Intralesional interferon-alpha and zidovudine in epidemic Kaposi's sarcoma

Kaposi Sarcoma Updates

Kaposi sarcoma (KS) is an angioproliferative mesenchymal neoplasm caused by Kaposi sarcoma-related herpesvirus. This review outlines our current understanding of the epidemiology, pathogenesis, clinical presentation, and staging for this disease. Recent research has informed a more comprehensive understanding of the epidemiology of KS in the post-antiretroviral therapy era, and highlights the continued need to better characterize the African endemic subtype. Advances in clinical oncology, including checkpoint inhibitors and new skin-directed therapies, have translated into exciting new developments for the future of KS treatment options.

Chemo-Immunotherapy of Advanced Aids-Related Kaposi'S Sarcoma

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.

Gingival Involvement in a Case Series of Patients With Acquired Immunodeficiency Syndrome-Related Kaposi Sarcoma

BACKGROUND

This case series presents the polymorphic clinical characteristics of gingival acquired immunodeficieny syndrome (AIDS)-related Kaposi sarcoma (KS), a malignancy that is gradually becoming uncommon in developed nations. An up-to-date overview of the related epidemiology, etiopathogenesis, histopathology, and treatment is provided, along with a pictorial guide to ease clinical diagnosis.

METHODS

The oral/maxillofacial pathology records at Aristotle University and the University of Geneva were retrospectively reviewed. Thirty-two cases diagnosed with oral AIDS-related KS were retrieved between 1991 and 2004. KS diagnosis was established histologically by incisional biopsies from intraoral lesions. All charts contained clinical oral examination data, radiological images, and detailed photographic records.

RESULTS

Thirteen patients (12 males and one female) presented with KS gingival involvement (40.6%). Eleven of the male patients were homosexual/bisexual men. The mean age of the patients at the time of intraoral KS diagnosis was 42.1 years, and the mean CD4 cell count was 103 (0 to 481). Gingival epidemic KS presented with various degrees of pigmentation and a wide range of clinical patterns, from relatively flat macules (early stage) to tumors with variable nodular morphology (advanced disease). Solitary or multiple gingival involvement may appear concomitantly with palatal and/or cutaneous lesions.

CONCLUSIONS

Even though the incidence of intraoral KS had fallen precipitously in developed countries after the mid-1990s, gingival KS should be considered in the differential diagnosis of every pigmented gingival lesion. Periodontists are in a unique position to identify gingival involvement of intraoral KS and facilitate early diagnosis.

Cutaneous malignancy and human immunodeficiency virus disease

Certain skin cancers occur with increased frequency or altered course in patients infected with HIV. Malignant melanoma and squamous cell carcinoma are examples of cutaneous malignancies that have a more aggressive course in patients with HIV. Others, such as basal cell carcinoma, appear more frequently in this population but do not appear to be more aggressive. The incidence of HIV-associated Kapsosi's sarcoma has markedly decreased since the advent of HIV antiretroviral therapy. Our understanding of the pathogenesis of this malignancy and its unique management issues are fully reviewed. Cutaneous T-cell lymphoma (CTCL) is rare in this population. Other types of cutaneous lymphoma and HIV-associated pseudo-CTCL are discussed. This article addresses prevention, treatment, and follow-up strategies for this at-risk population.

LEARNING OBJECTIVE

At the completion of this learning activity, participants should be familiar with the unique epidemiology, clinical course, and management of cutaneous malignancy in patients infected with HIV.

Approach to the treatment of cutaneous malignancy in HIV-infected patients

Patients infected with human immunodeficiency virus (HIV) have an increased risk of developing skin cancers. These at-risk patients may have atypical presentations and/or altered clinical courses. This article will review and discuss management issues for the following malignancies: lymphomas, malignant melanoma, basal cell carcinoma, squamous cell carcinoma, and Kaposi's sarcoma.

