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Campbell LR, Silverstein A, Peckham-Gregory E, Kamiyango W, Villiera J, McAtee CL, Bacha JM, Kovarik CL, Mehta PS, Chanroo T, Kapesa A, Malingoti B, Mzikamanda R, Ozuah NW, Allen CE, Scheurer ME, El-Mallawany NK. Divergent clinical presentations and outcomes among children and adolescents with Kaposi sarcoma in Malawi and Tanzania. HIV Med 2023; 24:664-675. [PMID: 36627111 PMCID: PMC10257738 DOI: 10.1111/hiv.13455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 12/18/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVES The Kaposi sarcoma (KS) T0 versus T1 staging classification does not address the unique clinical features of paediatric KS in human gammaherpesvirus 8 (HHV-8) endemic regions of Africa. This study seeks to define patterns of childhood KS using a paediatric-specific approach. METHODS The Lilongwe paediatric KS staging classification categorizes disease based on clinical phenotype: stage 1 = mild/moderate KS limited to cutaneous/oral involvement, stage 2 = primarily lymphadenopathic disease, stage 3 = woody edema KS, stage 4 = visceral and/or severe/disseminated mucocutaneous disease. Characteristics and outcomes were evaluated from paediatric referral centres in Lilongwe, Malawi, and Mbeya, Tanzania. RESULTS Among 171 patients, the median age was 9.3 years, 37% (n = 63) were female, and 87% (n = 149) had HIV. Breakdown by stage was as follows: 18% (n = 31) stage 1, 33% (n = 56) stage 2, 19% (n = 33) stage 3, and 30% (n = 51) stage 4. Age (younger stage 2 and older stage 3), severe CD4 count suppression (lower CD4 for stages 1 and 4), and presence of severe anaemia and thrombocytopenia (worse for stages 2 and 4) differed across stages. Estimated 2-year event-free survival/progression-free survival/overall survival by stage was as follows: stage 1, 81%/81%/87%; stage 2, 50%/50%/63%; stage 3, 24%/49%/81%; and stage 4, 29%/34%/54%. Sub-analysis of stage 2 lymphadenopathic KS demonstrated superior long-term 6-year event-free survival of 70% (95% confidence interval [CI] 49-83) for younger children (aged <7 years) versus 27% (95% CI 8-51) for older children. CONCLUSIONS This paediatric-specific staging classification categorizes patients with distinct characteristics and patterns of treatment response. This platform may guide clinicians to provide risk-stratified treatment with the hope of improving survival among children with KS.
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Affiliation(s)
- Liane R. Campbell
- Baylor College of Medicine International Pediatric AIDS Initiative at Texas Children’s Hospital, Houston, TX, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Baylor College of Medicine Children’s Foundation - Tanzania, Mbeya, Tanzania
| | - Allison Silverstein
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
- Texas Children’s Cancer and Hematology Centers Global HOPE (Hematology-Oncology Pediatric Excellence) Program, Lilongwe, Malawi
| | - Erin Peckham-Gregory
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Center for Epidemiology and Population Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - William Kamiyango
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
- Texas Children’s Cancer and Hematology Centers Global HOPE (Hematology-Oncology Pediatric Excellence) Program, Lilongwe, Malawi
| | - Jimmy Villiera
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
- Texas Children’s Cancer and Hematology Centers Global HOPE (Hematology-Oncology Pediatric Excellence) Program, Lilongwe, Malawi
| | - Casey L. McAtee
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
- Texas Children’s Cancer and Hematology Centers Global HOPE (Hematology-Oncology Pediatric Excellence) Program, Lilongwe, Malawi
- Global HOPE, Texas Children’s Cancer and Hematology Centers, Texas Children’s Hospital, Houston, TX, USA
| | - Jason M. Bacha
- Baylor College of Medicine International Pediatric AIDS Initiative at Texas Children’s Hospital, Houston, TX, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Baylor College of Medicine Children’s Foundation - Tanzania, Mbeya, Tanzania
| | | | - Parth S. Mehta
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Global HOPE, Texas Children’s Cancer and Hematology Centers, Texas Children’s Hospital, Houston, TX, USA
| | - Toni Chanroo
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
- Texas Children’s Cancer and Hematology Centers Global HOPE (Hematology-Oncology Pediatric Excellence) Program, Lilongwe, Malawi
| | - Asulwisye Kapesa
- Baylor College of Medicine Children’s Foundation - Tanzania, Mbeya, Tanzania
| | - Beatrice Malingoti
- Baylor College of Medicine Children’s Foundation - Tanzania, Mbeya, Tanzania
| | - Rizine Mzikamanda
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
- Texas Children’s Cancer and Hematology Centers Global HOPE (Hematology-Oncology Pediatric Excellence) Program, Lilongwe, Malawi
| | - Nmazuo W. Ozuah
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
- Texas Children’s Cancer and Hematology Centers Global HOPE (Hematology-Oncology Pediatric Excellence) Program, Lilongwe, Malawi
- Global HOPE, Texas Children’s Cancer and Hematology Centers, Texas Children’s Hospital, Houston, TX, USA
| | - Carl E. Allen
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Global HOPE, Texas Children’s Cancer and Hematology Centers, Texas Children’s Hospital, Houston, TX, USA
| | - Michael E. Scheurer
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Center for Epidemiology and Population Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Nader Kim El-Mallawany
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Global HOPE, Texas Children’s Cancer and Hematology Centers, Texas Children’s Hospital, Houston, TX, USA
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2
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Campbell LR, El-Mallawany NK, Slone JS, Malingoti BM, Mehta PS, Scheurer ME, Bacha JM, Peckham-Gregory EC. Clinical characteristics and successful treatment outcomes of children and adolescents with Kaposi sarcoma in Southwestern Tanzania. Pediatr Hematol Oncol 2022; 39:28-47. [PMID: 34243680 DOI: 10.1080/08880018.2021.1936315] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The HIV/AIDS epidemic has driven the rise in cases of Kaposi sarcoma (KS) among children and adolescents living with HIV in countries with high Human gammaherpesvirus 8 (HHV-8) seroprevalence, such as Tanzania, where specialized oncology programs are sparse. Consequently, descriptions of successful treatment of KS in children and adolescents by general pediatricians are important. A retrospective analysis was performed of children and adolescents diagnosed with KS and treated with chemotherapy and combination antiretroviral therapy (cART) at the Baylor College of Medicine Children's Foundation Tanzania Center of Excellence - Mbeya between 2011 and 2017. Sixty-one patients were diagnosed with KS with a median age of 12.6 years (interquartile range (IQR) 9.4 - 15.5). Diagnosis was confirmed by histopathology in 36% (22/61). Among HIV positive patients (59/61), 78% (46/59) were on cART at KS diagnosis. Severe immunosuppression was present in 63% (35/56) of those with CD4 data and 44% (27/61) had SAM. Advanced-stage T1 disease was present in 64% (39/61), including 28% (17/61) with visceral/disseminated KS. Two-year estimated overall survival (OS) was 72% (95% Confidence Interval (CI): 58%-82%) and median follow up for survivors was 25.7 months (IQR 14.2-53.8). No patients were lost to follow up. Two-year OS was 63% (95% CI: 44%-77%) in patients with severe immune suppression and 60% (95% CI: 37%-76%) in patients with SAM. Among patients with visceral/disseminated KS, 53% (9/17) survived. This retrospective analysis demonstrated favorable outcomes in a complex cohort of children and adolescents with KS treated with chemotherapy by general pediatricians in Tanzania.
