Clinical aspects and management of AIDS-related Kaposi's sarcoma

Kaposi sarcoma presenting as small bowel obstruction

Kaposi sarcoma (KS) is a low-grade tumor of the vascular endothelium. The majority of individuals affected have advanced human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS). The disease typically manifests as cutaneous lesions but reports have shown that systemic disease is not uncommon. Because gastrointestinal KS is often asymptomatic, it is likely underdiagnosed. Those with symptoms can present with vague abdominal pain, nausea/vomiting or anemia. Rarely the tumors can cause bowel obstruction or perforation. We present a case of small bowel obstruction cause by KS tumors in a young transgender male to female patient with poorly controlled AIDS, supported by literature review of the clinical presentation, diagnosis and treatment recommendations.

Chemotherapy-Induced Hepatotoxicity in HIV Patients

Human immunodeficiency virus (HIV) affects more than 37 million people globally, and in 2020, more than 680,000 people died from HIV-related causes. Recently, these numbers have decrease substantially and continue to reduce thanks to the use of antiretroviral therapy (ART), thus making HIV a chronic disease state for those dependent on lifelong use of ART. However, patients with HIV have an increased risk of developing some type of cancer compared to patients without HIV. Therefore, treatment of patients who are diagnosed with both HIV and cancer represents a complicated scenario because of the risk associated with drug-drug interaction (DDIs) and related toxicity. Selection of an alternative chemotherapy or ART or temporarily discontinuation of ART constitute a strategy to manage the risk of DDIs. Temporarily withholding ART is the less desirable clinical plan but risks and benefits must be considered in each scenario. In this review we focus on the hepatotoxicity associated with a simultaneous treatment with ART and chemotherapeutic drugs and mechanisms behind. Moreover, we also discuss the effect on the liver caused by the association of immunotherapeutic drugs, which have recently been used in clinical trials and also in HIV patients.

Primary Gastrointestinal Kaposi's Sarcoma in a Patient with Human Immunodeficiency Virus

Gastrointestinal bleeding in HIV patients secondary to coinfection by HHV8 and development of Kaposi's sarcoma (KS) is a rare complication even if no skin lesions are detected on physical examination. This article indicates which patients might develop this type of clinical sign and also tries to recall that absence of skin lesions never rules out the presence of KS, especially if gastrointestinal involvement is documented. Gastrointestinal bleeding in terms of hematemesis has rarely been reported in the literature. We review some important clinical findings, diagnosis, and treatment approach. We present the case of an HIV patient who presented to the emergency department with hematemesis and gastrointestinal signs of KS on upper gastrointestinal endoscopy without any dermatological involvement.

Alitretinoin in Dermatology-An Update

Alitretinoin is a pan retinoic acid agonist. It was initially used as 0.1% gel in the management of localized Kaposi's sarcoma. At present, the use of systemic alitretinoin has proved extremely efficacious in the management of recalcitrant chronic hand eczema. Furthermore, there have been other retinoid responsive dermatosis that have demonstrated remission post usage of systemic alitretinoin. With a better toxicity profile, compared to the other systemic retinoids, alitretinoin could be considered a valuable treatment option in the near future for the treatment of these dermatologic disorders.

Upper gastrointestinal Kaposi's sarcoma in HIV-infected patients: ten years of endoscopy observation at a single Brazilian center

BACKGROUND

Kaposi's sarcoma (KS) is the most common neoplasm among HIV-infected individuals. The frequency of involvement of KS in the gastrointestinal (GI) tract and the associated epidemiological, immune, endoscopic, and histopathological features in HIV-infected patients, were evaluated in this study.

METHODS

A review of the medical and endoscopy reports of 1428 HIV-infected patients, who had undergone upper GI endoscopy at the Endoscopy Service, Clinical Hospital, Faculty of Medicine of Ribeirão Preto between January 1999 and June 2009, was performed. Clinical, epidemiological, immunological, endoscopic, and histological data were collected.

RESULTS

Twenty-seven (1.9%) patients were diagnosed with GI KS. Patients were predominantly male (81.5%). Sexual activity was the main route of HIV transmission (81.5%). Cutaneous involvement was noted in 21 patients (78%). Fifteen patients (55%) received highly active antiretroviral therapy for a mean duration of 12.6 weeks (range 2-52 weeks) before endoscopy. GI lesions were mainly found in the stomach (55%). Analysis of the immunohistochemical methods HHV8 LNA-1, CD31, and CD34 for the diagnosis of gastric KS indicated high agreement (kappa=0.63, 95% confidence interval 0.32-0.94). There was no relationship between CD4 levels (p=0.34) or HIV viral load (p=0.99) and HHV8 LNA-1 positivity in gastric KS.

CONCLUSIONS

GI KS is an infrequent finding in patients with HIV infection. Among those with GI KS, 80% had concomitant skin lesions. Immunohistochemical methods for CD31, CD34, and LNA-1 were important tools in the diagnostic assessment of lesions suggestive of KS in the GI tract. Further studies are required to confirm these data, and the need for routine endoscopic investigation of the GI tract in HIV-infected patients with cutaneous KS should be assessed.

