Kaposi's sarcoma and its management in AIDS patients. Recommendations from a Scandinavian Study Group. SCANDINAVIAN JOURNAL OF INFECTIOUS DISEASES 1997; 29:3-12. [PMID: 9112290 DOI: 10.3109/00365549709008656] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
KS is the most frequent malignancy in homo/bisexual male AIDS patients, affecting more than 30% of these patients. KS may present itself as a few innocent cutaneous lesions or may show progression resulting in severe morbidity and mortality. Approximately half of the patients may develop severe progressive disease. The prognosis of patients with progressive disease is poor, with a median survival of less than 6 months. There is no cure for AIDS-related KS, but several therapies are available for palliation. The treatment options may be applied locally or systemically. Radiotherapy is efficacious and safe, but only a few lesions may be treated at one time. For severe progressive KS, systemic therapy with various forms of chemotherapy is used. Three regimes in particular have been focused on, namely bleomycin/vincristine (BV), doxorubicin + BV (DBV), or liposomal daunorubicin (LD) administered every 2 weeks. The agents result in a clinically relevant response (in 50-80% of patients) 2-4 weeks after initiation, but few patients have complete remission of the KS (< 10%), and the tumour may relapse after 4-6 months despite continued therapy. BV is less effective but also less toxic compared with the other regimens. Time to response for DBV may be slightly better than for LD, but the overall efficacy of these 2 regimes is similar. LD treatment is associated with significantly fewer episodes of peripheral neuropathy and alopecia than treatment with DBV. Thus, the recommended order of use of chemotherapeutic agents is BV, LD and DBV. Alpha-interferon may have a role in the small percentage of patients with CD4 cell count > 200 mill/L. In conclusion, several therapeutic options are available for palliation of KS. All systemically applied therapies are associated with severe side-effects and the optimal choice of treatment is a careful balance between response and toxicity. The recent discovery of human herpes virus 8 as a putative causative agent for KS and new potent groups of anti-retroviral agents, may lead to the development of more effective treatments of KS.
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45
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Saran FH, Adamietz IA, Thilmann C, Mose S, Böttcher HD. HIV-associated cutaneous Kaposi's sarcoma--palliative local treatment by radiotherapy. Acta Oncol 1997; 36:55-8. [PMID: 9090967 DOI: 10.3109/02841869709100733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The increasing number of HIV-infected patients makes palliative treatment of HIV-associated Kaposi's sarcoma more common. We retrospectively evaluated a reduced fractionated radiotherapy with 20 Gy in respect to response rates and acute side-effects. From January 1992 to January 1995, 52 patients with HIV-associated Kaposi's sarcoma were treated with 133 single portals. Six weeks after the end of radiotherapy 42 patients with 124 portals were evaluable with respect to response rates and side-effects. Of the treated portals 32% were judged as complete responses (CR), 55% as partial responses (PR) and 12% as no change (NC). Skin reactions RTOG, grade 1 were seen in 74% of the patients. Compared with literature data the reduced overall dose of 20 Gy in 10 fractions led to a reduction of CRs by approximately 50% while the overall response rate remained equal. The success of radiotherapy for the nodular component of Kaposi's sarcoma can be improved, if a dose exceeding 20 Gy in 10 fractions is applied but at the cost of increasing side-effects in case that non-conventional fractionation schemes are used.
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Affiliation(s)
- F H Saran
- Department of Radiotherapy and Oncology, Johann Wolfgang Goethe-University Frankfurt, Germany
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46
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Tirelli U, Errante D, Carbone A, Gloghini A, Vaccher E. Malignant tumors in patients with HIV infection. Crit Rev Oncol Hematol 1996; 24:165-84. [PMID: 8894402 DOI: 10.1016/1040-8428(96)00214-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Affiliation(s)
- U Tirelli
- Division of Medical Oncology and AIDS, Centro di Riferimento, Aviano (PN), Italy
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47
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Abstract
Kaposi's sarcoma (KS) is the most common tumor associated with AIDS. A growing number of patients with this tumor are presenting at later stages of HIV with more rapidly progressive, extensive, or symptomatic KS or with tumors involving visceral organs. Chemotherapy treatment is effective in inducing tumor regression, reducing edema, and ameliorating symptoms caused by these tumors. Side effects and toxicities from these agents, however, can be quite pronounced, especially in patients with advanced AIDS Antiretroviral therapy, prophylaxis for opportunistic infections, and the use of hematopoietic growth factors should be routinely included in the management of these patients. Newer chemotherapeutic agents and combination regimens may be more effective or less toxic than previously evaluated regimens.