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Affiliation(s)
- L R Campbell
- Baylor College of Medicine International Pediatric AIDS Initiative at, Texas Children's Hospital, Houston, Texas, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - N K El-Mallawany
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Global HOPE, Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
| | - J S Slone
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Global HOPE, Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
| | - B M Malingoti
- Global HOPE, Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
| | - P S Mehta
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Global HOPE, Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
| | - M E Scheurer
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Global HOPE, Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA.,Center for Epidemiology and Population Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - J M Bacha
- Baylor College of Medicine International Pediatric AIDS Initiative at, Texas Children's Hospital, Houston, Texas, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Global HOPE, Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA
| | - E C Peckham-Gregory
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Global HOPE, Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, Houston, Texas, USA.,Center for Epidemiology and Population Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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3
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Kamiyango W, Villiera J, Silverstein A, Peckham-Gregory E, Campbell LR, El-Mallawany NK. Navigating the heterogeneous landscape of pediatric Kaposi sarcoma. Cancer Metastasis Rev 2020; 38:749-758. [PMID: 31845111 DOI: 10.1007/s10555-019-09823-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Vivid descriptions of Kaposi sarcoma (KS) occurring in children and adolescents from central and eastern Africa originated over 50 years ago. Unique clinical characteristics of pediatric KS in Africa were well described within these geographic regions that were eventually understood to be endemic for human herpesvirus-8/Kaposi sarcoma herpesvirus (HHV-8/KSHV) infection, the causative agent of KS. Having catapulted in incidence with the HIV epidemic, KS is currently among the top five most common childhood cancers in numerous countries throughout the region. The main feature that differentiates the childhood form of KS from adult disease is clinical presentation with primarily bulging lymphadenopathy. This group of patients represents the most common clinical subtype of pediatric KS in KSHV-endemic regions. Lymphadenopathic KS in children is associated with other distinct features, such as sparse occurrence of prototypical hyperpigmented cutaneous lesions, frequent presentation with severe cytopenias and a normal CD4 count, and a fulminant clinical course if untreated with chemotherapy. Increased awareness and improved recognition of lymphadenopathic KS are critically important, particularly because this subset of patients typically experiences a favorable response to chemotherapy characterized by durable complete remission. Clinical phenotypes typically observed in adult KS also occur in children-mild/moderate disease limited to cutaneous and oral involvement, woody edema, and visceral disease. This review summarizes the heterogeneous patterns of disease presentation and treatment response observed among the divergent clinical phenotypes of pediatric KS, highlights additional KSHV-related malignancies, and explores some of the potential biological drivers of such clinical phenomena.
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Affiliation(s)
- William Kamiyango
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.,Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi
| | - Jimmy Villiera
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.,Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi
| | - Allison Silverstein
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.,Texas Children's Cancer and Hematology Centers Global HOPE Program, Lilongwe, Malawi.,Baylor College of Medicine, Houston, TX, USA
| | - Erin Peckham-Gregory
- Baylor College of Medicine, Houston, TX, USA.,Global HOPE (Hematology-Oncology Pediatric Excellence), Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, 1102 Bates Street, Feigin Tower, Room 1025.16, Houston, TX, 77030, USA
| | - Liane R Campbell
- Baylor College of Medicine, Houston, TX, USA.,Baylor College of Medicine Children's Foundation Tanzania, Mbeya, Tanzania
| | - Nader Kim El-Mallawany
- Baylor College of Medicine, Houston, TX, USA. .,Global HOPE (Hematology-Oncology Pediatric Excellence), Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, 1102 Bates Street, Feigin Tower, Room 1025.16, Houston, TX, 77030, USA.
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4
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El-Mallawany NK, Villiera J, Kamiyango W, Mhango J, Slone JS, Mehta PS, Kazembe PN, Scheurer ME. Increasing Numbers of New Kaposi Sarcoma Diagnoses in HIV-Infected Children and Adolescents Despite the Wide Availability of Antiretroviral Therapy in Malawi. Clin Infect Dis 2018; 64:818-819. [PMID: 28077522 DOI: 10.1093/cid/ciw879] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Nader Kim El-Mallawany
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Department of Pediatrics, Texas Children's Cancer and Hematology Centers, Houston, Texas, USA
| | - Jimmy Villiera
- Department of Pediatrics, Baylor College of Medicine Children's Foundation, Malawi, Lilongwe, Malawi
- Malawi Clinical Center of Excellence, Lilongwe, Malawi
| | - William Kamiyango
- Department of Pediatrics, Baylor College of Medicine Children's Foundation, Malawi, Lilongwe, Malawi
- Malawi Clinical Center of Excellence, Lilongwe, Malawi
| | - Joseph Mhango
- Department of Pediatrics, Baylor College of Medicine Children's Foundation, Malawi, Lilongwe, Malawi
- Malawi Clinical Center of Excellence, Lilongwe, Malawi
| | - Jeremy S Slone
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Department of Pediatrics, Texas Children's Cancer and Hematology Centers, Houston, Texas, USA
| | - Parth S Mehta
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Department of Pediatrics, Texas Children's Cancer and Hematology Centers, Houston, Texas, USA
| | - Peter N Kazembe
- Department of Pediatrics, Baylor College of Medicine Children's Foundation, Malawi, Lilongwe, Malawi
- Malawi Clinical Center of Excellence, Lilongwe, Malawi
| | - Michael E Scheurer
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Department of Pediatrics, Texas Children's Cancer and Hematology Centers, Houston, Texas, USA
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5
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El-Mallawany NK, Villiera J, Kamiyango W, Peckham-Gregory EC, Scheurer ME, Allen CE, McAtee CL, Legarreta A, Dittmer DP, Kovarik CL, Chiao EY, Martin SC, Ozuah NW, Mehta PS, Kazembe PN. Endemic Kaposi sarcoma in HIV-negative children and adolescents: an evaluation of overlapping and distinct clinical features in comparison with HIV-related disease. Infect Agent Cancer 2018; 13:33. [PMID: 30455728 PMCID: PMC6230225 DOI: 10.1186/s13027-018-0207-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 10/31/2018] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Endemic Kaposi sarcoma (KS) was first described in African children over fifty years ago, but has recently been overshadowed by HIV-related disease. We aimed to evaluate the similarities and differences between endemic HIV-negative and epidemic HIV-positive pediatric KS in a KS-associated herpesvirus-endemic region of Africa. METHODS We describe clinical characteristics of 20 HIV-negative children with endemic KS over a six-year period and compare findings with a historical control-an HIV-related pediatric KS cohort from Lilongwe, Malawi. RESULTS The HIV-negative endemic KS cohort was 70% male with a median age of 9.3 years. Lymph node involvement was present in 50%, hyperpigmented skin lesions in 45%, and woody edema in 40%. One patient (5%) presented with oral KS involvement and no patients presented initially with visceral KS. Significant anemia (hemoglobin < 8 g/dL) and thrombocytopenia (platelet count < 100 × 109/L) were found at time of original KS diagnosis in 45 and 40% respectively. In both HIV-negative and HIV-positive cohorts, lymphadenopathy was the most common presentation, prototypical skin lesions were often absent, severe cytopenias were a common clinical feature, and treatment outcomes were similar. Patients with endemic KS demonstrated less frequent oral involvement (5% versus 29%, P = 0.03) and a lower proportion of patients with visceral involvement (0% versus 16%, P = 0.06). CONCLUSIONS These data suggest clinical overlap between epidemiological variants. Treatment protocols for pediatric KS in sub-Saharan Africa should be devised to include both endemic HIV-negative and epidemic HIV-related disease to better define the clinical and biological comparison.