Gastrointestinal Kaposi’s sarcoma: Case report and review of the literature

Kaposi’s sarcoma (KS) of the gastrointestinal tract is not an uncommon disease among individuals with acquired immunodeficiency syndrome (AIDS). The majority is asymptomatic, and for this reason, gastrointestinal KS (GI-KS) remains undiagnosed. With continued tumor growth, considerable variation in clinical presentation occurs including abdominal pain, nausea, vomiting, iron deficiency anemia (either chronic or frank gastrointestinal bleeding), and rarely mechanical obstruction alone or combined with bowel perforation. Endoscopy with biopsy allows for histological and immunohistochemical testing to confirm the diagnosis of GI-KS among those with clinical symptoms. In previous studies, dual treatment with highly active antiretroviral therapy and systemic chemotherapy have been associated with improved morbidity and mortality in individuals with visceral KS. Therefore, investigators have suggested performing screening endoscopies in select patients for early detection and treatment to improve outcome. In this review, we describe a 44 years old man with AIDS and cutaneous KS who presented for evaluation of postprandial abdominal pain, vomiting, and weight loss. On upper endoscopy, an extensive, infiltrative, circumferential, reddish mass involving the entire body and antrum of the stomach was seen. Histologic examination later revealed spindle cell proliferation, and confirmatory immunohistochemical testing revealed human herpes virus 8 latent nuclear antigen expression consistent with a diagnosis of gastric KS. Following this, we present a comprehensive review of literature on KS with emphasis on gastrointestinal tract involvement and management.

Cost-Effectiveness Analysis Comparing Chemotherapy Regimens in the Treatment of AIDS-Related Kaposi’s Sarcoma in Brazil

BACKGROUND

Economic analyses of agents used in the treatment of AIDS and opportunistic diseases are particularly important in developing countries.

PURPOSE

To analyze the cost-effectiveness of AIDS-related Kaposi's sarcoma (AIDS-KS) chemotherapy regimens in Brazil.

METHOD

A decision-analysis model was developed, and effectiveness data were derived from randomized phase III trials evaluating pegylated liposomal doxorubicin (PLD), liposomal daunorubicin (DNX), and the ABV regimen (doxorubicin, bleomycin, and vincristine). Resource data on direct medical costs were obtained from local sources.

RESULTS

The cost-effectiveness estimates (defined as average costs per patient who responds completely or partially) favored PLD (US $10,272/responder) in comparison to DNX (US $16,263/responder). Regarding cost-effectiveness, the ABV regimen that is widely used in developing countries had better results when compared to both PLD (US $1,268 vs. US $10,271) and DNX (US $1,268 vs. US $16,260). The incremental cost per additional responder of using PLD instead of ABV was US $20,990. Sensitivity analyses suggest that these results hold over a wide range of assumptions.

CONCLUSION

ABV seems to be the most reasonable treatment option for AIDS-KS patients in resource-limited countries like Brazil.

Slit2/Robo4 signaling modulates HIV-1 gp120-induced lymphatic hyperpermeability

Dissemination of HIV in the host involves transit of the virus and virus-infected cells across the lymphatic endothelium. HIV may alter lymphatic endothelial permeability to foster dissemination, but the mechanism is largely unexplored. Using a primary human lymphatic endothelial cell model, we found that HIV-1 envelope protein gp120 induced lymphatic hyperpermeability by disturbing the normal function of Robo4, a novel regulator of endothelial permeability. HIV-1 gp120 induced fibronectin expression and integrin α₅β₁ phosphorylation, which led to the complexing of these three proteins, and their subsequent interaction with Robo4 through its fibronectin type III repeats. Moreover, pretreatment with an active N-terminus fragment of Slit2, a Robo4 agonist, protected lymphatic endothelial cells from HIV-1 gp120-induced hyperpermeability by inhibiting c-Src kinase activation. Our results indicate that targeting Slit2/Robo4 signaling may protect the integrity of the lymphatic barrier and limit the dissemination of HIV in the host.

Oral complications of HIV disease

Oral lesions are among the early signs of HIV infection and can predict its progression to acquired immunodeficiency syndrome (AIDS). A better understanding of the oral manifestations of AIDS in both adults and children has implications for all health care professionals. The knowledge of such alterations would allow for early recognition of HIV-infected patients. The present paper reviews epidemiology, relevant aspects of HIV infection related to the mouth in both adults and children, as well as current trends in antiretroviral therapy and its connection with orofacial manifestations related to AIDS.

Kaposi sarcoma: a continuing conundrum

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

LEARNING OBJECTIVES

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

99mTc-MIBI imaging of cutaneous AIDS-associated Kaposi's sarcoma

BACKGROUND

Kapoksi's sarcoma (KS) is a common neoplasm complicating acquired immunodeficiency syndrome (AIDS). Skin, mucus membranes, lymph nodes, gastrointestinal tract and lungs may be involved. Kaposi's sarcoma has been demonstrated by scintigraphy, and a (99m)Tc-hexakis-2-methoxy isobutyl isonitrile (MIBI) scan can demonstrate lymphoma and tumors of the brain, nasopharynx, thyroid, parathyroid, lung, breast and kidney. It may also be useful for detecting and delineating the extent of KS. The objective of this study was to determine the efficacy of (99m)Tc-MIBI scanning to demonstrate cutaneous AIDS-associated KS, lymphedema and lymphadenopathy in the extremities.