Oral Kaposi Sarcoma Associated with Severe Alveolar Bone Loss: Case Report and Review of the Literature

BACKGROUND

In AIDS patients who present with an oral neoplasm, Kaposi sarcoma is the tumor most frequently encountered, comprising 50% to 80% of all tumor occurrences. However, oral Kaposi sarcoma associated with erosion of underlying bone is a relatively rare finding. This report and review of the literature documents a case of AIDS-related oral Kaposi sarcoma exhibiting severe bilateral erosion of the maxillary alveolar ridges.

METHODS

An HIV-seropositive male with extensive maxillary Kaposi sarcoma and associated bilateral alveolar bone erosion presented for dental evaluation subsequent to radiation therapy. Clinical and radiographic examinations were performed. Medical and dental histories were procured and supplemented with consultations from the patient's primary physician and radiation oncologist. Maxillary edentulation with surgical revision for primary closure was the treatment of choice for management of the dentoalveolar pathology. A maxillary immediate treatment denture was designed to obturate anticipated antral communications with the maxillary sinus.

RESULTS

Surgical and prosthetic treatments were completed, but complicated by an oral-antral perforation that subsequently healed without complication. Soft tissue biopsies obtained during surgery revealed no evidence of residual Kaposi sarcoma.

CONCLUSIONS

Although AIDS-related oral Kaposi sarcoma is a relatively common finding, erosion of subjacent alveolar bone is uncommon. Treatment of the tumor with subsequent dental reconstruction can be complicated by the severe lack of bone, surgical perforation of the maxillary sinus, and lack of stable teeth to serve as abutments. Significant advances in understanding the pathogenesis of AIDS-related Kaposi sarcoma have occurred in the last decade. HHV-8 and various inflammatory cytokines have been implicated in the pathogenesis and are likely to become the primary targets for therapeutic intervention.

Recent advances in the treatment of AIDS-related Kaposi's sarcoma

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.

AIDS-associated malignancies: research perspectives

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.

Successful treatment of cutaneous Kaposi's sarcoma by the 585-nm pulsed dye laser

The clinical appearance of Kaposi's sarcoma (KS) can cause significant disfigurement and lead to functional impairment, particularly if the lesions ulcerate and become secondarily infected. We describe a patient with a KS plaque on the face that was successfully treated with 585-nm pulsed dye laser (PDL) therapy. No recurrence of the tumor was noted 12 months after the final laser treatment.

Acquired immunodeficiency syndrome-associated Kaposi's sarcoma. Biology and management

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.

Advances in Kaposi's sarcoma

KS remains a challenge to clinicians and investigators more than a century after its initial description. Debate continues as to the cell of origin, as well as whether or not it is a true cancer. KS appears to be an opportunistic neoplasm, which in its earliest phase retains some features of a benign hyperproliferative process, but in its late stages behaves like an aggressive malignancy. Pathogenesis seems to involve a predisposed individual (genetically susceptible or immunologically compromised) who comes into contact with an infectious agent, most likely a virus. Cytokines appear to play a major role in the growth of the tumor. The exact role of the KSHV in this process will likely be the subject of much investigation in the future.

Kaposi's sarcoma and its management in AIDS patients. Recommendations from a Scandinavian Study Group

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.

Overview of the management of AIDS-related Kaposi's sarcoma

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.

Phase II study of 5-fluoruracil leucovorin and azidothymidine in patients with metastatic colorectal cancer