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Affiliation(s)
- Nader Kim El-Mallawany
- Baylor College of Medicine, Department of Pediatrics, Section of Hematology-Oncology, Houston, TX USA
- Texas Children’s Cancer and Hematology Centers, Baylor College of Medicine, Global HOPE (Hematology-Oncology Pediatric Excellence), 1102 Bates Street, Feigin Tower, Suite 1025.16, Houston, TX 77030 USA
| | - Jimmy Villiera
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
- Kamuzu Central Hospital, Lilongwe, Malawi
| | - William Kamiyango
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
- Kamuzu Central Hospital, Lilongwe, Malawi
| | - Erin C. Peckham-Gregory
- Baylor College of Medicine, Department of Pediatrics, Section of Hematology-Oncology, Houston, TX USA
- Texas Children’s Cancer and Hematology Centers, Baylor College of Medicine, Global HOPE (Hematology-Oncology Pediatric Excellence), 1102 Bates Street, Feigin Tower, Suite 1025.16, Houston, TX 77030 USA
| | - Michael E. Scheurer
- Baylor College of Medicine, Department of Pediatrics, Section of Hematology-Oncology, Houston, TX USA
- Texas Children’s Cancer and Hematology Centers, Baylor College of Medicine, Global HOPE (Hematology-Oncology Pediatric Excellence), 1102 Bates Street, Feigin Tower, Suite 1025.16, Houston, TX 77030 USA
| | - Carl E. Allen
- Baylor College of Medicine, Department of Pediatrics, Section of Hematology-Oncology, Houston, TX USA
- Texas Children’s Cancer and Hematology Centers, Baylor College of Medicine, Global HOPE (Hematology-Oncology Pediatric Excellence), 1102 Bates Street, Feigin Tower, Suite 1025.16, Houston, TX 77030 USA
| | - Casey L. McAtee
- Baylor College of Medicine, Department of Pediatrics, Section of Hematology-Oncology, Houston, TX USA
- Texas Children’s Cancer and Hematology Centers, Baylor College of Medicine, Global HOPE (Hematology-Oncology Pediatric Excellence), 1102 Bates Street, Feigin Tower, Suite 1025.16, Houston, TX 77030 USA
| | - Alejandra Legarreta
- Baylor College of Medicine, Department of Pediatrics, Section of Hematology-Oncology, Houston, TX USA
- Texas Children’s Cancer and Hematology Centers, Baylor College of Medicine, Global HOPE (Hematology-Oncology Pediatric Excellence), 1102 Bates Street, Feigin Tower, Suite 1025.16, Houston, TX 77030 USA
| | - Dirk P. Dittmer
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC USA
| | | | - Elizabeth Y. Chiao
- Center for Innovation, Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, TX USA
- Baylor College of Medicine, Department of Medicine, Section of Infectious Diseases, Houston, TX USA
| | - Stephen C. Martin
- Baylor College of Medicine, Department of Pediatrics, Section of Hematology-Oncology, Houston, TX USA
- Texas Children’s Cancer and Hematology Centers, Baylor College of Medicine, Global HOPE (Hematology-Oncology Pediatric Excellence), 1102 Bates Street, Feigin Tower, Suite 1025.16, Houston, TX 77030 USA
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
| | - Nmazuo W. Ozuah
- Baylor College of Medicine, Department of Pediatrics, Section of Hematology-Oncology, Houston, TX USA
- Texas Children’s Cancer and Hematology Centers, Baylor College of Medicine, Global HOPE (Hematology-Oncology Pediatric Excellence), 1102 Bates Street, Feigin Tower, Suite 1025.16, Houston, TX 77030 USA
| | - Parth S. Mehta
- Baylor College of Medicine, Department of Pediatrics, Section of Hematology-Oncology, Houston, TX USA
- Texas Children’s Cancer and Hematology Centers, Baylor College of Medicine, Global HOPE (Hematology-Oncology Pediatric Excellence), 1102 Bates Street, Feigin Tower, Suite 1025.16, Houston, TX 77030 USA
| | - Peter N. Kazembe
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
- Kamuzu Central Hospital, Lilongwe, Malawi
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El-Mallawany NK, Mehta PS, Kamiyango W, Villiera J, Peckham-Gregory EC, Kampani C, Krysiak R, Sanders MK, Caro-Vegas C, Eason AB, Ahmed S, Schutze GE, Martin SC, Kazembe PN, Scheurer ME, Dittmer DP. KSHV viral load and Interleukin-6 in HIV-associated pediatric Kaposi sarcoma-Exploring the role of lytic activation in driving the unique clinical features seen in endemic regions. Int J Cancer 2018; 144:110-116. [PMID: 30204240 DOI: 10.1002/ijc.31863] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 08/15/2018] [Accepted: 08/23/2018] [Indexed: 01/12/2023]
Abstract
Kaposi sarcoma (KS) is among the most common childhood malignancies in central, eastern, and southern Africa. Although its unique clinical features have been established, biological mechanisms related to the causative agent, KS-associated herpes-virus (KSHV), have yet to be explored in children. We performed a prospective observational pilot study to explore associations between KSHV viral load (VL), human interleukin-6 (IL-6) and IL-10 levels, and clinical characteristics of 25 children with KS in Lilongwe, Malawi from June 2013-August 2015. The median age was 6.4 years. Lymphadenopathy was the most common site of KS involvement (64%), followed by skin and oral mucosa (44% each), woody edema (12%), and pulmonary (8%). Baseline samples for plasma KSHV VL, IL-6 and IL-10 analyses were available for 18/25 patients (72%) at time of KS diagnosis. KSHV VL was detectable at baseline in 12/18 (67%) patients, the median baseline IL-6 level was 8.53 pg/mL (range 4.31-28.33), and the median baseline IL-10 level was 19.53 pg/mL (range 6.91-419.69). Seven (39%) patients presented with an IL-6 level > 10 pg/mL (exceeding twice the upper limit of normal). Detectable KSHV VL was significantly associated with lymphadenopathic KS (p = 0.004), while having undetectable KSHV VL was associated with a higher likelihood of presenting with hyperpigmented skin lesions (p = 0.01). Detectable KSHV VL and elevated IL-6 levels are present in a subset of children with KS. Lytic activation of KSHV and associated elevation in KSHV VL may contribute to the unique clinical manifestations of pediatric KS in KSHV-endemic regions of Africa.