METHODS

Whole body (99m)Tc-MIBI scans were obtained on 40 patients with AIDS-associated KS. Abnormal uptake of (99m)Tc-MIBI in the skin, subcutaneous soft tissues and lymph nodes was compared with the clinical assessment.

RESULTS

The (99m)Tc-MIBI uptake was noted in the cutaneous/subcutaneous KS of the extremities with a sensitivity of 73.53%, a specificity of 96.91% and an accuracy of 91.31%. Abnormal lymph nodes and lymphedema were detected in more patients on (99m)Tc-MIBI scans (33 and 18 patients) than clinical assessment (10 and 12 patients), respectively. Lymphedema of the lower extremity was found in four of 17 patients without any palpable or abnormal lymph node uptake of (99m)Tc-MIBI in the inguinal regions. Follow-up (99m)Tc-MIBI scans after treatment showed no uptake in the skin lesions and decreased uptake in the lymph nodes corresponding to complete clearing on clinical assessment.

CONCLUSIONS

(99m)Tc-MIBI imaging provides additional information on the extent of lymph node involvement and more precise staging and therapeutic planning. It may be useful as a predictive test or follow up of response of cutaneous KS to treatment.

Tumours of the hand

Hand tumours of soft-tissue and bony origin are frequently encountered, and clinicians must be able to distinguish typical benign entities from life-threatening or limb-threatening malignant diseases. In this Review, we present a diagnostic approach to hand tumours and describe selected cancers and their treatments. Soft-tissue tumours include ganglion cysts, giant-cell cancers and fibromas of the tendon sheath, epidermal inclusion cysts, lipomas, vascular lesions, peripheral-nerve tumours, skin cancers, and soft-tissue sarcomas. Bony tumours encompass enchondromas, aneurysmal bone cysts, osteoid osteomas, giant-cell lesions of bone, bone sarcomas, and metastases. We look at rates of recurrence and 5-year survival, and recommendations for adjunct chemotherapy and radiotherapy for malignant lesions.

AIDS malignancies

Among individuals with HIV-infection, coinfection with oncogenic viruses including EBV, HHV-8, and HPV cause significant cancer-related morbidity and mortality. It is clear that these viruses interact with HIV in unique ways that predispose HIV-infected individuals to malignant diseases. In general, treatment directed specifically against these viruses does not appear to change the natural history of the malignant disease, and once the malignancy develops, if their health permits, HIV-infected patients should be treated using similar treatment protocols to HIV-negative patients. However, for the less frequent HIV-related malignancies, such as PEL, or MCD, optimal treatments are still emerging. For certain AIDS-defining malignancies, it is clear that the widespread access to HAART has significantly decreased the incidence, and improved outcomes. However, for other cancers, such as the HPV-related tumors, the role of HAART is much less clear. Further research into prevention and treatment of these oncogenic virally mediated AIDS-related malignancies is necessary.

Systemic treatment of AIDS-related Kaposi sarcoma: current status and perspectives

Kaposi's sarcoma (KS) is the most frequent type of cancer in patients with Acquired Immune Deficiency Syndrome (AIDS). In the western world, its incidence decreased dramatically in the era of highly active anti-retroviral therapy (HAART). In contrast, the incidence of KS has been steadily climbing in parallel with the AIDS epidemic in Africa over the past 10-15 years, being the most common cancer in adult men in countries like Uganda and Zimbabwe. AIDS-KS can be diagnosed at any stage of HIV infection, although it more commonly occurs in the setting of severe immune suppression, especially with an elevated viral load. Up to now, AIDS-KS is still an incurable disease. Its clinical course is variable, ranging from very indolent cases, requiring no or minimal therapy, to a rapidly progressive disease. Various local therapies are available to control small and asymptomatic lesions, while cytotoxic, immunological and biological therapies can be considered for more aggressive disease. The primary goal of therapy in most of the cases is to provide safe and effective palliation, in order to quality of life. Optimal anti-retroviral therapy is a key component of AIDS-KS management. There are still many questions to be answered in the management of patients with AIDS-KS, such as (1) What are the therapeutic agents that should be used in this disease, and in which sequence? and (2) What are the benefits and risks expected with each treatment option? The aim of this review is to discuss the systemic management of AIDS-KS, with special focus on the above mentioned questions.

HIV-Related Oral Lesions, Demographic Factors, Clinical Staging and Anti-Retroviral Use

BACKGROUND

The aim of the present study was to compare the prevalence of HIV-related oral lesions (HIV-OL) between two health centers for HIV in Mexico City and to analyze the factors that, in addition to combined antiretroviral therapy (CART) and low CD4(+), may be associated with possible differences in prevalence.

METHODS

A cross-sectional observational study was performed between January 2000 and February 2003 at the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMNSZ), a specialized referral center for HIV/AIDS patients and the Clínica Especializada Condesa (CEC), a primary care center for HIV-infected individuals without social security insurance. A consecutive sample of HIV-infected individuals had an oral examination based on established clinical criteria. Demographic, clinical and laboratory data were obtained. Independent association of each factor with specific HIV-OL was assessed by logistic regression modeling.

