Classical Kaposi sarcoma: prognostic factor analysis of 248 patients

A Single-Center Retrospective Analysis of Kaposi's Sarcoma: Is There a Relationship Between Emmprin/CD147 Expression and Biological Behavior?

OBJECTIVES

Emmprin (CD147/BSG) protein is estimated to play a key role in cell migration and chemoresistance in viral carcinogenesis. However, there are very limited studies investigating the CD147 in the oncogenesis of Kaposi's sarcoma-associated herpesvirus. This study aims to reveal the relationship between CD147 expression with histopathological parameters, disease pattern, and recurrence in Kaposi's sarcoma (KS).

METHODS

The study included 67 patients diagnosed with KS between January 1982 and September 2023. Clinical and histopathological features were analyzed retrospectively. HHV-8, CD31, and CD147 expressions were evaluated by immunohistochemistry.

RESULTS

Sixteen (24%) female and 51 (76%) male patients with median age of 64 (10-86) were included in the study. CD147 was positive in 57 (85%) cases and associated with nodular pattern (P = .001), presence of solid/fibrosarcomatous area (P = .005), and high mitotic activity (P = .035). The disease relapsed in 17 (27%) of the 63 patients with median 2 (0-12) years follow-up. While a 5-year relapse-free survival was 48.5% in the CD147 diffuse positive group, it was 83.4% in focal positive and 100% in negative cases (P = .029).

CONCLUSION

Our study exhibited the relationship between CD147 overexpression and recurrence in KS, but the inhomogeneity of the treatment groups and the small number of patients should also be considered. These findings may provide insight into the pathogenesis of KS and the development of targeted therapies in the future.

A SEER data-based nomogram for the prognostic analysis of survival of patients with Kaposi's sarcoma

Background

This study developed the first comprehensive nomogram for predicting the cancer-specific survival (CSS) of patients with Kaposi's sarcoma (KS).

Methods

Data on the demographic and clinical characteristics of 4143 patients with KS were collected from the Surveillance, Epidemiology, and End Results (SEER) database and used for the prognostic analysis. The patients were randomly divided into two groups: training cohort (n = 2900) and validation cohort (n = 1243). Multivariate Cox regression analysis was used to identify the predictive variables for developing the first nomogram for the survival prediction of patients with KS. The new survival nomogram was further evaluated using the concordance index (C-index), area under the time-dependent receiver operating characteristic curve (AUC), net reclassification improvement (NRI), integrated discrimination improvement (IDI), calibration plotting, and decision curve analysis (DCA).

Results

A nomogram was developed for determining the 3-, 5-, 8-, and 10-year CSS probabilities for patients with KS. The nomogram showed that tumor stage had the greatest influence on the CSS of patients with KS, followed by demographic variables (race, marital status, and age at diagnosis) and other clinical characteristics (surgery status, chemotherapy status, tumor risk classification, and radiotherapy status). The nomogram exhibited excellent performance based on the values of the C-index, AUC, NRI, and IDI as well as calibration plots. DCA further confirmed that the nomogram had good net benefits for 3-, 5-, 8-, and 10-year survival analyses.

Conclusions

In this study, by using data from the SEER database, we developed the first comprehensive nomogram for analyzing the survival of patients with KS. This nomogram could serve as a convenient and reliable tool for clinicians to predict CSS probabilities for individual patients with KS.

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.

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, a Trifecta of Pathogenic Mechanisms