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Affiliation(s)
- Nader Kim El-Mallawany
- Baylor College of Medicine, Houston, TX.,Texas Children's Cancer and Hematology Centers, Houston, TX
| | - Parth S Mehta
- Baylor College of Medicine, Houston, TX.,Texas Children's Cancer and Hematology Centers, Houston, TX
| | - William Kamiyango
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Jimmy Villiera
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Erin C Peckham-Gregory
- Baylor College of Medicine, Houston, TX.,Texas Children's Cancer and Hematology Centers, Houston, TX
| | - Coxcilly Kampani
- University of North Carolina (UNC) Project Malawi, Lilongwe, Malawi
| | - Robert Krysiak
- University of North Carolina (UNC) Project Malawi, Lilongwe, Malawi
| | | | | | - Anthony B Eason
- Lineberger Comprehensive Cancer Center, UNC, Chapel Hill, NC
| | - Saeed Ahmed
- Baylor College of Medicine, Houston, TX.,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Gordon E Schutze
- Baylor College of Medicine, Houston, TX.,Texas Children's Hospital, Houston, TX
| | - Stephen C Martin
- Baylor College of Medicine, Houston, TX.,Texas Children's Cancer and Hematology Centers, Houston, TX.,Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Peter N Kazembe
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Michael E Scheurer
- Baylor College of Medicine, Houston, TX.,Texas Children's Cancer and Hematology Centers, Houston, TX
| | - Dirk P Dittmer
- Lineberger Comprehensive Cancer Center, UNC, Chapel Hill, NC
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7
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El-Mallawany NK, McAtee CL, Campbell LR, Kazembe PN. Pediatric Kaposi sarcoma in context of the HIV epidemic in sub-Saharan Africa: current perspectives. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2018; 9:35-46. [PMID: 29722363 PMCID: PMC5919159 DOI: 10.2147/phmt.s142816] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The global experience with pediatric Kaposi sarcoma (KS) has evolved immensely since the onset of HIV (human immunodeficiency virus). In this review, current perspectives on childhood KS are discussed in the context of the HIV epidemic in sub-Saharan Africa. Endemic (HIV-unrelated) KS was first described over 50 years ago in central and eastern Africa, regions where human herpesvirus-8, the causative agent of KS, is endemic. With the alarming rise in HIV prevalence over the past few decades, KS has become not only the most common HIV-related malignancy in Africa, but also one of the most common overall childhood cancers throughout the central, eastern, and southern regions of the continent. The unique clinical features of pediatric KS that were described in those early endemic KS reports have been re-affirmed by the contemporary experience with HIV-related KS. These characteristics include a predilection for primary lymph node involvement, significant proportions of patients lacking prototypical cutaneous lesions, and the potential for fulminant disease progression. Other clinical features that distinguish childhood KS from adult disease include disease presentation with severe cytopenias, and the common occurrence of childhood KS without severe CD4 count suppression. Distinct clinical heterogeneity in disease presentation and treatment response have been demonstrated. Long-term complete remission and event-free survival can be achieved—especially in children with lymphadenopathic KS—utilizing treatment with antiretroviral therapy plus mild–moderate chemotherapy regimens that are well tolerated, even in low-income settings. A pediatric-specific staging classification and risk-stratification platform have been retrospectively validated, and may help guide therapeutic strategies. With expansion of the HIV treatment infrastructure throughout Africa, coupled with recent developments in establishing comprehensive pediatric oncology programs, there is great potential for improving outcomes for children with KS. Increased awareness of the unique clinical nuances and collaborative evaluations of pediatric-specific treatment paradigms are required to optimize survival for children with KS.
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Affiliation(s)
- Nader Kim El-Mallawany
- Department of Pediatrics, Section of Hematology and Oncology, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Casey L McAtee
- Department of Pediatrics, Section of Hematology and Oncology, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Liane R Campbell
- Department of Pediatrics, Baylor College of Medicine Children's Foundation Tanzania, Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Mbeya, Tanzania
| | - Peter N Kazembe
- Department of Pediatrics, Baylor College of Medicine Children's Foundation Malawi, Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Lilongwe, Malawi.,Department of Pediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
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8
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Macken M, Dale H, Moyo D, Chakmata E, Depani S, Israels T, Niyrenda D, Bailey S, Chagaluka G, Molyneux EM. Triple therapy of vincristine, bleomycin and etoposide for children with Kaposi sarcoma: Results of a study in Malawian children. Pediatr Blood Cancer 2018; 65. [PMID: 28988435 DOI: 10.1002/pbc.26841] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 09/05/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND Kaposi sarcoma (KS) is the most common paediatric cancer in human immunodeficiency virus (HIV) endemic countries of sub-Saharan Africa, but there is little research on management and outcomes. METHODS Children with KS at Queen Elizabeth Central Hospital, Blantyre, Malawi treated between August 2012 and March 2015 with six courses of vincristine, bleomycin and etoposide combination chemotherapy, including antiretroviral therapy (ART) if HIV infected, were studied and outcomes compared with previously reported results. FINDINGS Fifty-six children were included; 38 (68%) were male; and 48 (86%) were HIV positive, of whom 36 (77%) were on ART at diagnosis. Median age at diagnosis was 8 years (interquartile range [IQR] 3-12) and median follow-up was 16.9 months (IQR 3.4-36.4). Quality of life improved in 45 (80%) children; the median Lansky Score increased from 80% pre-treatment to 100% post-treatment. Eighteen (32%) children had complete response to treatment. At 12 months, overall survival was 71% (95% confidence interval [CI] 56-82) and event-free survival (event = death, loss to follow-up or relapse) was 50% (95% CI 36-63). At 1 year, the risk of loss to follow-up was 13.4%. In a previous, same-site, randomized controlled study of vincristine monotherapy, vincristine and bleomycin, or oral etoposide, oral etoposide monotherapy had the best outcome with survival at 12 month of 66% (95% CI 46-80) and event-free survival of 52% (95% CI 33-68); however, loss to follow-up was not reported. CONCLUSION Overall survival, event-free survival and quality of life appear to have improved with this three-agent combination chemotherapy; however larger, randomized studies are needed to determine optimal management.
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Affiliation(s)
- Marita Macken
- Department of Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK
| | - Helen Dale
- Sheffield Children's Hospital, Sheffield, UK
| | - Dominic Moyo
- Queen Elizabeth Central Hospital, College of Medicine, Blantyre, Malawi
| | - Eunice Chakmata
- Queen Elizabeth Central Hospital, College of Medicine, Blantyre, Malawi
| | | | - Trijn Israels
- Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Dalida Niyrenda
- Queen Elizabeth Central Hospital, College of Medicine, Blantyre, Malawi
| | - Simon Bailey
- Sir James Spence Institute of Child Health, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - George Chagaluka
- Queen Elizabeth Central Hospital, College of Medicine, Blantyre, Malawi
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El-Mallawany NK, Kamiyango W, Villiera J, Slone JS, Kovarik CL, Campbell LR, Agrawal AK, Dittmer DP, Eason AB, Ahmed S, Schutze GE, Scheurer ME, Kazembe PN, Mehta PS. Proposal of a Risk-Stratification Platform to Address Distinct Clinical Features of Pediatric Kaposi Sarcoma in Lilongwe, Malawi. J Glob Oncol 2017; 4:1-7. [PMID: 29272148 PMCID: PMC6180767 DOI: 10.1200/jgo.17.00054] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Affiliation(s)
- Nader Kim El-Mallawany
- Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, Saeed Ahmed, Gordon E. Schutze, and Parth S. Mehta, Baylor College of Medicine; Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, and Parth S. Mehta, Texas Children's Cancer and Hematology Centers, Houston, TX; William Kamiyango, Jimmy Villiera, Saeed Ahmed, and Peter N. Kazembe, Baylor College of Medicine Children's Foundation Malawi; William Kamiyango, Jimmy Villiera, and Peter N. Kazembe, Kamuzu Central Hospital, Lilongwe, Malawi; Carrie L. Kovarik, University of Pennsylvania, Philadelphia, PA; Liane R. Campbell, Baylor College of Medicine Children's Foundation Tanzania, Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Mbeya, Tanzania; Anurag K. Agrawal, Children's Hospital and Research Center Oakland, Oakland, CA; and Dirk P. Dittmer and Anthony B. Eason, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - William Kamiyango
- Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, Saeed Ahmed, Gordon E. Schutze, and Parth S. Mehta, Baylor College of Medicine; Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, and Parth S. Mehta, Texas Children's Cancer and Hematology Centers, Houston, TX; William Kamiyango, Jimmy Villiera, Saeed Ahmed, and Peter N. Kazembe, Baylor College of Medicine Children's Foundation Malawi; William Kamiyango, Jimmy Villiera, and Peter N. Kazembe, Kamuzu Central Hospital, Lilongwe, Malawi; Carrie L. Kovarik, University of Pennsylvania, Philadelphia, PA; Liane R. Campbell, Baylor College of Medicine Children's Foundation Tanzania, Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Mbeya, Tanzania; Anurag K. Agrawal, Children's Hospital and Research Center Oakland, Oakland, CA; and Dirk P. Dittmer and Anthony B. Eason, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Jimmy Villiera
- Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, Saeed Ahmed, Gordon E. Schutze, and Parth S. Mehta, Baylor College of Medicine; Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, and Parth S. Mehta, Texas Children's Cancer and Hematology Centers, Houston, TX; William Kamiyango, Jimmy Villiera, Saeed Ahmed, and Peter N. Kazembe, Baylor College of Medicine Children's Foundation Malawi; William Kamiyango, Jimmy Villiera, and Peter N. Kazembe, Kamuzu Central Hospital, Lilongwe, Malawi; Carrie L. Kovarik, University of Pennsylvania, Philadelphia, PA; Liane R. Campbell, Baylor College of Medicine Children's Foundation Tanzania, Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Mbeya, Tanzania; Anurag K. Agrawal, Children's Hospital and Research Center Oakland, Oakland, CA; and Dirk P. Dittmer and Anthony B. Eason, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Jeremy S Slone
- Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, Saeed Ahmed, Gordon E. Schutze, and Parth S. Mehta, Baylor College of Medicine; Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, and Parth S. Mehta, Texas Children's Cancer and Hematology Centers, Houston, TX; William Kamiyango, Jimmy Villiera, Saeed Ahmed, and Peter N. Kazembe, Baylor College of Medicine Children's Foundation Malawi; William Kamiyango, Jimmy Villiera, and Peter N. Kazembe, Kamuzu Central Hospital, Lilongwe, Malawi; Carrie L. Kovarik, University of Pennsylvania, Philadelphia, PA; Liane R. Campbell, Baylor College of Medicine Children's Foundation Tanzania, Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Mbeya, Tanzania; Anurag K. Agrawal, Children's Hospital and Research Center Oakland, Oakland, CA; and Dirk P. Dittmer and Anthony B. Eason, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Carrie L Kovarik
- Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, Saeed Ahmed, Gordon E. Schutze, and Parth S. Mehta, Baylor College of Medicine; Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, and Parth S. Mehta, Texas Children's Cancer and Hematology Centers, Houston, TX; William Kamiyango, Jimmy Villiera, Saeed Ahmed, and Peter N. Kazembe, Baylor College of Medicine Children's Foundation Malawi; William Kamiyango, Jimmy Villiera, and Peter N. Kazembe, Kamuzu Central Hospital, Lilongwe, Malawi; Carrie L. Kovarik, University of Pennsylvania, Philadelphia, PA; Liane R. Campbell, Baylor College of Medicine Children's Foundation Tanzania, Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Mbeya, Tanzania; Anurag K. Agrawal, Children's Hospital and Research Center Oakland, Oakland, CA; and Dirk P. Dittmer and Anthony B. Eason, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Liane R Campbell
- Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, Saeed Ahmed, Gordon E. Schutze, and Parth S. Mehta, Baylor College of Medicine; Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, and Parth S. Mehta, Texas Children's Cancer and Hematology Centers, Houston, TX; William Kamiyango, Jimmy Villiera, Saeed Ahmed, and Peter N. Kazembe, Baylor College of Medicine Children's Foundation Malawi; William Kamiyango, Jimmy Villiera, and Peter N. Kazembe, Kamuzu Central Hospital, Lilongwe, Malawi; Carrie L. Kovarik, University of Pennsylvania, Philadelphia, PA; Liane R. Campbell, Baylor College of Medicine Children's Foundation Tanzania, Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Mbeya, Tanzania; Anurag K. Agrawal, Children's Hospital and Research Center Oakland, Oakland, CA; and Dirk P. Dittmer and Anthony B. Eason, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Anurag K Agrawal
- Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, Saeed Ahmed, Gordon E. Schutze, and Parth S. Mehta, Baylor College of Medicine; Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, and Parth S. Mehta, Texas Children's Cancer and Hematology Centers, Houston, TX; William Kamiyango, Jimmy Villiera, Saeed Ahmed, and Peter N. Kazembe, Baylor College of Medicine Children's Foundation Malawi; William Kamiyango, Jimmy Villiera, and Peter N. Kazembe, Kamuzu Central Hospital, Lilongwe, Malawi; Carrie L. Kovarik, University of Pennsylvania, Philadelphia, PA; Liane R. Campbell, Baylor College of Medicine Children's Foundation Tanzania, Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Mbeya, Tanzania; Anurag K. Agrawal, Children's Hospital and Research Center Oakland, Oakland, CA; and Dirk P. Dittmer and Anthony B. Eason, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Dirk P Dittmer
- Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, Saeed Ahmed, Gordon E. Schutze, and Parth S. Mehta, Baylor College of Medicine; Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, and Parth S. Mehta, Texas Children's Cancer and Hematology Centers, Houston, TX; William Kamiyango, Jimmy Villiera, Saeed Ahmed, and Peter N. Kazembe, Baylor College of Medicine Children's Foundation Malawi; William Kamiyango, Jimmy Villiera, and Peter N. Kazembe, Kamuzu Central Hospital, Lilongwe, Malawi; Carrie L. Kovarik, University of Pennsylvania, Philadelphia, PA; Liane R. Campbell, Baylor College of Medicine Children's Foundation Tanzania, Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Mbeya, Tanzania; Anurag K. Agrawal, Children's Hospital and Research Center Oakland, Oakland, CA; and Dirk P. Dittmer and Anthony B. Eason, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Anthony B Eason
- Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, Saeed Ahmed, Gordon E. Schutze, and Parth S. Mehta, Baylor College of Medicine; Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, and Parth S. Mehta, Texas Children's Cancer and Hematology Centers, Houston, TX; William Kamiyango, Jimmy Villiera, Saeed Ahmed, and Peter N. Kazembe, Baylor College of Medicine Children's Foundation Malawi; William Kamiyango, Jimmy Villiera, and Peter N. Kazembe, Kamuzu Central Hospital, Lilongwe, Malawi; Carrie L. Kovarik, University of Pennsylvania, Philadelphia, PA; Liane R. Campbell, Baylor College of Medicine Children's Foundation Tanzania, Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Mbeya, Tanzania; Anurag K. Agrawal, Children's Hospital and Research Center Oakland, Oakland, CA; and Dirk P. Dittmer and Anthony B. Eason, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Saeed Ahmed
- Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, Saeed Ahmed, Gordon E. Schutze, and Parth S. Mehta, Baylor College of Medicine; Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, and Parth S. Mehta, Texas Children's Cancer and Hematology Centers, Houston, TX; William Kamiyango, Jimmy Villiera, Saeed Ahmed, and Peter N. Kazembe, Baylor College of Medicine Children's Foundation Malawi; William Kamiyango, Jimmy Villiera, and Peter N. Kazembe, Kamuzu Central Hospital, Lilongwe, Malawi; Carrie L. Kovarik, University of Pennsylvania, Philadelphia, PA; Liane R. Campbell, Baylor College of Medicine Children's Foundation Tanzania, Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Mbeya, Tanzania; Anurag K. Agrawal, Children's Hospital and Research Center Oakland, Oakland, CA; and Dirk P. Dittmer and Anthony B. Eason, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Gordon E Schutze
- Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, Saeed Ahmed, Gordon E. Schutze, and Parth S. Mehta, Baylor College of Medicine; Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, and Parth S. Mehta, Texas Children's Cancer and Hematology Centers, Houston, TX; William Kamiyango, Jimmy Villiera, Saeed Ahmed, and Peter N. Kazembe, Baylor College of Medicine Children's Foundation Malawi; William Kamiyango, Jimmy Villiera, and Peter N. Kazembe, Kamuzu Central Hospital, Lilongwe, Malawi; Carrie L. Kovarik, University of Pennsylvania, Philadelphia, PA; Liane R. Campbell, Baylor College of Medicine Children's Foundation Tanzania, Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Mbeya, Tanzania; Anurag K. Agrawal, Children's Hospital and Research Center Oakland, Oakland, CA; and Dirk P. Dittmer and Anthony B. Eason, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Michael E Scheurer
- Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, Saeed Ahmed, Gordon E. Schutze, and Parth S. Mehta, Baylor College of Medicine; Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, and Parth S. Mehta, Texas Children's Cancer and Hematology Centers, Houston, TX; William Kamiyango, Jimmy Villiera, Saeed Ahmed, and Peter N. Kazembe, Baylor College of Medicine Children's Foundation Malawi; William Kamiyango, Jimmy Villiera, and Peter N. Kazembe, Kamuzu Central Hospital, Lilongwe, Malawi; Carrie L. Kovarik, University of Pennsylvania, Philadelphia, PA; Liane R. Campbell, Baylor College of Medicine Children's Foundation Tanzania, Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Mbeya, Tanzania; Anurag K. Agrawal, Children's Hospital and Research Center Oakland, Oakland, CA; and Dirk P. Dittmer and Anthony B. Eason, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Peter N Kazembe
- Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, Saeed Ahmed, Gordon E. Schutze, and Parth S. Mehta, Baylor College of Medicine; Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, and Parth S. Mehta, Texas Children's Cancer and Hematology Centers, Houston, TX; William Kamiyango, Jimmy Villiera, Saeed Ahmed, and Peter N. Kazembe, Baylor College of Medicine Children's Foundation Malawi; William Kamiyango, Jimmy Villiera, and Peter N. Kazembe, Kamuzu Central Hospital, Lilongwe, Malawi; Carrie L. Kovarik, University of Pennsylvania, Philadelphia, PA; Liane R. Campbell, Baylor College of Medicine Children's Foundation Tanzania, Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Mbeya, Tanzania; Anurag K. Agrawal, Children's Hospital and Research Center Oakland, Oakland, CA; and Dirk P. Dittmer and Anthony B. Eason, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Parth S Mehta
- Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, Saeed Ahmed, Gordon E. Schutze, and Parth S. Mehta, Baylor College of Medicine; Nader Kim El-Mallawany, Jeremy S. Slone, Michael E. Scheurer, and Parth S. Mehta, Texas Children's Cancer and Hematology Centers, Houston, TX; William Kamiyango, Jimmy Villiera, Saeed Ahmed, and Peter N. Kazembe, Baylor College of Medicine Children's Foundation Malawi; William Kamiyango, Jimmy Villiera, and Peter N. Kazembe, Kamuzu Central Hospital, Lilongwe, Malawi; Carrie L. Kovarik, University of Pennsylvania, Philadelphia, PA; Liane R. Campbell, Baylor College of Medicine Children's Foundation Tanzania, Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Mbeya, Tanzania; Anurag K. Agrawal, Children's Hospital and Research Center Oakland, Oakland, CA; and Dirk P. Dittmer and Anthony B. Eason, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
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10
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Abstract
Kaposi sarcoma (KS) is the most common neoplasm of people living with HIV today. In Sub-Saharan Africa, KS is among the most common cancers in men, overall. Not only HIV-positive individuals present with KS; any immune compromised person infected with KS-associated herpesvirus (KSHV) or human herpesvirus 8 is at risk: the elderly, children in KSHV-endemic areas, and transplant recipients. KS diagnosis is based on detection of the viral protein latency-associated nuclear antigen (LANA) in the biopsy, but not all cases of KS are the same or will respond to the same therapy. Standard KS therapy has not changed in 20 years, but newer modalities are on the horizon and will be discussed.
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11
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Hudson BF, Oostendorp LJM, Candy B, Vickerstaff V, Jones L, Lakhanpaul M, Bluebond-Langner M, Stone P. The under reporting of recruitment strategies in research with children with life-threatening illnesses: A systematic review. Palliat Med 2017; 31:419-436. [PMID: 27609607 PMCID: PMC5405809 DOI: 10.1177/0269216316663856] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Researchers report difficulties in conducting research with children and young people with life-limiting conditions or life-threatening illnesses and their families. Recruitment is challenged by barriers including ethical, logistical and clinical considerations. AIM To explore how children and young people (aged 0-25 years) with life-limiting conditions or life-threatening illnesses and their families were identified, invited and consented to research published in the last 5 years. DESIGN Systematic review. DATA SOURCES MEDLINE, PsycINFO, Web of Science, Sciences Citation Index and SCOPUS were searched for original English language research published between 2009 and 2014, recruiting children and young people with life-limiting conditions or life-threatening illness and their families. RESULTS A total of 215 studies - 152 qualitative, 54 quantitative and 9 mixed methods - were included. Limited recruitment information but a range of strategies and difficulties were provided. The proportion of eligible participants from those screened could not be calculated in 80% of studies. Recruitment rates could not be calculated in 77%. A total of 31% of studies recruited less than 50% of eligible participants. Reasons given for non-invitation included missing clinical or contact data, or clinician judgements of participant unsuitability. Reasons for non-participation included lack of interest and participants' perceptions of potential burdens. CONCLUSION All stages of recruitment were under reported. Transparency in reporting of participant identification, invitation and consent is needed to enable researchers to understand research implications, bias risk and to whom results apply. Research is needed to explore why consenting participants decide to take part or not and their experiences of research recruitment.
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Affiliation(s)
- Briony F Hudson
- Louis Dundas Centre for Children’s Palliative Care, UCL Institute of Child Health, London, UK
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, London, UK
| | - Linda JM Oostendorp
- Louis Dundas Centre for Children’s Palliative Care, UCL Institute of Child Health, London, UK
| | - Bridget Candy
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, London, UK
| | - Louise Jones
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, London, UK
| | - Monica Lakhanpaul
- Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK
| | - Myra Bluebond-Langner
- Louis Dundas Centre for Children’s Palliative Care, UCL Institute of Child Health, London, UK
| | - Paddy Stone
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, London, UK
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12
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Bohlius J, Rohner E, Egger M. Reply to El-Mallawany et al. Clin Infect Dis 2017; 64:819-820. [PMID: 28077521 DOI: 10.1093/cid/ciw880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Julia Bohlius
- Institute of Social and Preventive Medicine, University of Bern, Switzerland
| | - Eliane Rohner
- Institute of Social and Preventive Medicine, University of Bern, Switzerland
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Switzerland.,Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
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13
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Ndounga Diakou LA, Ntoumi F, Ravaud P, Boutron I. Published randomized trials performed in Sub-Saharan Africa focus on high-burden diseases but are frequently funded and led by high-income countries. J Clin Epidemiol 2017; 82:29-36.e6. [DOI: 10.1016/j.jclinepi.2016.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 10/10/2016] [Accepted: 10/26/2016] [Indexed: 01/05/2023]
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14
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Abstract
PURPOSE OF REVIEW HIV-infected children are at an increased risk of developing cancer. Many of the cancers in HIV-infected children are linked to immunosuppression and oncogenic coinfections. Worldwide most HIV-infected children live in sub-Saharan Africa, but cancer data for this population are scarce. In this article, we review the current literature on the epidemiology and prevention of cancer in HIV-infected children. RECENT FINDINGS Combined antiretroviral therapy (cART) reduces the risk of developing cancer in HIV-infected children. Cancer risk remains increased in children who start cART at older ages or more advanced immunosuppression as compared with children who start cART at younger age and with mild immunosuppression. Starting cART before severe immunosuppression develops is key to prevent cancer in HIV-infected children but most children in low-income countries start cART at severe immunosuppression levels. Vaccination against high-risk variants of human papillomavirus may protect again human papillomavirus-associated cancer later in life. However, tailoring of human papillomavirus vaccination guidelines for HIV-infected children and young women awaits answers to determine the best vaccination strategies. SUMMARY Better data on the short-term and long-term risks of developing cancer and the effects of preventive measures in HIV-infected children from regions with high burden of HIV/AIDS are urgently needed.
