Kaposi's sarcoma in patients with and without human immunodeficiency virus infection, in a tertiary referral centre in Kenya

Survival Following Diagnosis of HIV-Associated Kaposi Sarcoma Among Adults in East Africa in the "Treat-All" Era

Background

Despite widespread access to antiretroviral therapy (ART) in the "Treat All" era, HIV-associated Kaposi sarcoma (KS) remains among the most common malignancies in sub-Saharan Africa. Survival after KS diagnosis has historically been poor in Africa, but knowledge whether survival has changed at the population level in the contemporary era has been limited by lack of community-representative surveillance and monitoring systems.

Methods

We identified all adult persons living with HIV (PLWH) with a new diagnosis of KS made between 2016 and 2019 during outpatient or inpatient care at prototypical primary care-providing medical facilities in Kenya and Uganda using rapid case ascertainment. Participants were subsequently followed for vital status, including community tracking for those who became lost to follow-up.

Findings

Among 411 participants with newly diagnosed KS, 71% were men, median age was 34 (IQR: 30 to 41) years, and 91% had ACTG T1 tumor extent. Over a median follow-up of 7.8 (IQR: 2.4 to 17.9) months, cumulative incidence of death (95% CI) at months 6, 12 and 18 were 34% (30% to 39%), 41% (36% to 46%) and 45% (40% to 51%), respectively. Having the highest number of anatomic sites (11 to 16) harboring KS lesions (hazard ratio 2.2 (95% CI: 1.3-3.8) compared to 1 to 3 sites) and presence of oral KS lesions (hazard ratio 2.2 (95% CI: 1.4-3.3)) were independently associated with higher mortality. Lower hemoglobin and CD4 count as well as higher plasma HIV RNA were also associated with higher mortality.

Interpretation

Among PLWH with newly diagnosed KS in East Africa in the "Treat All" era, survival was poor and related to mucocutaneous extent of KS. The findings emphasize the need for better control of KS in Africa, including novel approaches for earlier detection, better linkage to oncologic care, and more potent therapy.

Divergent clinical presentations and outcomes among children and adolescents with Kaposi sarcoma in Malawi and Tanzania

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.

Characteristics and Treatment Response of Patients with HIV Associated Kaposi's Sarcoma in Central Kenya

Introduction

Kaposi's sarcoma (KS) is the most common HIV-associated malignancy in Sub Saharan Africa. In 2018, it was the 7th most common cancer and the 10th most common cause of cancer death in Kenya. This study aimed to describe the baseline and clinical characteristics and treatment response observed following combined antiretroviral treatment (ART) and chemotherapy in KS patients.

Methods

This was a descriptive analysis of patients aged ≥15 years treated for KS and HIV at 11 treatment hubs in Central Kenya between 2011 and 2014. Data on baseline and clinical characteristics, ART and chemotherapy regimens as well as treatment responses were collected from patient files and KS registers.

Results

A total of 95 patients presenting with clinically suspected KS with no history of prior treatment with chemotherapy were reviewed. All had histological diagnostic samples taken with 67 (71%) having confirmed KS. All were on ART, either newly initiated or continuing on ART, and 63 of the 67 (94.0%) confirmed to have KS received chemotherapy. Among the 67 patients with confirmed KS, mean age was 37.2 years (± 13.2) and 40 (59.7%) were male. More than 80% had normal baseline and follow-up BMI, and 34 (50.7%) were on a TDF-based regimen, 52 (77.6%) were treated with the Adriamycin, bleomycin and vinblastine protocol, and 55 (82.1%) had KS diagnosis before HIV diagnosis. All 67 patients had mucocutaneous lesions. Complete, partial response and stable disease occurred in 27 (40.3%), 10 (14.9%) and 7 (10.4%), respectively, 11 (16.4%) defaulted care during treatment, six patients died during treatment, four patients died before treatment while two patients had progressive disease during chemotherapy.

Conclusion

The diagnosis of KS preceded HIV in the majority of cases reviewed, with histology helpful to reduce misdiagnosis. Patients generally complied with their chemotherapy, with overall good response rate for this intervention implemented at primary health-care facilities.