RESULTS

Eight hundred fifty individuals were examined (INCMNSZ: 479; CEC: 371). Hairy leukoplakia (HL), periodontal disease (PD) and Kaposi's sarcoma (KS) were independently associated with the study site [odds ratio (OR) = 1.7 (95% confidence interval (CI): 1.1-2.4), OR = 4.2 (95% CI: 1.3-13), OR = 10.1 (95% CI: 2.7-38.2), respectively], being more frequent in CEC patients. HL was independently associated with men having sex with men OR = 1.7 (95% CI: 1.1-2.8). All HIV-OL were independently associated with CD4(+) counts and, with the exception of PD and KS, with time under CART.

CONCLUSIONS

The present comparative study showed that several factors were associated with a difference in prevalence of oral lesions found in two AIDS clinics located in Mexico City. Severe immune suppression, CART duration and the study site were associated with HIV-OL. Further investigation into factors such as socioeconomic determinants associated with HIV-OL is warranted.

Remission from Kaposi's sarcoma on HAART is associated with suppression of HIV replication and is independent of protease inhibitor therapy

Highly active antiretroviral therapy (HAART) reduces the incidence and improves the prognosis of Kaposi's sarcoma (KS). This study was designed to identify factors associated with KS clinical responses in HIV-infected patients during HAART. We reviewed the files of 138 HIV-1-infected patients with KS. Epidemiologic and HIV-related clinical and biological parameters were recorded at KS diagnosis (baseline) and every 6 months thereafter. In a subset of 73 antiretroviral-naive patients, we compared the clinical outcome of KS according to the use or nonuse of protease inhibitors (PI). After 6 months of follow-up, KS remission was more frequent in patients who were naive of HAART and who were at ACTG stage S0 at baseline (P=0.03 and 0.02). Undetectable HIV viral load was strongly associated with KS remission (P⩽0.004 at all time points), while CD4 cell count was not. Among the 73 antiretroviral-naive patients at baseline, and who were studied for 24 months, KS outcome did not differ between patients who were prescribed PI-containing and PI-sparing regimens. Intercurrent multicentric Castleman's disease was associated with poor outcome after 60 months of follow-up (P⩽0.0001). Fourteen deaths occurred after a median follow-up of 37.5 months, eight of which were KS related. Suppression of HIV replication appears to be crucial to control KS. Non-PI-based regimens were equivalent to PI-based regimens as regards the clinical and virological outcome of antiretroviral-naive HIV-infected patients with KS.

AIDS-related malignancies: emerging challenges in the era of highly active antiretroviral therapy

Human immunodeficiency virus (HIV)-infected patients are at increased risk of developing cancer, particularly in the later stages of acquired immune deficiency syndrome (AIDS). Despite the advent of highly active anti-retroviral therapy (HAART), malignancy in this population is a leading cause of morbidity and mortality. Kaposi's sarcoma (KS) and AIDS-related non-Hodgkin's lymphoma (ARL) are the most common AIDS-defining malignancies. AIDS-related KS varies from minimal to fulminant disease. Treatment decisions for AIDS-related KS are guided largely by the presence and extent of symptomatic disease. In addition to HAART, excellent treatments exist for both localized disease (topical gel, radiotherapy, and intralesional therapy) and advanced disease (liposomal anthracyclines, paclitaxel). Novel therapies that have become available to treat AIDS-related KS include angiogenesis inhibitors and antiviral agents. ARL comprises a heterogeneous group of malignancies. With the immune restoration afforded by HAART, standard-dose chemotherapies now can be safely administered to treat ARL with curative intent. The role of analogous treatments used in HIV-negative patients, including monoclonal antibodies and autologous stem cell transplantation, requires further clarification in HIV-positive patients. HIV-infected patients also appear to be at increased risk for developing certain non-AIDS-defining cancers, such as Hodgkin's lymphoma and multiple myeloma. Although the optimal treatment of these neoplasms is at present uncertain, recent advances in chemotherapy, antiretroviral drugs, and supportive care protocols are allowing for more aggressive management of many of the AIDS-related cancers. This article provides an up-to-date review of the epidemiology, pathogenesis, clinical features, and treatment of various AIDS-related malignancies that are likely to be encountered by an oncologist practicing in the current HAART era.

Methylene blue in photodynamic therapy: From basic mechanisms to clinical applications

Methylene blue (MB) is a molecule that has been playing important roles in microbiology and pharmacology for some time. It has been widely used to stain living organisms, to treat methemoglobinemia, and lately it has been considered as a drug for photodynamic therapy (PDT). In this review, we start from the fundamental photophysical, photochemical and photobiological characteristics of this molecule and evolved to show in vitro and in vivo applications related to PDT. The clinical cases shown include treatments of basal cell carcinoma, Kaposi's Sarcoma, melanoma, virus and fungal infections. We concluded that used together with a recently developed continuous light source (RL50(®)), MB has the potential to treat a variety of cancerous and non-cancerous diseases, with low toxicity and no side effects.