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

Optimal control application to a Kaposi’s sarcoma treatment model

Kaposi’s sarcoma (KS) is a malignant disorder of lymphatic endothelial origin that can have two main variants: AIDS-related KS (AKS) and non-AIDS related KS (NAKS) that all share a causal relationship with the human herpesvirus-8 (KSHV or HHV-8). We develop a mathematical model that accounts for B-cells latently and lytically infected with HHV-8 as well as the innate and adaptive arms of the immune system. As a sequel to numerous studies that have investigated the inhibition of HHV-8 endocytosis and reactivation of HHV-8 replication, we employ optimal control strategy to obtain treatment efficacies for these two therapeutic approaches. We have shown that when [Formula: see text] of the B-cell infections result in latency, administration of high efficacy drugs that inhibit entry and reactivation of latently infected B-cells leads to the clearance of KS as the population of infected cells cannot be sustained. Our results also reveal that at [Formula: see text] latency of B-cells, the therapy could produce similar results if the drug that targets viral entry is of moderate efficacy but the efficacy of the drug inhibiting reactivation is considerably more than [Formula: see text] Administration of the same drugs but both at moderate efficacy levels leads to the depletion of both uninfected B- and progenitor cells, a scenario which can lead to the growth of KS variants. When [Formula: see text] of the B-cell infections result in latency, administration with high efficacy drugs reduces the viral entry of HHV-8 but as [Formula: see text] of the infected B-cells are productive, this event leads to production of HHV-8 which ultimately results in more progenitor cells getting infected and the growth of KS. Our findings have the potential to offer more effective therapeutic approaches in the treatment of NAKS.

Mucosal Kaposi's sarcoma in HIV-negative patients: a large case series from a single, tertiary referral center in Italy

BACKGROUND

Mucosal involvement in HIV-negative Kaposi's sarcoma (KS) is uncommon but has potentially serious repercussions on patient care. Evidence regarding its epidemiology and optimal management is limited. Invasive endoscopic staging at diagnosis and periodically during follow-up is currently recommended by major guidelines.

MATERIALS AND METHODS

We reviewed the clinical records of 1,308 HIV-negative KS patients followed at our dedicated KS outpatient service. Demographics, clinical characteristics, and treatment outcomes for cases with biopsy proven mucosal lesions were collected.

RESULTS

Mucosal involvement was documented in 53 patients (4.1% of our cohort), being present at diagnosis in 28 (52.8%) and occurring at a later time in the remaining 25 (47.2%) patients, with a mean latency of 8 years (±7.7). Oral cavity (43.4%) and glans penis (39.6%) were the most frequently involved anatomical sites. Of those with available treatment response data, complete response (CR) of mucosal KS was appreciated in 41 cases (93.2%), while partial response (PR) and stable disease (SD) were documented in one (2.3%) and two cases (4.5%), respectively. Same-site recurrences were noticed in seven patients (17.1%).

CONCLUSION

Mucosal involvement in HIV-negative KS is rare, and its recurrence, if properly treated, appears to be infrequent. Thus, routine invasive monitoring in this setting may be unnecessary. We propose a tailored approach based on the clinical manifestations of each patient, limiting the indication of invasive procedures to the first evaluation and in case of significant clinical worsening or to monitor known mucosal localizations.

Quadruple Multiple Primary Malignancies: Early Detection of Second Primary Malignancy by Esophagogastroduodenoscopy/Colonoscopy Is Crucial for Patients with Classic Kaposi's Sarcoma

Currently, Kaposi's sarcoma (KS) is treated following the recommendations of international guidelines. These guidelines recommend esophagogastroduodenoscopy/colonoscopy for detecting multicentric KS of visceral lesions. Second primary malignancies (SPMs) are also a common KS complication; however, information on their detection and treatment is unfortunately not yet indicated in these guidelines. This paper reports on an 86-year-old man who suffered from quadruple primary malignancies: skin classic KS with colon adenocarcinoma, oral squamous cell carcinoma (maxilla), and well-differentiated stomach adenocarcinoma. Gastric cancer was incidentally detected during esophagogastroduodenoscopy, which was performed to detect visceral KS. We suggest that esophagogastroduodenoscopy/colonoscopy be routinely performed during the follow-up of patients with KS. As SPMs are crucial complications in patients with KS, these malignancies should be detected as early as possible.

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.