Comparative transcriptome analysis of endemic and epidemic Kaposi's sarcoma (KS) lesions and the secondary role of HIV-1 in KS pathogenesis

In sub-Saharan Africa, endemic Kaposi's sarcoma (EnKS) is still prevalent despite high incidence of epidemic Kaposi's sarcoma (EpKS) resulting from the on-going HIV-1 epidemic. While KSHV is clearly the etiologic agent of KS, the mechanisms underlying KS development are not fully understood. For example, HIV-1 co-infection and concomitant immune dysfunction have been associated with EpKS development. However, the direct or indirect role(s) of HIV-1, and therefore of immune suppression, in EpKS remains unclear. How, or whether, EpKS is mechanistically distinct from EnKS is unknown. Thus, the absence of HIV-1 co-infection in EnKS provides a unique control for investigating and deciphering whether HIV-1 plays a direct or indirect role in the EpKS tumor microenvironment. We hypothesized that HIV-1 co-infection would induce transcriptome changes that differentiate EpKS from EnKS, thereby defining the direct intra-tumor role of HIV-1 in KS. Comparison of ART-treated and -naïve patients would further define the impact of ART on the KS transcriptome. We utilized RNA-seq followed by multiparameter bioinformatics analysis to compare transcriptomes from KS lesions to uninvolved control skin. We provide the first transcriptomic comparison of EpKS versus EnKS, ART-treated vs-naïve EpKS and male vs female EpKS to define the roles of HIV-1 co-infection, the impact of ART, and gender on KS gene expression profiles. Our findings suggest that ART-use and gender have minimal impact on transcriptome profiles of KS lesions. Gene expression profiles strongly correlated between EpKS and EnKS patients (Spearman r = 0.83, p<10-10). A subset of genes involved in tumorigenesis and inflammation/immune responses showed higher magnitude, but not unique dysregulation in EnKS compared to EpKS. While gender and ART had no detectable contribution, the trend toward higher magnitude of gene dysregulation in EnKS coupled with the absence of HIV-1 transcripts in EpKS may suggest an indirect or systemic effect of HIV-1 to promote KS tumorigenesis.

Relationship between human leukocyte antigen alleles and risk of Kaposi's sarcoma in Cameroon

Several studies published to date report associations between human leukocyte antigen (HLA) alleles and different types of Kaposi's Sarcoma (KS). However, there is little concordance between the HLA alleles identified and the populations studied. To test whether HLA alleles associate with KS in a Cameroonian case-control study, we performed high-resolution HLA typing in KSHV seropositive individuals. Among HIV-positive individuals, carriers of HLA-B*14:01 were at a significantly higher risk of AIDS-KS (p = 0.033). For HIV-negative patients, a gene-wise comparison of allele frequencies identified the HLA-B (p = 0.008) and -DQA1 (p = 0.002) loci as possible risk factors for endemic KS. Our study provides additional understanding of genetic determinants of KS and their implications in disease pathogenesis. Further validation of these findings is needed to define the functional relevance of these associations.

Dermatology-Driven Quality Improvement Interventions to Decrease Diagnostic Delays for Kaposi Sarcoma in Botswana

PURPOSE

Kaposi sarcoma (KS) is an HIV-associated skin cancer that is highly prevalent in Botswana and associated with significant morbidity and mortality. Histopathology-confirmed diagnosis is required for chemotherapeutic interventions in Botswana, which creates barriers to care because of limited biopsy and pathology services. We sought to understand the role a dermatology specialist can play in improving KS care through quality improvement (QI) initiatives to reduce histologic turnaround times (TATs) for KS.

METHODS

Employment of a dermatology specialist within a public health care system that previously lacked a local dermatologist generated quality improvements in KS care. Retrospective review identified patients diagnosed with KS by skin biopsy in the predermatology QI interval (January 1, 2015, to December 31, 2015) versus the postdermatology QI interval (January 1, 2016, to November 31, 2017). Histology TATs and clinical characteristics were recorded. A t test compared the median histology TATs in the pre- and post-QI intervals.