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Affiliation(s)
- Elvira Singh
- National Cancer Registry, National Health Laboratory Service, Johannesburg, South Africa
| | - Gita Naidu
- Paediatric Haematology Oncology, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Julia Bohlius
- Institute for Social and Preventive Medicine, University of Bern, Switzerland
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15
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Chinula L, Moses A, Gopal S. HIV-associated malignancies in sub-Saharan Africa: progress, challenges, and opportunities. Curr Opin HIV AIDS 2017; 12:89-95. [PMID: 27607593 PMCID: PMC5241291 DOI: 10.1097/coh.0000000000000329] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW To summarize recent developments for HIV-associated malignancies (HIVAM) in low-income and middle-income countries (LMIC) with particular focus on sub-Saharan Africa (SSA). RECENT FINDINGS Antiretroviral therapy (ART) scale-up is leading to epidemiologic transitions in LMIC similar to high-income countries, with aging and growth of HIV-infected populations, declining infectious deaths, increasing cancer deaths, and transitions from AIDS-defining cancers to non-AIDS defining cancers. Despite ART scale-up, the HIVAM burden remains high including an enormous AIDS-defining cancers burden in SSA. For Kaposi sarcoma, patients treated with ART and chemotherapy can experience good outcomes even in rural SSA, but Kaposi sarcoma heterogeneity remains insufficiently understood including virologic, immunologic, and inflammatory features that may be unique to LMIC. For cervical cancer, scale-up of prevention efforts including vaccination and screening is underway, with benefits already apparent despite continuing high disease burden. For non-Hodgkin lymphoma, curative treatment is possible in the ART era even in SSA, and multifaceted approaches can improve outcomes further. For many other prevalent HIVAM, care and research efforts are being established to guide treatment and prevention specifically in LMIC. SUMMARY Sustained investment for HIVAM in LMIC can help catalyze a cancer care and research agenda that benefits HIV-positive and HIV-negative patients worldwide.
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Affiliation(s)
- Lameck Chinula
- UNC Project-Malawi
- University of North Carolina at Chapel Hill
- University of Malawi College of Medicine
| | - Agnes Moses
- UNC Project-Malawi
- University of North Carolina at Chapel Hill
- University of Malawi College of Medicine
| | - Satish Gopal
- UNC Project-Malawi
- University of North Carolina at Chapel Hill
- University of Malawi College of Medicine
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16
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Rohner E, Schmidlin K, Zwahlen M, Chakraborty R, Clifford G, Obel N, Grabar S, Verbon A, Noguera-Julian A, Collins IJ, Rojo P, Brockmeyer N, Campbell M, Chêne G, Prozesky H, Eley B, Stefan DC, Davidson A, Chimbetete C, Sawry S, Davies MA, Kariminia A, Vibol U, Sohn A, Egger M, Bohlius J. Kaposi Sarcoma Risk in HIV-Infected Children and Adolescents on Combination Antiretroviral Therapy From Sub-Saharan Africa, Europe, and Asia. Clin Infect Dis 2016; 63:1245-1253. [PMID: 27578823 PMCID: PMC5064163 DOI: 10.1093/cid/ciw519] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 07/21/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The burden of Kaposi sarcoma (KS) in human immunodeficiency virus (HIV)-infected children and adolescents on combination antiretroviral therapy (cART) has not been compared globally. METHODS We analyzed cohort data from the International Epidemiologic Databases to Evaluate AIDS and the Collaboration of Observational HIV Epidemiological Research in Europe. We included HIV-infected children aged <16 years at cART initiation from 1996 onward. We used Cox models to calculate hazard ratios (HRs), adjusted for region and origin, sex, cART start year, age, and HIV/AIDS stage at cART initiation. RESULTS We included 24 991 children from eastern Africa, southern Africa, Europe and Asia; 26 developed KS after starting cART. Incidence rates per 100 000 person-years (PYs) were 86 in eastern Africa (95% confidence interval [CI], 55-133), 11 in southern Africa (95% CI, 4-35), and 81 (95% CI, 26-252) in children of sub-Saharan African (SSA) origin in Europe. The KS incidence rates were 0/100 000 PYs in children of non-SSA origin in Europe (95% CI, 0-50) and in Asia (95% CI, 0-27). KS risk was lower in girls than in boys (adjusted HR [aHR], 0.3; 95% CI, .1-.9) and increased with age (10-15 vs 0-4 years; aHR, 3.4; 95% CI, 1.2-10.1) and advanced HIV/AIDS stage (CDC stage C vs A/B; aHR, 2.4; 95% CI, .8-7.3) at cART initiation. CONCLUSIONS HIV-infected children from SSA but not those from other regions, have a high risk of developing KS after cART initiation. Early cART initiation in these children might reduce KS risk.
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El-Mallawany NK, Kamiyango W, Slone JS, Villiera J, Kovarik CL, Cox CM, Dittmer DP, Ahmed S, Schutze GE, Scheurer ME, Kazembe PN, Mehta PS. Clinical Factors Associated with Long-Term Complete Remission versus Poor Response to Chemotherapy in HIV-Infected Children and Adolescents with Kaposi Sarcoma Receiving Bleomycin and Vincristine: A Retrospective Observational Study. PLoS One 2016; 11:e0153335. [PMID: 27082863 PMCID: PMC4833299 DOI: 10.1371/journal.pone.0153335] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 03/28/2016] [Indexed: 01/09/2023] Open
Abstract
Kaposi sarcoma (KS) is the most common HIV-associated malignancy in children and adolescents in Africa. Pediatric KS is distinct from adult disease. We evaluated the clinical characteristics associated with long-term outcomes. We performed a retrospective observational analysis of 70 HIV-infected children and adolescents with KS less than 18 years of age diagnosed between 8/2010 and 6/2013 in Lilongwe, Malawi. Local first-line treatment included bleomycin and vincristine plus nevirapine-based highly active anti-retroviral therapy (HAART). Median age was 8.6 years (range 1.7–17.9); there were 35 females (50%). Most common sites of presentation were: lymph node (74%), skin (59%), subcutaneous nodules (33%), oral (27%), woody edema (24%), and visceral (16%). Eighteen (26%) presented with lymphadenopathy only. Severe CD4 suppression occurred in 28%. At time of KS diagnosis, 49% were already on HAART. Overall, 28% presented with a platelet count < 100 x 109/L and 37% with hemoglobin < 8 g/dL. The 2-year event-free (EFS) and overall survival (OS) were 46% and 58% respectively (median follow-up 29 months, range 15–50). Multivariable analysis of risk of death and failure to achieve EFS demonstrated that visceral disease (odds ratios [OR] 19.08 and 11.61, 95% CI 2.22–163.90 and 1.60–83.95 respectively) and presenting with more than 20 skin/oral lesions (OR 9.57 and 22.90, 95% CI 1.01–90.99 and 1.00–524.13 respectively) were independent risk factors for both. Woody edema was associated with failure to achieve EFS (OR 7.80, 95% CI 1.84–33.08) but not death. Univariable analysis revealed that lymph node involvement was favorable for EFS (OR 0.28, 95% CI 0.08–0.99), while T1 TIS staging criteria, presence of cytopenias, and severe immune suppression were not associated with increased mortality. Long-term complete remission is achievable in pediatric KS, however outcomes vary according to clinical presentation. Based on clinical heterogeneity, treatment according to risk-stratification is necessary to improve overall outcomes.