Evidence of activity of Irinotecan in patients with advanced AIDS-related Kaposi's sarcoma

Fourteen HIV-infected patients with advanced Kaposi's sarcoma (KS) received Irinotecan 150 mg/m intravenously on days 1 and 10. All patients were relapsed/progressed during highly active antiretroviral therapy, administered as primary antineoplastic therapy. An objective response, all partial remissions, occurred in 75% of patients. Irinotecan was well tolerated, severe leukopenia occurred in only 33% of patients. In HIV-infected patients with advanced KS, irinotecan is active and well tolerated.

Oral malignancies in HIV disease: Changes in disease presentation, increasing understanding of molecular pathogenesis, and current management

Infection with human immunodeficiency virus (HIV) and progression to acquired immune deficiency syndrome (AIDS) are associated with a vide variety of morbidities. Local and systemic diseases can develop in association with HIV infection and may manifest themselves as malignancies of the oropharynx. Advances in HIV management, fueled by increasing understanding of molecular pathogenesis, have resulted in marked changes in the prevalence of oral malignant disease. This paper discusses recent trends in the presentation and treatment of malignancies related to HIV and AIDS with an emphasis on malignancies seen in the oral cavity.

Current trends of HIV disease of the mouth

HIV infection affects residents of all countries of the world, but the greater majority of affected individuals reside in the developing world. In the past decade there have been substantial changes in the management of HIV disease, particularly the introduction of highly active antiretroviral therapy (HAART). Such agents have reduced significantly the morbidity and mortality associated with HIV disease, however, they are not available for most HIV-infected individuals in the developing world. There is now considerable understanding of the molecular epidemiology, transmission and therapy of the common opportunistic oral infections of HIV disease, and as a consequence of improved anti-HIV strategies, the frequency and severity of oral disease associated with HIV infection have reduced considerably, although HAART may predispose to human papilloma virus infection of the mouth and potentially increase the risk of later oral squamous cell carcinoma. Despite advances in clinical care the majority of individuals with HIV disease worldwide will continue to develop oral disease, as they are resident in the developing world and do not have ready access to even simple therapies.

Impact of highly active antiretroviral therapy on organ-specific manifestations of HIV-1 infection

In the last 10 years, interesting results have been reported concerning the impact of highly active antiretroviral therapy (HAART) on the changing pattern of organ‐specific manifestations of HIV‐1 infection. There has been a clear step‐wise reduction in the incidence of several opportunistic infections (OIs), particularly Pneumocystis carinii pneumonia, whereas a nonsignificant reduction in incidence has been observed for other organ‐specific diseases, including invasive cervical cancer and Hodgkin disease. In addition, several organ‐specific manifestations, including HIV‐associated nephropathy, wasting syndrome and cardiomiopathy, are a direct consequence of damage by HIV‐1, and so HAART may have a therapeutic effect in improving or preventing these manifestations. Finally, the introduction of HAART has seen the emergence of several complications, termed immune reconstitution inflammatory syndrome, which includes OIs such as cytomegalovirus vitritis, Mycobacterium avium complex lymphadenitis, paradoxical responses to treatment for tuberculosis, and exacerbation of cryptococcosis. Because not all HIV‐1 organ‐specific manifestations are decreasing in the HAART era, this review will analyse the influence of HAART on several organ‐specific manifestations, and in particular OIs related to several organs, cerebral disorders and HIV‐1‐related neoplasia.

Physiotherapy management of patients with HIV-associated Kaposi's sarcoma

BACKGROUND

Kaposi's sarcoma is the most common form of cancer in patients with human immunodeficiency virus (HIV) infection. Although Kaposi sarcoma lesions may contribute to significant physical impairments, there is a lack of scientific literature detailing the role of physiotherapy in the treatment of HIV-associated Kaposi's sarcoma. The present Case Report includes two males, aged 36 and 39 years, seropositive for HIV with invasive Kaposi's sarcoma.

METHOD AND RESULTS

Patient A was evaluated for bilateral foot pain caused by plantar surface Kaposi s sarcoma lesions that rendered him unable to walk. He progressed to walking 400feet after a treatment regimen of gait training with the use of custom plastazote sandals. Patient B was evaluated for right lower extremity lymphoedema secondary to invasive Kaposi's sarcoma. He experienced an 18% reduction in limb volume, a 38% reduction in pain and a 20 degrees increase in terminal knee flexion after therapeutic exercise and the use of compressive bandaging and garments.

CONCLUSIONS

This Case Report suggests that physiotherapy interventions may be valuable in the conservative management of patients with HIV-associated Kaposi s sarcoma.

AIDS-related cancer in the era of highly active antiretroviral therapy (HAART): a model of the interplay of the immune system, virus, and cancer. "On the offensive--the Trojan Horse is being destroyed"--Part A: Kaposi's sarcoma

The introduction of highly active antiretroviral therapy (HAART), aimed at controlling human immunodeficiency virus (HIV), has been associated with a dramatic decrease in the incidence of acquired immunodeficiency syndrome-Kaposi's sarcoma (AIDS-KS) and the clinical manifestations of KS appear to be less aggressive. The pathogenesis of AIDS-related KS is related to a system of cytokines (e.g., interleukin-6) driven by autocrine and paracrine loops. More recently, human herpesvirus 8 (HHV-8), was discovered to be the putative etiological agent of this disease. This virus encodes several unique open reading frames that are homologs of human cellular proteins involved in cellular regulations, cell proliferation, apoptosis, and immune regulation. The treatment of this disease depends on whether it is "limited" disease or "extensive" disease. For "limited" disease, local therapy or non-bone marrow suppressive agents should be used. For "extensive" disease, new chemotherapeutic agents, such as liposomal anthracycline, which are active and have little adverse reactions, are indicated. The control of HIV infection continues to be essential. Knowledge of the pathogenesis of the disease has led to the development of novel treatment strategies, aimed at the inflammatory or angiogenesis cytokines necessary for growth or at HHV-8 as the target of therapy.

