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

Diagnosis and treatment of classic and iatrogenic Kaposi's sarcoma: Italian recommendations

Kaposi's sarcoma (KS) is a lymphangioproliferative disorder associated with Human herpesvirus 8 (HHV8) infection. Four clinical subtypes are recognized: classic, endemic, epidemic (HIV-related) and iatrogenic. KS diagnosis is based on clinical features, histopathological assessment, and HHV8 serology. Classic KS is usually skin-limited and has a chronic course, while the iatrogenic variant may show mucosal, nodal or visceral involvement. Clinical staging is fundamental to guide the management. Localized disease may be treated with different local therapies, even if there are no randomized trials comparing these different modalities. Aggressive, disseminated KS and cases with visceral involvement usually require systemic chemotherapy, most commonly vinblastine, bleomycin or paclitaxel. Iatrogenic KS needs immunosuppression tapering/withdrawal and, if possible, switch to m-TOR inhibitors in post-transplant KS. The present work by a panel of Italian experts provides guidelines on KS diagnosis and management based on a critical review of the literature and a long and extensive personal experience.

Kaposi's sarcoma in persons living with HIV/AIDS: a case series in a tertiary referral hospital

BACKGROUND

Kaposi's sarcoma (KS) is a rare neoplasm with indolent progression. Since 1981, the Kaposi's sarcoma epidemic has increased as co-infection with HIV.

OBJECTIVES

The study aimed to identify the clinical and demographic characteristics and therapeutic approaches in HIV/AIDS patients in a regional referral hospital.

METHODS

We analyzed the medical records of 51 patients with histopathological diagnosis of Kaposi's sarcoma hospitalized at Hospital Universitário João de Barros Barreto (HUJBB) from 2004 to 2015.

RESULTS

The study sample consisted of individuals 15 to 44 years of age (80.4%), male (80.4%), single (86.3%), and residing in Greater Metropolitan Belém, Pará State, Brazil. The primary skin lesions identified at diagnosis were violaceous macules (45%) and violaceous papules (25%). Visceral involvement was seen in 62.7%, mainly affecting the stomach (75%). The most frequent treatment regimen was 2 NRTI + NNRTI, and 60.8% were referred to chemotherapy.

STUDY LIMITATIONS

We assumed that more patients had been admitted to hospital without histopathological confirmation or with pathology reports from other services, so that the current study probably underestimated the number of KS cases.

CONCLUSION

Although the cutaneous manifestations in most of these patients were non-exuberant skin lesions like macules and papules, many already showed visceral involvement. Meticulous screening of these patients is thus mandatory, even if the skin lesions are subtle and localized.

High Prevalence of Distinct Human Herpesvirus 8 Contributes to the High Incidence of Non-acquired Immune Deficiency Syndrome-Associated Kaposi's Sarcoma in Isolated Japanese Islands

Background

Non-acquired immune deficiency syndrome (AIDS) Kaposi's sarcoma (KS) is extremely rare in Japan but highly endemic in Okinawa, especially in Miyako Islands. We aimed to elucidate the exact incidence and cause of this high prevalence.

Methods

Non-AIDS KS cases in Okinawa Prefecture over the past 31 years were reviewed, and human herpesvirus 8 (HHV8) seroprevalence in Miyako Islands was determined. We examined whole-genome sequences of 3 HHV8 strains and performed whole-exome sequencing of 4 male patients from Miyako Islands.

Results

Approximately half of the non-AIDS KS cases in Okinawa Prefecture were from Miyako Islands. The age-adjusted incidence rate was 0.87/105 per year for Miyako Islands and 0.056/105 per year for the rest of Okinawa. Human herpesvirus 8 seroprevalence was 15.4% in Miyako Islands. The 3 HHV8 genomes isolated from Miyako islanders formed a phylogenetically branch distinct from those of previously sequenced HHV8 strains and shared specific mutations in 9 proteins. These mutations were verified in Okinawan patients other than those from Miyako Islands. Whole-exome sequencing of the 4 male Miyako Islanders did not reveal shared pathogenic mutations.

Conclusions

Miyako Islands are an endemic area of non-AIDS KS. The high rate of a distinct HHV8 may contribute to the high incidence of KS in the region.

Oropharyngeal Kaposi Sarcoma in Related Persons Negative for Human Immunodeficiency Virus

Objectives: Kaposi sarcoma (KS) is a vascular tumor that can affect the mucosa of the upper aerodigestive tract. Although KS is the most common malignancy in patients with acquired immunodeficiency syndrome, it is rare in immunocompetent persons. We describe an unusual presentation of KS in 2 related individuals and describe our attempts to determine whether oropharyngeal KS is associated with human herpesvirus 8 (HHV-8).