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Affiliation(s)
- F C Lee
- Division of Hematology-Oncology, University of California, Los Angeles, USA
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48
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Abstract
OBJECTIVE To review the epidemiology, pathogenesis, clinical presentation, diagnosis, and staging of Kaposi's sarcoma (KS), as well as the current role of local and systemic therapies in the management of AIDS-related KS (AIDS-KS). DATA SOURCES AND STUDY SELECTION MEDLINE and CANCERLIT searches of the English-language medical literature were conducted. Emphasis was placed on studies published since the onset of the AIDS epidemic in the early 1980s. A manual review of selected bibliographies was also completed. DATA SYNTHESIS AIDS-KS is a disease with a heterogeneous presentation that affects approximately 20% of patients with AIDS. Although the proportion of AIDS patients developing this disease during the course of their illness is declining, the actual number of AIDS-KS cases is increasing. The etiology of AIDS-KS is not clear, but a sexually transmitted cofactor has been implicated. Recent reports demonstrate that a herpes-like virus may be responsible for the development of KS in patients with and without AIDS. Furthermore, the cellular origin of KS has not been identified and questions remain about whether KS represents a true malignancy. The system used in staging patients with AIDS-KS has changed dramatically since initial therapeutic trials were conducted; this may account for observed differences in outcome among trials. The immunologic status of patients is now included as part of the staging system, since it has prognostic significance. Since specific therapy for AIDS-KS is not curative and does not prolong survival, it should be directed at improving patient cosmesis and palliation of disease-related symptoms. Local therapy, such as radiation, cryotherapy, and intralesional chemotherapy, is recommended for the management of limited disease. Systemic interferon alfa or chemotherapy is indicated for disseminated disease. Interferon alfa is useful in patients with predominantly mucocutaneous disease and is most effective in patients with good prognostic factors, such as absence of B symptoms, no history of opportunistic infections, and a CD4 count of more than 200 cells/mm3. Interferon alfa alone or in combination with zidovudine produces responses in approximately 30% of AIDS-KS patients with good prognostic factors. Single-agent or combination chemotherapy is indicated for rapidly progressive or advanced AIDS-KS. Commonly used agents include doxorubicin, daunorubicin, bleomycin, vincristine, and vinblastine. Responses can be expected in at least 50% of patients treated with single-agent or combination chemotherapy. However, many patients are unable to tolerate the toxicity associated with systemic AIDS-KS therapy. Future research will focus on therapies that target the underlying pathogenesis of this disease. CONCLUSIONS The optimal therapy for patients with AIDS-KS has not been determined. Treatment is appropriately directed at palliation of disease-related symptoms as no therapy has been unequivocally proven to impact survival. Local therapies should be used in the management of localized disease, while systemic therapy is appropriate for disseminated disease. Interferon alfa is useful in patients with primarily mucocutaneous disease or asymptomatic visceral involvement. Chemotherapy is indicated in patients who have rapidly progressive or advanced disease. Therapy must be individualized according to the patient's disease course and other patient-specific factors.
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Affiliation(s)
- A K Morris
- Audie L Murphy Memorial Veterans Affairs Hospital, San Antonio, TX 78284, USA
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49
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Affiliation(s)
- M Ranson
- CRC Department of Medical Oncology, Christie Hospital NHS Trust, Manchester, U.K
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50
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Tavio M, Vaccher E, Antinori A, Ammassari A, Cusini M, Fasan M, Accurso V, Garavelli LP, Repetto L, Tirelli U. Combination chemotherapy with doxorubicin, bleomycin, and vindesine for AIDS-related Kaposi's sarcoma. Cancer 1996; 77:2117-22. [PMID: 8640679 DOI: 10.1002/(sici)1097-0142(19960515)77:10<2117::aid-cncr23>3.0.co;2-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Kaposi's sarcoma is the most common neoplasm in patients with human immunodeficiency virus (HIV) infection. Although the best therapeutic approach is still unclear, patients with advanced KS are usually treated with systemic chemotherapy. METHODS A prospective multiinstitutional Italian study evaluated the efficacy and toxicity of combination chemotherapy with doxorubicin, bleomycin, and vindesine (ABVi) in patients with progressive and extensive HIV-related KS. Patients were given doxorubicin, 20 mg/m2 on Day 1; bleomycin, 15 mg on Day 1, and vindesine, 4 mg on Day 1 biweekly +/- granulocyte-colony stimulating factor. RESULTS Overall, 21 of 38 evaluable patients (55%) achieved an objective response (OR): there was 1 complete response and 20 partial responses. The most important bone marrow toxicity was granulocytopenia in 61% of the evaluable patients; 34% had Grades 3-4 toxicity, according to the World Health Organization Classification. The majority of patients (64%) developed some type of opportunistic infection (OI) during chemotherapy or the follow-up, with cytomegalovirus infection being the most frequent OI observed. The median duration of survival from KS diagnosis and from the start of ABVi therapy was 19 months (range, 3.4-88.5 months) and 9.9 months (range, 0.1-42.4 months), respectively. CONCLUSIONS The high rate of OI during ABVi chemotherapy and the follow-up is of concern, although these infections possibly could be due to our patients' low CD4+ lymphocyte counts. However, no toxic death was observed in our patients, suggesting that ABVi could be used in patients with aggressive disease, especially those who were previously untreated.
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Affiliation(s)
- M Tavio
- Division of Medical Oncology and AIDS, Centro di Riferimento Oncologico, Aviano, Italy
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