Therapeutic options for human herpesvirus-8/Kaposi's sarcoma-associated herpesvirus-related disorders

Human herpesvirus-8/Kaposi's sarcoma-associated herpesvirus infection is associated with three proliferative disorders in immunocompromised patients - Kaposi's sarcoma, primary effusion lymphoma and multicentric Castleman's disease. These disorders often develop in patients with advanced AIDS who present a number of therapeutic challenges, underscoring the importance of continuing efforts dedicated to basic and clinical research in this field. In the era of highly active antiretroviral therapy, the incidence of AIDS and Kaposi's sarcoma has considerably decreased, presumably due to enhanced anti-Kaposi's sarcoma-associated herpesvirus immune responses, whereas the situation with primary effusion lymphoma and multicentric Castleman's disease is more complex. Based on advances in the understanding of Kaposi's sarcoma-associated herpesvirus-related disorders and availability of antiretroviral agents, current and future therapeutic approaches will be discussed.

Paclitaxel for anthracycline-resistant AIDS-related Kaposi's sarcoma: clinical and angiogenic correlations

BACKGROUND

Murine data indicate that angiogenesis is central to the aetiopathogenesis of Kaposi's sarcoma (KS). Therefore, we measured angiogenic cytokines and growth factors in patients with AIDS-related KS during treatment with both antiretrovirals and second-line paclitaxel chemotherapy. Cytokines measured included tumour necrosis factor-alpha (TNF-alpha), basic fibroblast growth factor (bFGF), vascular endothelial growth factor (VEGF) and the interleukins IL-2, -6 and -12.

PATIENTS AND METHODS

Enzyme-linked immunosorbent assays (ELISAs) were carried out to measure plasma cytokine levels in 17 patients with AIDS-related KS who had progressed within 6 months of receiving liposomal anthracyclines and were treated with paclitaxel 100 mg/m(2) every 2 weeks. Measurements were carried out before progression, at commencement and at the completion of paclitaxel.

RESULTS

The objective response rate to paclitaxel was 71% (95% confidence interval 60% to 81%). In 17 patients with AIDS-related KS, we observed eight partial responses and four complete responses. Patients with AIDS Clinical Trial Group stage T1 disease had higher plasma VEGF (P = 0.05) and lower plasma TNF-alpha levels (P = 0.05) than patients with earlier stage T0 KS. There were no correlations between plasma cytokines (bFGF, VEGF, TNF-alpha, and IL-2,-6 and -12) and the CD4 and CD8 cell counts or HIV-1 RNA viral load. Response to paclitaxel was associated with a fall in plasma IL-6 levels (P = 0.04) but no change in other cytokines. There were no significant changes in CD4, CD8, CD16/56, CD19 cell counts and HIV-1 viral loads during chemotherapy.

CONCLUSIONS

Angiogenic cytokines may correlate with KS disease extent but not with cellular immune function or HIV viraemia. Response to paclitaxel therapy correlates with a fall in plasma IL-6 levels and recent data indicate this may be a surrogate marker of KS-associated herpesvirus viral load. Overall, clinical response in KS correlates poorly with known angiogenic cytokines.

HIV-1 Tat enhances Kaposi sarcoma-associated herpesvirus (KSHV) infectivity

The high frequency of Kaposi sarcoma (KS) in immunodeficiency states, particularly in patients with AIDS, has been attributed to increased replication of KS-associated herpesvirus (KSHV), a necessary cofactor for KS development. However, experimental KSHV infection of endothelial lineage cells that compose KS lesions has been difficult even in the absence of immune cells. Here we show that HIV-1 Tat protein can directly promote KSHV transmission. Full-length HIV-1 Tat and a 13-amino-acid peptide corresponding to the basic region of Tat specifically enhances the entry of KSHV into endothelial and other cells, presenting evidence for an active role of HIV-1 in the development of KSHV-associated diseases. These results can explain why AIDS-KS is more frequent and clinically more aggressive than KS in other immunodeficiency states.

Isolated intraparotid Kaposi sarcoma in human immunodeficiency virus type 1 infection

Isolated Kaposi sarcoma (KS) of the parotid gland is an uncommon but distinct entity in patients with human immunodeficiency virus type 1 (HIV-1). A 30-year-old white homosexual man in whom HIV-1 had been diagnosed 2 years previously developed right parotid gland enlargement in the absence of constitutional symptoms. He had been taking zidovudine, lamivudine, and indinavir; his CD4 cell count was 0.297 x 10(9)/L, and HIV-1 RNA load was 47 copies/mL. After surgical excision of the parotid gland, biopsy findings disclosed KS of an intraparotid lymph node. A literature review revealed 6 other men with HIV-1 and isolated parotid KS. To our knowledge, our patient is the first to have received triple antiretroviral therapy with excellent immunological and virological response and parotid gland enlargement that might reflect immune reconstitution. Even in the absence of skin or other lesions, KS should be considered in the differential diagnosis of parotid gland enlargement in patients with HIV-1, even in those who are responding to highly active antiretroviral treatment.