Methods: All relevant clinical and surgical information, including information on tumor histopathologic and human immunodeficiency virus (HIV) serologic tests, was abstracted from the patient charts and electronic databases. HHV-8 immunohistochemistry was performed on paraffin-fixed specimens.

Results: Both patient 1 and patient 2 (the nephew of patient 1) were referred for workup of a tonsillar mass that was pathologically confirmed to be KS. In each case, HIV serologic testing was negative, and a screening immunologic workup, including a quantitative natural killer cell count, a B- and T-lymphocyte count, and immunoglobulin analysis, also yielded findings that were within normal limits. Immunohistochemistry performed on 1 pathological specimen showed positive staining for the presence of HHV-8, the etiologic agent of KS.

Conclusions: The presence of oropharyngeal KS in 2 related HIV-negative individuals supports a role for genetic factors in susceptibility to KS, a common exposure to an infectious agent such as HHV-8, or both. Whereas most KS cases in industrialized countries are associated with immunodeficiency, clinical and laboratory data do not suggest that either of the patients described in this report are immunodeficient. Their susceptibility to KS may be secondary to a subtle inherited defect in host resistance to HHV-8, or another unknown factor.

One hundred and five Kaposi sarcoma patients: a clinical study in Xinjiang, Northwest of China

BACKGROUND

Kaposi's sarcoma (KS) is an unusual illness that may be associated with human herpes virus 8 (HHV-8) infections, and appears mainly in Jews, Italians and Greeks. There is a lack of patient data in Xinjiang regarding the clinical characteristics of KS.

OBJECTIVES

To review the clinical characteristics of a series of patients with KS in Xinjiang, Northwest China, over 16-year period.

METHODS

A retrospective analysis of patients referred to a Xinjiang hospital in Northwest China with classic KS (CKS) and AIDS-associated KS (AIDS-KS) between January 1997 and April 2013 was performed. Reviewed information included demographics, clinical features, histopathological traits, treatment and presence of HHV-8 infection.

RESULTS

During the study period, 105 patients with a diagnosis of KS, including 77 CKS and 28 AIDS-KS, were referred to our hospital. Mean age at diagnosis was 55.8 ± 16.8 years (range: 25-85 years). There were 70 (90.9%) males and 7 (9.1%) females (male-to-female ratio: 10 : 1) having CKS and 21 (75.0%) males and 7 (25.0%) females (male-to-female ratio: 3 : 1) with AIDS-KS. Most of the patients were Uyghur, including 67 CKS and 24 AIDS-KS. The rate of multifocal lesions at diagnosis was 98.1% (103/105). The most common area of lesions was between 1% and 5% of CKS and AIDS-KS. The main types of lesions were nodules, patches and plaques. The lower extremity and foot were the most common locations for CKS and AIDS-KS. In addition to skin damage, the penis, mouth, lymph nodes and interstitial lung tissues were involved in some cases. No second primary malignancy was diagnosed. Systemic chemotherapy and radiotherapy were effective treatments for CKS. The HHV-8 positivity rate was 98.98% in 98 KS cases.

CONCLUSIONS

In Xinjiang, most CKS and AIDS-KS patients were older Uyghur men. AIDS-KS was found predominantly among 30-year-old Uyghur patients, compared with 60 years for those having CKS. The latter exhibited certain characteristics such as disseminated skin disease; in some patients, the condition was accompanied by lymphedema, visceral or lymph node involvement, but no secondary malignancies. In addition, the HHV-8 positivity rate associated with KS was very high.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Seroprevalence of Human herpesvirus 8 (HHV-8) and incidence of Kaposi's sarcoma in Iran

Seroepidemiological surveys show that the prevalence of human herpesvirus 8 (HHV-8) infection mostly varies in various geographical areas and reflects the local incidence of classic and endemic KS, being widespread in sub-Saharan Africa and Mediterranean countries and uncommon in the USA and Northern Europe. In the Middle East only few populations, such as Ashkenazi and Sephardic groups in Israel, have been adequately evaluated for HHV-8 seroprevalence. Among Iranian population a striking higher seroprevalence of HHV8 has been reported among haemodialysis (16.9%), renal transplant recipients (25%) and HIV (45.7%) patients compared to blood donors (2%). Kaposi's sarcoma (KS) is the rarest cancer in Iran, with an annual age-standardized incidence varying from 0.10 to 0.17 per 100,000 in males and from 0.06 to 0.08 per 100,000 in females. KS, however, is one of the most important malignancies in Iranian renal transplanted patients affecting up to 2.4% of organ recipients. The epidemiology of HHV8 and KS in Iran needs further evaluation. While the high prevalence of HHV-8 antibodies in HIV positive and haemodialysis individuals may be attributed to high-risk sexual behavior and polytransfusions, respectively, unknown determinants may be responsible for high seroprevalence of HHV8 and high incidence of KS in solid organ recipients. A global survey on HHV8 seroprevalence in Iran is mandatory to define co-factors associated with HHV8 infection and KS risk in the general Iranian population and in specific patient groups.