Radiotherapy in the management of classic Kaposi's sarcoma: A single institution experience from Northeast Turkey

Kaposi sarcoma is a rare adult neoplasm and there has been no certain consensus on standard treatment, either local or systemic. Radiotherapy is an effective, suitable treatment modality. Between 1996 and 2016, patients who were diagnosed with Kaposi sarcoma and referred to our clinic for radiotherapy were included in this retrospective study. Ninety-two patients were examined in total and it was diagnosed that all the patients had non-HIV associated Kaposi's sarcoma. There were 36 (39%) females and 56 (61%) males and female to male ratio was 2/3. Median age at presentation was 72 (30-93) years. Sixty-eight patients (77%) were treated with 8 Gy (1 fraction), 15 patients (16%) were treated with 20 Gy (2 Gy/fraction), four patients (4%) were treated 25 Gy (2.5 Gy/fraction), and five patients (6%) were treated 30 Gy (3 Gy/fraction). The median follow-up time was 72 (5-192) months. The complete response at 5 years was 91.6% with >20 Gy and 89.6% with 8 Gy. Radiotherapy is an effective, suitable treatment modality of Classic Kaposi sarcoma and usually, radiotherapy is well tolerated with minimal side effects.

Kaposi's Sarcoma in Young Patients Treated with Orthovoltage Irradiation and Having a Minimum Follow-Up of Forty-Six Years

Purpose

To describe the clinical outcome and to evaluate the role of orthovoltage radiotherapy in the treatment of young (less than 30 years old) Mediterranean men with Kaposi's sarcoma.

Patients and methods

We reviewed the records of 198 consecutive patients with Kaposi's sarcoma treated with orthovoltage radiation therapy at our department between January 1920 and December 1987.

Result

We found three young shepherds, aged less than 30 years, with an available follow-up ranging from 45 to 67 years. One patient died at the age of 84 years of chronic renal failure while suffering from cutaneous Kaposi's sarcoma; two patients are still alive with recurrent Kaposi's sarcoma.

Conclusions

We presume that an indolent form of Kaposi's sarcoma may occur in young men. This very indolent form can be controlled for the duration of the patient's life by judiciously applied radiation therapy.

[Classic and aggressive Kaposi sarcoma with bone involvement]

Le sarcome de Kaposi classique est une tumeur rare multifocale d'origine des cellules endothéliales vasculaires à caractère évolutif progressif et peu maligne. L'atteinte viscérale dans le sarcome de kaposi est parfois observée chez les patients VIH positif par contre la dissémination tumorale dans les ganglions lymphatiques viscérales dans le SK classique reste très rare. On rapporte un cas rare de sarcome de kaposi classique agressif de la main avec une évolution rapide et destructive.

Classical Kaposi sarcoma: case reports with unusual presentation on the penis and scrotum

BACKGROUND

Kaposi sarcoma (KS) is the most common vascular neoplasm. Any skin area could be involved, including the genitalia. Traditionally, classic KS lesions have a general distribution, often involving skin of the feet and legs, and to a lesser extent, that of the hands, arms, and trunk. KS limited to the external genitalia is extremely rare in HIV seronegative individuals.

METHODS

We report six patients of classic KS with generalized dermal KS lesions.

RESULTS

Two of them presenting with unusual KS lesions on the penis and scrotum beside the other dermal lesions. Patients were HIV negative and human herpes virus eight positive. Histological examination showed classical KS.

CONCLUSIONS

Primary KS of the penis and scrotum is rare but could occur in HIV-negative patients.

Aggressive classical Kaposi's sarcoma mimicking malignant lymphoma

Classical Kaposi's sarcoma is an unusual multifocal neoplasm of vascular endothelial cell origin, and considered a less malignant, slowly-progressing tumor. Although visceral involvement is occasionally seen in HIV/AIDS patients with KS, tumor dissemination to visceral lymph nodes in classical KS is very rare. A 72-year-old woman without any other relevant past medical history presented with anorexia, weight loss, night sweats, and skin eruptions. As the rapid progression of cytopenias and lymphadenopathy were observed, bone marrow biopsy and imaging were performed. Positron emission tomography showed disseminated lymphadenopathy in the cervical, axillary, mediastinal, inguinal, and abdomino-pelvic nodal areas. Inguinal lymph node biopsy was compatible with KS, positive for CD31, CD34, and human herpesvirus-8 by immunohistochemical stain. We report a case of aggressive classical KS mimicking aggressive malignant lymphoma.

Treatments for classic Kaposi sarcoma: a systematic review of the literature

BACKGROUND

Treatment guidelines are lacking for classic Kaposi sarcoma.