RESULTS

A total of 192 cases of KS were diagnosed by skin biopsy. Nearly all (98.4%) were HIV-positive; and 52.8% of patients were male with a median age of 39 years. Median TAT in the postdermatology QI interval was 11 days (interquartile range, 12-23 days) compared with 32 days in the predermatology QI interval (interquartile range, 24-56 days; P < .00).

CONCLUSION

Dermatology-led QI initiatives to improve multispecialty care coordination can significantly decrease histology TATs for KS. The reduction of diagnostic delays is a key first step to decreasing the morbidity and mortality associated with this cancer in resource-limited settings.

Endemic Kaposi sarcoma in HIV-negative children and adolescents: an evaluation of overlapping and distinct clinical features in comparison with HIV-related disease

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.

Association of CD4+ T-cell Count, HIV-1 RNA Viral Load, and Antiretroviral Therapy With Kaposi Sarcoma Risk Among HIV-infected Persons in the United States and Canada

BACKGROUND

Kaposi sarcoma (KS) remains common among HIV-infected persons. To better understand KS etiology and to help target prevention efforts, we comprehensively examined a variety of CD4 T-cell count and HIV-1 RNA viral load (VL) measures, as well as antiretroviral therapy (ART) use, to determine independent predictors of KS risk.

SETTING

North American AIDS Cohort Collaboration on Research and Design.

METHODS

We followed HIV-infected persons during 1996-2009 from 18 cohorts. We used time-updated Cox regression to model relationships between KS risk and recent, lagged, trajectory, and cumulative CD4 count or VL measures, as well as ART use. We used Akaike's information criterion and global P values to derive a final model.

RESULTS

In separate models, the relationship between each measure and KS risk was highly significant (P < 0.0001). Our final mutually adjusted model included recent CD4 count [hazard ratio (HR) for <50 vs. ≥500 cells/μL = 12.4; 95% confidence interval (CI): 6.5 to 23.8], recent VL (HR for ≥100,000 vs. ≤500 copies/mL = 3.8; 95% CI: 2.0 to 7.3), and cumulative (time-weighted mean) VL (HR for ≥100,000 vs. ≤500 copies/mL = 2.5; 95% CI: 1.0 to 5.9). Each P-trend was <0.0001. After adjusting for these measures, we did not detect an independent association between ART use and KS risk.

CONCLUSIONS

Our results suggested a multifactorial etiology for KS, with early and late phases of development. The cumulative VL effect suggested that controlling HIV replication promptly after HIV diagnosis is important for KS prevention. We observed no evidence for direct anti-KS activity of ART, independent of CD4 count and VL.

A prospective ascertainment of cancer incidence in sub-Saharan Africa: The case of Kaposi sarcoma

In resource‐limited areas, such as sub‐Saharan Africa, problems in accurate cancer case ascertainment and enumeration of the at‐risk population make it difficult to estimate cancer incidence. We took advantage of a large well‐enumerated healthcare system to estimate the incidence of Kaposi sarcoma (KS), a cancer which has become prominent in the HIV era and whose incidence may be changing with the rollout of antiretroviral therapy (ART). To achieve this, we evaluated HIV‐infected adults receiving care between 2007 and 2012 at any of three medical centers in Kenya and Uganda that participate in the East Africa International Epidemiologic Databases to Evaluate AIDS (IeDEA) Consortium. Through IeDEA, clinicians received training in KS recognition and biopsy equipment. We found that the overall prevalence of KS among 102,945 HIV‐infected adults upon clinic enrollment was 1.4%; it declined over time at the largest site. Among 140,552 patients followed for 319,632 person‐years, the age‐standardized incidence rate was 334/100,000 person‐years (95% CI: 314–354/100,000 person‐years). Incidence decreased over time and was lower in women, persons on ART, and those with higher CD4 counts. The incidence rate among patients on ART with a CD4 count >350 cells/mm³ was 32/100,000 person‐years (95% CI: 14–70/100,000 person‐years). Despite reductions over time coincident with the expansion of ART, KS incidence among HIV‐infected adults in East Africa equals or exceeds the most common cancers in resource‐replete settings. In resource‐limited settings, strategic efforts to improve cancer diagnosis in combination with already well‐enumerated at‐risk denominators can make healthcare systems attractive platforms for estimating cancer incidence.