Human herpesvirus type 8 variants circulating in Europe, Africa and North America in classic, endemic and epidemic Kaposi's sarcoma lesions during pre-AIDS and AIDS era

Human herpesvirus-8 (HHV-8) variants have been found heterogeneously distributed among human populations living in diverse geographic regions, but their differential pathogenicity in Kaposi's sarcoma development remains controversial. In the present study, HHV-8 variant distribution has been analyzed in classic, iatrogenic, endemic as well as epidemic Kaposi's sarcoma (KS) during pre-AIDS and AIDS period (1971-2008) in countries with different KS incidence rate. DNA samples from cutaneous KS lesions of 68 patients living in Africa (n=23, Cameroon, Kenya and Uganda), Europe (n=34, Greece and Italy) and North America (n=11) have been subjected to PCR amplification of HHV-8 ORF 26, T0.7, K1 and K14.1/15, followed by direct nucleotide sequencing and phylogenetic analysis. Among the 23 African samples, the majority of HHV-8 ORF 26 variants clustered with the subtype R (n=12) and B (n=5). Conversely, the viral sequences obtained from 45 European and North European tumors belonged mainly to subtype A/C (n=36). In general, HHV-8 and K1 variant clustering paralleled that of ORF 26 and T0.7. Genotyping of the K14.1/15 loci revealed a large predominance of P subtype in all tumors. In conclusion, comparison of the HHV-8 sequences from classic or endemic versus AIDS-associated KS showed a strong linkage of the HHV-8 variants with specific populations, which has not changed during AIDS epidemic.

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.

Classic Kaposi sarcoma in northern Sardinia: A prospective epidemiologic overview (1977-2003) correlated with malaria prevalence (1934)

BACKGROUND

Studies have demonstrated considerable variations in classic Kaposi sarcoma (CKS) incidence within Europe, with some of the highest incidences found in the Mediterranean area. As a Mediterranean area, northern Sardinia has a high CKS frequency.

OBJECTIVE

In order to determine CKS incidence in people born in and residing in northern Sardinia, a clinical prospective epidemiologic study was carried out between 1977 and 2003 by the Department of Dermatology, University of Sassari. We also evaluated a correlation between malaria prevalence in 1934, estimated on the eight historical sub-areas of the Sassari province, and the standardized morbidity ratio from 1977 to 2003.

RESULTS

A total of 332 patients with CKS were identified. Incidence among the northern Sardinian population > or =40 years of age was 4.06/100,000 persons/year and it was almost stable through the years. The male to female ratio showed a significant decline from 3.6 to 2.5 (P = .03). Females had a statistically decreased risk of developing CKS compared to males (adjusted incidence rate ratio = 0.27; 95% CI: 0.21-0.34), and the risk of developing CKS increased exponentially with age. The prevalence of malaria in each sub-area ranged from 9% to 91%. The standardized morbidity ratio for CKS in the years between 1977 and 2003 ranged from 0.27 to 1.76; the regression coefficient was -0.85 (95% CI: -2.94-1.24), yielding a nonsignificant relationship between the two diseases.

LIMITATIONS

These results were obtained from patients with CKS in northern Sardinia and may not be applicable to other populations.

CONCLUSIONS

The northern Sardinian population consistently has a very high incidence of CKS, while in our data, the correlation between malaria and CKS remains open to question.

Absence of human herpesvirus 8 DNA sequences in lung biopsies from Israeli patients with pulmonary arterial hypertension

BACKGROUND

Pulmonary hypertension is a severe pulmonary vascular disease leading to rapid deterioration and death. Histological and clinical evidence suggests that smooth muscle proliferation is part of the pathogenesis of the disease. Human herpesvirus 8 (HHV-8) is a gamma-herpesvirus that is implicated in malignancies and in Kaposi's sarcoma. Recently, the association of HHV-8 with idiopathic pulmonary arterial hypertension (PAH) has been found.