OBJECTIVE

We sought to review the evidence on efficacy of treatments for classic Kaposi sarcoma.

METHODS

Articles published in English or French in MEDLINE, Trip, Cochrane Library, and Pascal databases from 1980 to December 2010 were screened. Studies reporting at least 5 patients treated for histologically confirmed classic Kaposi sarcoma were selected. Primary outcome was a decrease in the number or size of lesions or of lymphedema. We reviewed 26 articles matching the inclusion criteria for methodologic quality, classifying them according to World Health Organization criteria.

RESULTS

The percentage of patients with a 50% or greater decrease in lesions was 71% to 100% for pegylated liposomal doxorubicin, 58% to 90% for vinca-alkaloids, 74% to 76% for etoposide, 93% to 100% for taxanes, 100% for gemcitabine, 97% for the combination of vinblastine and bleomycin, 71% to 100% for interferon alfa-2, 43% for thalidomide, and 12% for indinavir. For local treatments, a decrease of 50% or greater was achieved in 62% of lesions for intralesional vincristine, 50% to 90% for intralesional interferon alfa-2, 56% for imiquimod, and 25% for nicotine patches. A complete response was attained in 60% to 93% of lesions with radiotherapy.

LIMITATIONS

Eligible trials were of poor quality. The lack of standardized classification of disease activity and clinical outcomes precluded the comparison of studies.

CONCLUSION

The evidence for efficacy of any particular intervention is of low quality and does not support recommending any particular therapeutic strategy. Further studies are required and it will be important to standardize the assessment of disease activity and clinical response.

Classic Kaposi's Sarcoma: A Case Report and Literature Review

Kaposi's Sarcoma (KS) is a rare multifocal spindle cell tumor with four epidemiologic variants: classic KS, African endemic KS, AIDS related KS, and immunosuppressant therapy related KS. Classic KS remains a rare but challenging disease because of its protracted, indolent course. The authors describe a case recently observed in our clinic, emphasizing the clinical management of the disease.

Classic Kaposi's sarcoma in Morocco: clinico-epidemiological study at the National Institute of Oncology

BACKGROUND

Classic Kaposi's sarcoma (CKS) is a rare disease likely associated with human herpes virus 8 (HHV-8) infection, and occurs predominantly in Jewish, Mediterranean and middle eastern men. There is a dearth of data in Moroccan patients with CKS regarding epidemiology, clinical characteristics and outcomes. This report examines a cohort of patients with CKS evaluated at the national institute of oncology over 11-year period.

METHODS

A retrospective analysis of patients referred to the national institute of oncology with classical Kaposi sarcoma, between January 1998 and February 2008, was performed. Reviewed information included demographics, clinical and pathological staging, death or last follow-up.

RESULTS

During the study period, 56 patients with a diagnosis of CKS have been referred to our hospital. There were 11 (19.7%) females and 45 (80.3%) males (male-to-female ratio: 4:1). Mean age at diagnosis was 61.7 ± 15 (range: 15-86 years). Nodules and/or plaques were the most frequent type of lesion. The most common location was the lower limbs, particularly the distal lower extremity (90%). In addition to skin involvement, visceral spread was evident in 9 cases. The most common visceral involvement sites were lymph nodes (44%), lung (22%), and gastrointestinal tract (22%). Associated lymphoedema was seen in 24 (42%) of the patients. There were 18 stage I patients (32.14%), 8: stage II (14.28%), 21 stage III (37.5%) and 9 stage IV (16.07%). A second primary malignancy was diagnosed in 6 cases (10.7%), none of the reticuloendothelial system. With a median follow-up of 45 months, 38 (67.8) patients are alive, of whom 25 (65.78%) patients with stable disease, five with progressive disease currently under systemic chemotherapy and 8 (21.05%) are alive and free of disease, over a mean interval of 5 years.

CONCLUSION

This is the largest reported series in our context. In Morocco, CKS exhibits some special characteristics including a disseminated skin disease at diagnosis especially in men, a more common visceral or lymph node involvement and a less frequent association with second malignancies.