Therapeutic approaches to AIDS-related malignancies

The introduction of highly active antiretroviral therapy (HAART) has changed dramatically the landscape of HIV disease. Deaths from AIDS-related diseases have been reduced by 75% since protease inhibitor therapy and combination antiretroviral therapy came into use in late 1995. While KS is declining, the situation for non-Hodgkin's lymphoma is more complex with a reduced incidence of primary central nervous system lymphoma, but a relatively stability in the number of patients developing systemic NHL. AIDS related NHL appears not to be markedly decreased by the introduction of HAART and it is the greatest therapeutic challenge in the area of AIDS oncology. The emphasis has now shifted to cure while maintaining vigilance regarding the unique vulnerability of HIV-infected hosts. Furthermore, also for the prolongation of the survival expectancy of these patients, other non AIDS-defining tumors, such as Hodgkin's disease, anal and head and neck, lung and testicular cancer, and melanoma have been recently reported with increased frequency in patients with HIV infection.

Seroprevalence of HHV 8 antibodies among the general population and HIV positive persons in the Czech Republic

BACKGROUND

The seroprevalence rates of herpesvirus 8 (HHV 8) antibodies were determined for the general Czech population and HIV-positive individuals.

OBJECTIVES

Six hundred and sixty six serum samples from the general Czech population and 129 serum samples from HIV-positive persons were tested for the presence of antibodies to the HHV 8 lytic and latent antigens.

STUDY DESIGN

HHV 8 antibodies were detected by the indirect immunofluorescence test.

RESULTS

In the general Czech population, only 2.4 and 0.3% of the serum samples tested positive for antibodies against the lytic and latent HHV 8 antigens, respectively. As many as 34.9 and 10.9% HIV positive individuals had antibodies to the HHV 8 antigens, respectively. Only three of them have developed Kaposi's sarcoma (KS) to date. At the time of KS diagnosis, the three patients had antibodies to both HHV 8 antigens. HIV-positive homo/bisexuals were at significantly higher risk of acquiring HHV 8 infection compared with HIV-positive heterosexuals. The increase in HHV 8 seroprevalence was associated with progression of the HIV infection from stage A to stage B. No correlation was found between the HHV 8 seroprevalence and CD 4+T-lymphocytes counts or the HIV viral load.

CONCLUSIONS

Among the general Czech population, the HHV 8 seroprevalence is as low as in the West European countries. The mean HHV 8 seroprevalence rate in HIV-positive individuals was 34.9% and was comparable with those reported in other low seroprevalence countries.

HIV protease inhibitors as new treatment options for Kaposi's sarcoma

A reduced incidence and regression of Kaposi's sarcoma (KS) and other tumours has been reported in Acquired Immune Deficiency Syndrome (AIDS) patients treated with antiretroviral combination therapies containing Human Immunodeficiency Virus (HIV) protease inhibitors (PIs) such as indinavir or saquinavir. Indeed, evidence indicates that although PIs were designed to selectively inhibit the HIV protease activity, they can interfere with several cellular pathways and can inhibit tumour growth. In particular, our recent results indicate that doses of indinavir or saquinavir similar to those employed to treat AIDS patients can induce regression of experimental KS by directly blocking two fundamental steps of KS initiation and progression: new blood vessel formation (angiogenesis) and KS tumour cell invasion. This is because indinavir or saquinavir inhibit the activation of matrix metalloproteinase-2 (MMP-2), a basement membrane-degrading enzyme, which is required for the progression of most tumours. Based on these results, a multicentre clinical trial is now starting in Italy, which will assess PI effects on the progression of KS in HIV-uninfected individuals (classical KS).

A comparison of regimens based on non-nucleoside reverse transcriptase inhibitors or protease inhibitors in preventing Kaposi's sarcoma

OBJECTIVE

To determine the incidence of Kaposi's sarcoma (KS) in a prospective longitudinal cohort of HIV-1-infected individuals before during and after the introduction of highly active antiretroviral therapy (HAART) and to compare the incidence of KS between specific HAART regimens.

DESIGN

Univariate and multivariate analysis of 8640 HIV-1-infected individuals.

METHODS

The protective effect of HAART regimens based on either protease inhibitors (PI) or non-nucleoside reverse transcriptase inhibitors (NNRTI) on the development of KS was examined in prospectively recorded data to determine whether treatments based on the two types of drug were comparable with regard to a reduction in the incidence of KS.

RESULTS

A total of 1204 patients with KS were identified. The incidence of KS decreased from 30/1000 patient-years prior to 1995 to 0.03/1000 patient-years in 2001. Multivariate analysis showed that age, nadir CD4 cell count and antiretroviral class exposure were significant independent predictors of KS. NNRTI-based HAART (adjusted rate ratio, 0.42; 95% confidence interval 0.24-0.37) had a similar protective effect to PI-based HAART (adjusted rate ratio, 0.47; 95% confidence interval 0.38-0.58). Most patients who develop KS on HAART [30/35 (86%)] had evidence of virological treatment failure.