OBJECTIVE

The aim of this study was to investigate the presence of HHV-8 in the lung tissue of Israeli patients with PAH.

METHOD

The presence of HHV-8 sequences was investigated by polymerase chain reaction examination in 6 biopsies of patients with pulmonary hypertension. Three patients had idiopathic pulmonary hypertension, 2 patients pulmonary venoocclusive disease, and 1 patient pulmonary hypertension associated with mixed connective tissue disease.

RESULT

We did not find any association between HHV-8 and PAH in these Israeli patients, as all the samples were negative for polymerase chain reaction.

CONCLUSION

Our findings, together with the epidemiological data of HHV-8 prevalence and incidence rates of Kaposi's sarcoma and PAH in Israel, provide further evidence which argues against an association between HHV-8 infection and PAH.

Classic Kaposi sarcoma. Which KSHV-seropositive individuals are at risk?

BACKGROUND

Classic Kaposi sarcoma (CKS) is a relatively rare vascular disease primarily affecting human immunodeficiency virus (HIV)-uninfected elderly men. The infection with Kaposi sarcoma-associated herpesvirus (KSHV) is necessary for the establishment of Kaposi sarcoma (KS), although it is not sufficient. Thus, only a small fraction of KSHV-infected individuals develops KS. The cofactors that influence risk of KS among HIV-uninfected individuals are yet to be determined. The objective of the current study was to assess potential risk factors for CKS in the KSHV-infected Jewish population in Israel.

METHODS

A case-control study involved 35 CKS cases and 48 matched KSHV-infected controls. Lifestyle and medical history data from case patients and controls were compared by logistic regression analysis.

RESULTS

In a multivariate analysis, the authors identified an age-related small increased risk for CKS in subjects originating from Asia and Africa. The risk for CKS increased, although not significantly statistically, in subjects who reported alcohol consumption, diabetes mellitus, herpes simplex, and asthma. No relation was found with cigarette smoking, family size, number of lifetime sexual partners, or sexually transmitted disease.

CONCLUSIONS

A borderline increase in CKS risk among elderly subjects originating from Africa or Asia was identified. These results need to be further evaluated by larger studies. The authors believe that genetic and immunologic parameters may alter risk for CKS and, therefore, should also be investigated.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSION

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

Classic Kaposi's sarcoma in Italy, 1985-1998

To evaluate incidence rates (IRs) of classic Kaposi's sarcoma (CKS) in Italy after the spread of AIDS, we distinguished CKS from AIDS-related KS (AKS) using an 'ad hoc' record linkage procedure between 15 Cancer Registries (CRs) (21% of the Italian population) and the national AIDS Registry. Between 1985 and 1998, 874 cases of CKS and 634 cases of AKS were diagnosed in the study areas. CKS accounted for 16 and 27% of KS cases below 55 years of age in men and women, respectively, but for 91 and 100% of those above age 55. The IRs for CKS were 1.0/ in men and 0.4/100,000 in women, but they varied between 0.3 in Umbria and 4.7 in Sassari in men, and between 0.1 in Parma and 1.7 in Sassari in women. IRs of CKS in both genders were stable between 1985-1987 and 1993-1998. In Northern and Central CRs the IR (adjusted for age and gender) for CKS was 0.5 in individuals born in the same area, but 1.6 in individuals born in Southern Italy or in the Islands (rate ratio = 3.2) suggesting that KS-associated herpesvirus, the cause of KS, is acquired early in life.

Inhibition of angiogenesis in vivo and growth of Kaposi's sarcoma xenograft tumors by the anti-malarial artesunate

Artesunate (ART) is a semi-synthetic derivative of the sesquiterpene artemisinin used for the second line therapy of malaria infections with Plasmodium falciparum. ART also inhibits growth of many transformed cell lines. In the present investigation, we show that ART inhibited the growth of normal human umbilical endothelial cells and of KS-IMM cells that we have established from a Kaposi's sarcoma lesion obtained from a renal transplant patient. The growth inhibitory activity correlated with the induction of apoptosis in KS-IMM cells. Apoptosis was not observed in normal endothelial cells, which, however, showed drastically increased cell doubling times upon ART treatment. ART strongly reduced angiogenesis in vivo in terms of vascularization of Matrigel plugs injected subcutaneously into syngenic mice. We conclude that ART represents a promising candidate drug for the treatment of the highly angiogenic Kaposi's sarcoma. As a low-cost drug, it might be of particular interest for areas of Kaposi's sarcoma endemics. ART could be useful for the prevention of tumor angiogenesis.