Electrochemotherapy in the treatment of Kaposi sarcoma cutaneous lesions: a two-center prospective phase II trial

BACKGROUND

Electrochemotherapy (ECT) is an emerging treatment for cutaneous lesions of different tumor types. The combination of chemotherapy and electroporation enhances drug uptake into tumoral cells. However, its role in the treatment of Kaposi sarcoma (KS) has not yet been well defined, and to date, literature reports are scarce. We prospectively evaluated clinical activity and safety of ECT in KS patients.

METHODS

Twenty-three patients with histologically confirmed unresectable KS, not treatable by radiotherapy or intralesional vincristine therapy, were enrolled onto the study according to the European Standard Operating Procedures of Electrochemotherapy (ESOPE) guidelines and treated with a pulse generator.

RESULTS

A response to the first ECT session was obtained in all patients, with a complete response (CR) in 14 (60.9%) of 23 patients. A second ECT was performed in 5 (21.7%) and a third in 2, with a median interval between two sessions of 5.1 (range 2.5-25.5) months. Overall, a total of 15 patients (65%) experienced a CR. After a median follow-up of 1.5 years (range 2 months to 4.2 years), 16 patients maintained the response, 4 after repeated courses. Sustained local control of treated lesions was present in 20 of 23 patients. The overall survival rate was 74.4% at 2 years.

CONCLUSIONS

ECT represents an additional therapeutic tool for the management of KS cutaneous lesions, characterized by a definite clinical activity and long-lasting remissions. The absence of systemic side effects and the low impact on the immune system also make this treatment suitable for elderly people, even with repeated courses.

Kaposi sarcoma: a continuing conundrum

Kaposi sarcoma (KS) remains a challenge. Its classic or Mediterranean form tends to be benign. In transplant recipients it may be less so. As part of the AIDS pandemic, of which it was an original defining component, it may be life-threatening. It is due to human herpesvirus-8, which is necessary but not sufficient to produce the disease. KS has a low prevalence in the general population of the United States and United Kingdom, with an intermediate rate in Italy and Greece, and a high one in parts of Africa. In Italy, hot spots include its southern regions, the Po River Valley, and Sardinia, possibly related to a high density of blood-sucking insects. An important challenge is to treat KS patients without immunocompromising them. The potential of effective anti-herpes virus therapy and the use of sirolimus in transplantation recipients have added new opportunities for KS prevention.

LEARNING OBJECTIVES

At the conclusion of this learning activity, participants should be able to provide the most recent information about Kaposi sarcoma in the context in which it occurs. Its classic or Mediterranean form, its pattern in transplant recipients and others iatrogenically immunosuppressed, and its occurrence as a potentially life-threatening part of the AIDS pandemic will be stressed. Its etiology and transmission will be discussed in detail to facilitate understanding of Kaposi sarcoma and of human herpesvirus-8 infection in the general population of the United States and United Kingdom, in Italy and Greece, and in certain parts of Africa. Its therapy, including the concept of doing it without immunocompromising the patient, will be stressed. New opportunities for Kaposi sarcoma prevention will also be discussed.

Kaposi's sarcoma-associated herpesvirus viremia is associated with the progression of classic and endemic Kaposi's sarcoma

In order to gain further insight on the role of Kaposi's sarcoma-associated herpesvirus (KSHV) in classic and endemic Kaposi's sarcoma (KS) pathogenesis, we aimed to determine (i) whether KSHV is detectable in peripheral blood mononuclear cells (PBMCs), (ii) which PBMCs subpopulation harbor the virus, (iii) which clinical, histologic, and immunologic parameters are associated with KSHV viremia in a population of classic and endemic KS. KSHV viremia and various immunologic parameters were screened on 81 patients. KSHV viremia was positive in 58% of the patients. KSHV was detected in B cells, T cells, and monocytes. CD34+ cells depleted in circulating endothelial cells (CECs) were never infected and 50% of the patients tested had CECs infected by KSHV. We observed a significant increase of IL-2 and IFN-gamma production by CD4 T cells and an increase of IFN-gamma production by CD8 T cells compared to control patients. KS progression (P = 0.001) and KS staging (P = 0.03) were significantly and independently associated with positive KSHV viremia. Our results show that there is no specific immunosuppression in classic or endemic KS. We showed that KSHV can be detected within CECs and that KSHV viremia could be an indicator of circulating mature or precursor spindle cells.