CONCLUSION

PI- and NNRTI-based HAART regimens are equally effective as protection against KS. This is the first study to demonstrate a decreased incidence of an AIDS-defining disease with NNRTI-based therapy.

Human papillomavirus, type 40-associated papilloma, and concurrent Kaposi's sarcoma involving the anterior hard palate of an HIV-positive man

A number of oral lesions have been reported in association with HIV, including lesions caused by other viruses such as the epitheliotropic human papillomavirus (HPV). More than 90 types of HPV have been identified, with the less commonly encountered strains of HPV tending to show association with immunodeficiency states. In addition, HIV-infected patients may have Kaposi's sarcoma develop, a malignancy thought to be caused by human herpes virus, type 8. Recent evidence suggests a sexual mode of transmission for this virus. We report an HIV-positive man with a large, HPV type 40-associated papilloma of the anterior palate and a previously undiagnosed focus of Kaposi's sarcoma.

Treatment of Kaposi's sarcoma--an update

Kaposi's sarcoma (KS) is an angioproliferative disease of multifactorial origin arising in different clinic-epidemiologic forms, which show the same histopathological features. It generally starts as a hyperplastic reactive-inflammatory and angiogenic process, which may evolve into monomorphic nodules of KS cells that can be clonal (late-stage lesions) and resemble a true sarcoma. Infection with the human herpesvirus 8, cytokine- and angiogenic factor-induced growth together with an immuno-dysregulated state represent fundamental conditions for the development of this tumor. Several local therapies are used to eradicate early and confined skin lesions, whereas widely disseminated, progressive or symptomatic disease requires a more aggressive treatment. Although different chemotherapeutic agents have been used to treat aggressive KS, the growing understanding of the pathogenetic factors participating in KS development has provided a strong rationale for using less- or non-cytotoxic agents that block the mechanisms involved in KS pathogenesis. The angiogenic nature of KS makes it particularly suitable for using therapies based on anti-angiogenic agents. Of note on this goal, recent studies indicate that the highly active anti-retroviral therapy, including at least one human immunodeficiency virus (HIV) protease inhibitor (PI), is associated with a dramatic decrease in the incidence of AIDS-KS and with a regression of KS in treated individuals. Consistent with this, results from preclinical studies indicate that PIs have potent and direct anti-angiogenic and anti-KS activities, suggesting that they should be further investigated, alone or combined with other therapies, as a novel treatment for KS in both HIV seropositive or seronegative individuals.

Dermatological aspects of angiogenesis

Neovascularization is vital for the growth of tumours, providing a lifeline for sustenance and waste disposal. Tumour vessels can grow by sprouting, intussusception or by incorporating bone marrow-derived endothelial precursor cells into growing vessels. Recent advances in vascular biology have identified some key factors that control vascular growth, and have led to the hypothesis that in normal tissues vascular quiescence is maintained by the dominant influence of endogenous angiogenesis inhibitors over angiogenic stimuli. In contrast, increased secretion of angiogenic factors and the down-regulation of endogenous angiogenesis inhibitors induce tumour angiogenesis. Vascular quiescence in the skin seems to be primarily maintained by a balance between the endogenous angiogenesis inhibitors thrombospondin 1 and thrombospondin 2 and the potent proangiogenic factor vascular endothelial growth factor A. Inhibiting tumour growth by controlling angiogenesis is an intriguing approach with great potential for the treatment of vascular tumours such as haemangioma, Kaposi's sarcoma and solid cutaneous tumours such as squamous cell carcinoma, melanoma and basal cell carcinoma. In this review, the role of angiogenesis and more recent topics such as lymphangiogenesis in cutaneous tumour growth, invasion and metastasis will be discussed.

Update on Kaposi's sarcoma and other HHV8 associated diseases. Part 1: epidemiology, environmental predispositions, clinical manifestations, and therapy

Kaposi's sarcoma (KS) is a mesenchymal tumour involving blood and lymphatic vessels. Only recently has the pathogenesis of this extraordinary neoplasm been elucidated. Viral oncogenesis and cytokine-induced growth together with some state of immunocompromise represent important conditions for this tumour to develop. In 1994, a novel virus was discovered and termed human herpesvirus 8 (HHV8), also known as Kaposi's sarcoma-associated herpes virus, which can be found in all types of KS, whether related to HIV or not. In the era of highly active antiretroviral therapy (HAART), the incidence of AIDS-KS has considerably declined, probably due to enhanced immune reconstitution and anti-HHV8-specific immune responses. If HAART is able to prevent spreading of KS, local therapy of KS may become an essential component of patient management. Part 1 of the review covers the epidemiology, environmental predispositions, clinical manifestations, and therapy of KS. Newer treatments such as pegylated liposomal anthracyclines and experimental strategies are discussed. We also present rationales and graduated treatment algorithms for local and systemic therapy in patients with KS to appropriately meet the challenges of this extraordinary neoplasm. Part 2, to be published next month, will summarise recent insights in the pathogenesis of KS and will discuss other HHV8-related diseases such as Castleman's disease and primary effusion lymphoma.