The primary objective of this study was to determine the response rate of patients with metastatic colorectal cancer to combined therapy with 5-fluorouracil (5-FU), leucovorin, and intravenous azidothymidine (AZT), a thymidine nucleoside analog. By itself, AZT has limited antineoplastic efficacy. However, experimental studies indicate that 5-FU enhances the antitumor activity of AZT by inhibiting synthesis of normal thymidine nucleotides with which AZT competes for incorporation into nucleic acids. A phase I study defined the maximum tolerated dose of AZT as 7 g/m2 with hypotension during the infusion being the dose-limiting toxicity. A phase II study was performed with oral leucovorin (100 mg p.o. hourly for 4 h prior to 5-FU and 4 h and 8 h after 5-FU), bolus 5-FU (400 mg/m2) followed 1 h later by a 2-h infusion of AZT (7 g/m2). Treatment was given weekly for 4 weeks followed by a 1-week break, which constituted a cycle of therapy. Responses were evaluated after every two cycles. Patients continued on therapy as long as they tolerated treatment and did not have progressive disease. Of 15 evaluable patients who had received no chemotherapy there was 1 complete response and 4 partial responses (a 33% response rate), whereas only 1 of 6 patients who had received prior adjuvant chemotherapy had a partial response (17%). An additional 10 patients had stable disease lasting 2-14 months. Therapy was well tolerated with the only one instance each of grade 3 nausea and vomiting, diarrhea, anemia, and hypotension. Approximately 50% of treatments were accompanied by mild hypotension, which was easily corrected by increasing the rate of normal saline infusion. There was no difficulty administering this regimen in the outpatient setting. While the overall response rate (29%) is comparable to that seen with combinations of 5-FU and leucovorin alone, in most reported series a considerably higher dose of 5-FU was utilized than in this study. Since patients in the present study experienced relatively little 5-FU toxicity, increasing the dose of 5-FU in this regimen would appear to be feasible and might result in a higher response rate.

Immune-based therapies for treatment of HIV infection

OBJECTIVE

To review the in vitro, animal, and clinical data on immune-based therapies for treatment of HIV infection.

DATA SOURCES

An extensive MEDLINE search was performed for interleukins, interferons, immunotoxins, tumor necrosis factor (TNF)-directed agents, vaccines, and gene therapy.

STUDY SELECTION

In vitro experiments with immune-based agents in cell lines infected with HIV were included. In addition, all human studies and case reports that used these agents in patients infected with HIV were selected. Additional literature included abstracts from international meetings on HIV and AIDS.

DATA EXTRACTION

Data regarding activity, efficacy, and toxicity were extracted from in vitro and in vivo studies. When conflicting data were observed, both viewpoints were stated to give an unbiased analysis. Because HIV research involves multiple social, ethical, and scientific issues, perspectives on these problems were addressed, where appropriate.

DATA SYNTHESIS

Current antiretroviral therapy is limited to short-term responses and has minimal effect on overall survival. Because the human immune response to HIV infection is effective at keeping the virus suppressed for a number of years, a focus of HIV research has been to examine immune-based therapies for treatment of HIV infection that attempt to augment enhance, or boost the patient's immune system. Interleukins, interferons, immunotoxins, TNF-directed therapies, vaccines, and gene therapy have been studied in patients infected with HIV. Properties shared among these therapeutic modalities include adverse effect profiles, response rates dependent on baseline immunocompetence, the potential to activate viral replication, the need for supportive care, and sensitive laboratory tests required for monitoring.

CONCLUSIONS

Immune-based agents represent a new approach to the treatment of HIV infection. Whereas antiretrovirals only inhibit viral replication, these agents are designed to enhance the immune system of the patient. Future attempts to manage HIV infection may combine standard nucleoside analogs with immune-based therapies.

Local therapy for mucocutaneous Kaposi's sarcoma in patients with acquired immunodeficiency syndrome

BACKGROUND

Kaposi's sarcoma (KS) accounts for significant morbidity in AIDS patients. Lessons are often numerous, disfiguring, painful, and may interfere with function. Although generalized therapy is available, local treatment is often more desirable.

OBJECTIVE

To summarize the available data on local therapy for KS.

METHODS

Literature was searched using Medline.

RESULTS

Excision, laser destruction, cryotherapy, intralesional chemotherapy, immunotherapy, and radiation therapy were compared for success rate, cost, and convenience.

CONCLUSION

Intralesional therapy, cryotherapy, and radiation all have substantial advantages over excision or laser surgery. Choice of the appropriate modality varies with different sites and patients.

Dermatologic therapy: 1993

This article reviews some therapeutic results reported in the English-language literature during 1993. Readers should review the original article in full before attempting any experimental or controversial therapy.