Human herpesvirus 8--a novel human pathogen

In 1994, Chang and Moore reported on the latest of the gammaherpesviruses to infect humans, human herpesvirus 8 (HHV-8) [1]. This novel herpesvirus has and continues to present challenges to define its scope of involvement in human disease. In this review, aspects of HHV-8 infection are discussed, such as, the human immune response, viral pathogenesis and transmission, viral disease entities, and the virus's epidemiology with an emphasis on HHV-8 diagnostics.

Epidemiological and clinical characteristics of classic Kaposi's sarcoma in Peru

BACKGROUND

Classic Kaposi sarcoma (KS) occurs predominantly among the elderly, with predominance among Jews, Italians, and Greeks. Classic KS has been seen relatively frequently in Peru.

OBJECTIVE

Our purpose was to outline the epidemiological and clinical profile of classic KS in Peru.

METHODS

Epidemiological and clinical features of all classic KS cases diagnosed between 1969 and 2003 at Hospital Nacional Cayetano Heredia (HNCH) and between 1946 and 2004 at Instituto Nacional de Enfermedades Neoplasicas (INEN) were reviewed and studied retrospectively.

RESULTS

An overall incidence of 2.54 per 10,000 attended patients was obtained at the INEN during the 48-year period (mean, 2.39; standard deviation: 1.99; 95% confidence interval, 2.92-1.86). Twenty-one cases were discovered at HNCH and 106 cases at INEN. A male/female ratio of 2.62:1 was found. Mean age at diagnosis was 68.5 years. Lower limbs were involved in 109 patients (85.8%); the trunk was involved in 11 patients (8.6%). Nodules were the most common type of lesion (85.8%); less commonly found were plaques (27.5%), macules (12.5%), papules (12.5%), and ulcers (8.6%). Sixty-two patients had no symptoms (48.8%). Pain was the most common symptom (26.7%), followed by edema (21.2%), bleeding (14.9%), and pruritus (3.9%). A second primary malignancy was found in 11 patients (8.6%).

LIMITATIONS

These results were obtained from patients with classic KS in Peru and may not be applicable to other populations.

CONCLUSION

Classic KS is quite common in Peru with sporadic cases found throughout the country and some clustering in the coastal region. Classic KS in Peru has a clinical presentation that is very similar, but not identical, to the classic KS described in the Mediterranean region, exhibiting some special clinical and epidemiological characteristics with a nodular, nonsymmetric presentation that usually affects the lower extremities.

Case report: classic Kaposi's sarcoma

Classic KS usually appears between ages 50 and 70 years and has a relatively benign, indolent course for 15 years or longer. Treatment usually controls the disease quite well.

Aggressive Behavior of Classical Kaposi's Sarcoma and Coexistence With Angiosarcoma

An 82-year-old Caucasian man presented with initially asymptomatic livid red plaques on the plantar surface of the feet that become confluent and evolved into invasively growing nodules accompanied by massive edema. Histology allowed a diagnosis of the classical form of Kaposi's sarcoma; the serology test result for HIV was negative, whereas the associated human herpes virus type 8 was detected by polymerase chain reaction on the skin sample. Over the subsequent 6 months, skin lesions become vegetative and partially necrotic, and extended to the hands and eyelids. Chemotherapy with vinblastine appeared to stabilize the cutaneous disease, but the patient developed a massive gastrointestinal hemorrhage secondary to dissemination to the stomach. Twelve months after the onset of the disease, vegetative and easily bleeding lesions progressively occluded the mouth of the patient: histological features were consistent with a low-grade angiosarcoma distinct from that of Kaposi's sarcoma. The patient could not chew and swallow anymore; he was put on an artificial nutrition but died shortly thereafter. This case illustrates that, even in its classical form, Kaposi's sarcoma may be a malignant, rapidly progressing tumor.