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Affiliation(s)
- Nader Kim El-Mallawany
- Department of Pediatrics, Division of Hematology, Oncology, and Hematopoietic Stem Cell Transplantation, New York Medical College, Valhalla, New York, United States of America
- Department of Pediatrics, Section of Hematology and Oncology, Baylor College of Medicine, Houston, Texas, United States of America
- * E-mail:
| | - William Kamiyango
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
| | - Jeremy S. Slone
- Department of Pediatrics, Section of Hematology and Oncology, Baylor College of Medicine, Houston, Texas, United States of America
- Texas Children’s Cancer and Hematology Centers, Houston, Texas, United States of America
| | - Jimmy Villiera
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
| | - Carrie L. Kovarik
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Carrie M. Cox
- Department of Pediatrics, Loyola University Chicago, Stritch School of Medicine, Maywood, Illinois, United States of America
| | - Dirk P. Dittmer
- Department of Microbiology and Immunology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Saeed Ahmed
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States of America
| | - Gordon E. Schutze
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States of America
| | - Michael E. Scheurer
- Department of Pediatrics, Section of Hematology and Oncology, Baylor College of Medicine, Houston, Texas, United States of America
- Texas Children’s Cancer and Hematology Centers, Houston, Texas, United States of America
| | - Peter N. Kazembe
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
| | - Parth S. Mehta
- Department of Pediatrics, Section of Hematology and Oncology, Baylor College of Medicine, Houston, Texas, United States of America
- Texas Children’s Cancer and Hematology Centers, Houston, Texas, United States of America
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Jackson CC, Dickson MA, Sadjadi M, Gessain A, Abel L, Jouanguy E, Casanova J. Kaposi Sarcoma of Childhood: Inborn or Acquired Immunodeficiency to Oncogenic HHV-8. Pediatr Blood Cancer 2016; 63:392-7. [PMID: 26469702 PMCID: PMC4984265 DOI: 10.1002/pbc.25779] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 09/04/2015] [Accepted: 09/10/2015] [Indexed: 12/13/2022]
Abstract
Kaposi sarcoma (KS) is an endothelial malignancy caused by human herpes virus-8 (HHV-8) infection. The epidemic and iatrogenic forms of childhood KS result from a profound and acquired T cell deficiency. Recent studies have shown that classic KS of childhood can result from rare single-gene inborn errors of immunity, with mutations in WAS, IFNGR1, STIM1, and TNFRSF4. The pathogenesis of the endemic form of childhood KS has remained elusive. We review childhood KS pathogenesis and its relationship to inherited and acquired immunodeficiency to oncogenic HHV-8.
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Affiliation(s)
- Carolyn C. Jackson
- St. Giles Laboratory of Human Genetics of Infectious DiseasesRockefeller BranchThe Rockefeller UniversityNew York
- Department of PediatricsMemorial Sloan Kettering Cancer CenterNew York
| | - Mark A. Dickson
- Department of MedicineMemorial Sloan Kettering Cancer CenterNew York
- Department of MedicineWeill Cornell Medical CollegeNew York
| | - Mahan Sadjadi
- St. Giles Laboratory of Human Genetics of Infectious DiseasesRockefeller BranchThe Rockefeller UniversityNew York
| | - Antoine Gessain
- Unit of Epidemiology and Physiopathology of Oncogenic VirusesInstitut PasteurParisFrance
| | - Laurent Abel
- St. Giles Laboratory of Human Genetics of Infectious DiseasesRockefeller BranchThe Rockefeller UniversityNew York
- Laboratory of Human Genetics of Infectious DiseasesNecker BranchINSERM U1163ParisFrance
- Paris Descartes UniversityImagine InstituteParisFrance
| | - Emmanuelle Jouanguy
- St. Giles Laboratory of Human Genetics of Infectious DiseasesRockefeller BranchThe Rockefeller UniversityNew York
- Laboratory of Human Genetics of Infectious DiseasesNecker BranchINSERM U1163ParisFrance
- Paris Descartes UniversityImagine InstituteParisFrance
| | - Jean‐Laurent Casanova
- St. Giles Laboratory of Human Genetics of Infectious DiseasesRockefeller BranchThe Rockefeller UniversityNew York
- Laboratory of Human Genetics of Infectious DiseasesNecker BranchINSERM U1163ParisFrance
- Paris Descartes UniversityImagine InstituteParisFrance
- Howard Hughes Medical Institute
- Pediatric Hematology‐Immunology UnitNecker Hospital for Sick ChildrenParisFrance
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Mittermayer-Vassallo K, Banda K, Molyneux EM. Kaposi sarcoma in HIV-seronegative children presenting to the paediatric oncology ward in The Queen Elizabeth Central Hospital, Blantyre, Malawi during 2002-2014. Trop Doct 2015; 46:138-42. [PMID: 26620689 DOI: 10.1177/0049475515614738] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
One of the most common malignancies in HIV-endemic, resource-poor countries is Kaposi sarcoma (KS). It is an AIDS-defining disease and as Malawi's incidence and prevalence of HIV is high, KS is now the most common cancer in adult male Malawians and the second most common in women and children. Most attention has focused on HIV-seropositive adults as their number far outweighs those of children. This audit concerns the presentation and outcome of HIV-seronegative children with KS who presented in a 12-year period (2002-2014) to The Queen Elizabeth Central Hospital. Twenty (10.5%) of the 191 children with KS presenting to the paediatric oncology ward during 2002-2014 were HIV-seronegative. They were usually younger than seropositive children and 62% had severe anaemia. The main presenting complaints in the HIV-seronegative group were woody oedema, commonly of a limb, and lymphadenopathy. Woody oedema was common in children with or without HIV infection. Seronegative children with KS were less likely to have oral KS than HIV infected children. Of 11 children who completed courses of chemotherapy, seven (63%) had complete cure sustained over a 1-year follow-up period. KS is potentially curable in this group of children. Chemotherapy regimens are equally effective in HIV-seropositive and HIV-seronegative children. The presentation of HIV-seronegative children with KS differs from adults and HIV-seropositive children. Further research is necessary to determine possible triggers for developing KS in HIV-seronegative children.
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Affiliation(s)
| | - Kondwani Banda
- Clinical Officer, Queen Elizabeth Central Hospital, Blantyre, Malawi
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