LEARNING POINTS

a) The extent and rate of spread of initial skin lesions should be considered to be early signs of aggressive dissemination, even in the absence of other variables (i.e., histological pattern, human herpes virus type 8 positive mononuclear cells) associated with progression of the disease. b) An endoscopy may be useful given the high prevalence of gastrointestinal involvement. c) When classical Kaposi's sarcoma displays aggressive behavior a second, primary malignant tumor arising from the vascular tissue should be investigated.

TAKE-HOME MESSAGE

Even in its classical form, Kaposi's sarcoma may be a malignant, rapidly progressing tumor with visceral involvement; also, a second malignancy may occur in nearly one patient of four. Because localized skin lesions can regress completely with radiotherapy, watchful waiting is probably inappropriate in most cases.

Kaposi's sarcoma: An update

While there have been many important advances in the study of Kaposi's sarcoma (KS), it remains both a challenge and an enigma in many ways. Kaposi's original description of "multiple idiopathic hemorrhagic sarcoma[s]" in patients who died within 2-3 years resembles KS in AIDS more than classic KS in elderly men of Italian, Jewish, or Mediterranean lineage, in whom the disease is usually benign. KS had been evident in about one-third of those with early AIDS, often as its presenting sign, a pattern markedly reduced in recent times since the introduction of highly active anti-retroviral therapy (HAART). The most important advance has been the convincing etiologic linkage of KS with human herpesvirus 8 (HHV-8), which is necessary but not sufficient. It has a low prevalence in the general population of the USA and UK, with an intermediate rate in Italy and Greece, and a high one in Uganda. KS risk may be significantly lower in AIDS patients with a history of anti-herpes therapy. Many aspects of HHV-8, including its transmission pattern and different genospecies, are being scrutinized. The diagnosis of KS may be difficult. One should be aware of KS clinical variants, including telangiectatic, eccymotic, and keloidal KS. One must consider a number of other disorders, including bacillary angiomatosis. HHV-8 DNA sequences in dermatofibromas and other tumors should probably not be viewed as representing a marker for KS. Therapeutic options vary for KS. Intralesional and low-dose outpatient intravenous vinblastine may be valuable, as immunosuppression with KS is not a good idea if it can be avoided. Anti-herpes virus therapy may have potential for wide use, especially in preventing the development of KS in at risk populations, such as HHV-8 seropositive individuals undergoing transplantation surgery.

Epidemiology of classic Kaposi's sarcoma in the Israeli Jewish population between 1960 and 1998

Trends in the incidence of classic Kaposi's sarcoma in the Jewish population in Israel for the period between 1960 and 1998 were analysed. World standardised incidence rates of 20.7 and 7.5 per million among men and women, respectively, were calculated. The highest incidence rates were displayed by men originated from Africa and by Asian-born women.

Molecular genetics of Kaposi's sarcoma-associated herpesvirus (human herpesvirus-8) epidemiology and pathogenesis

Kaposi's sarcoma had been recognized as unique human cancer for a century before it manifested as an AIDS-defining illness with a suspected infectious etiology. The discovery of Kaposi's sarcoma-associated herpesvirus (KSHV), also known as human herpesvirus-8, in 1994 by using representational difference analysis, a subtractive method previously employed for cloning differences in human genomic DNA, was a fitting harbinger for the powerful bioinformatic approaches since employed to understand its pathogenesis in KS. Indeed, the discovery of KSHV was rapidly followed by publication of its complete sequence, which revealed that the virus had coopted a wide armamentarium of human genes; in the short time since then, the functions of many of these viral gene variants in cell growth control, signaling apoptosis, angiogenesis, and immunomodulation have been characterized. This critical literature review explores the pathogenic potential of these genes within the framework of current knowledge of the basic herpesvirology of KSHV, including the relationships between viral genotypic variation and the four clinicoepidemiologic forms of Kaposi's sarcoma, current viral detection methods and their utility, primary infection by KSHV, tissue culture and animal models of latent- and lytic-cycle gene expression and pathogenesis, and viral reactivation from latency. Recent advances in models of de novo endothelial infection, microarray analyses of the host response to infection, receptor identification, and cloning of full-length, infectious KSHV genomic DNA promise to reveal key molecular mechanisms of the candidate pathogeneic genes when expressed in the context of viral infection.