Classical Kaposi's Sarcoma in a Nigerian Farmer: A Case Report

Classical Kaposi's sarcoma (KS) typically affects elderly men of Mediterranean and Jewish origin. We present an unusual case of classical KS in a human immunodeficiency virus (HIV) negative elderly farmer from rural Nigeria. He had multiple brownish nodules and plaques on both lower extremities associated with lymphoedema. Histopathological examination of a biopsy of the skin nodule confirmed the diagnosis of KS. The lesions only showed marginal improvement on chemotherapy which necessitated a referral for radiotherapy. There is a need to look beyond the traditional geographical distinction of KS variants as we continue to experience a dynamic role for environmental co-factors in the development of KS.

Effect of AIDS on women who have sex-determined health issues

Worldwide, women account for a growing percentage of human immunodeficiency virus (HIV)-infected patients and more than half of all HIV infections. For many years, morphologic imaging methods were the main approaches employed to investigate HIV and its complications. However, during the past decade, advancements in PET and SPECT imaging technologies opened new possibilities for improved understanding of the pathophysiological processes in HIV. Diagnosis of early HIV-associated neurocognitive disorders (HAND) is important, as many of its symptoms can be caused by other conditions common to people with HIV/AIDS. Presently, there are no PET and SPECT tracers or combination of markers for HAND, hence novel HAND-specific tracers are needed if nuclear medicine is to play a role in solving the problem of the HAND "epidemic." As both highly active antiretroviral therapy (HAART)-induced lipoatrophy and cardiovascular diseases are characterized by ongoing inflammation, FDG-PET/CT imaging may represent an important imaging technique for better understanding the metabolic risk in HIV-infected women on HAART. HIV-infected women are at increased risk for the development of human papilloma virus-associated neoplasms such as cervical and anal carcinomas; these aggressive tumors could be treated better with integration of FDG-PET as part of the standard pretreatment workup. A similar value of FDG-PET may be realized in women with HIV-associated Kaposi sarcoma, as they have more extensive cutaneous disease than men do. In the era of HAART, the incidence and local invasiveness of breast cancer may change, thus creating a need to redefine the pathophysiology of breast cancer in HIV-positive women. Finally, mammary tuberculosis, occasionally the presenting symptom in HIV-infected women, may present with nonspecific clinical, radiological, and histologic findings. In these women, FDG-PET can be of value to detect the lesion for a representative biopsy, staging to exclude pulmonary and other extrapulmonary lesions, and also for therapy monitoring.

Excellent clinical outcomes and retention in care for adults with HIV-associated Kaposi sarcoma treated with systemic chemotherapy and integrated antiretroviral therapy in rural Malawi

INTRODUCTION

HIV-associated Kaposi sarcoma (HIV-KS) is the most common cancer in Malawi. In 2008, the non-governmental organization, Partners In Health, and the Ministry of Health established the Neno Kaposi Sarcoma Clinic (NKSC) to treat HIV-KS in rural Neno district. We aimed to evaluate 12-month clinical outcomes and retention in care for HIV-KS patients in the NKSC, and to describe our implementation model, which featured protocol-guided chemotherapy, integrated antiretroviral therapy (ART) and psychosocial support delivered by community health workers.

METHODS

We conducted a retrospective cohort study using routine clinical data from 114 adult HIV-KS patients who received ART and ≥1 chemotherapy cycle in the NKSC between March 2008 and February 2012.

RESULTS

At enrolment 97% of patients (n/N=103/106) had advanced HIV-KS (stage T1). Most patients were male (n/N=85/114, 75%) with median age 36 years (interquartile range, IQR: 29-42). Patients started ART a median of 77 days prior to chemotherapy (IQR: 36-252), with 97% (n/N=105/108) receiving nevirapine/lamivudine/stavudine. Following standardized protocols, we treated 20 patients (18%) with first-line paclitaxel and 94 patients (82%) with bleomycin plus vincristine (BV). Of the 94 BV patients, 24 (26%) failed to respond to BV requiring change to second-line paclitaxel. A Division of AIDS grade 3/4 adverse event occurred in 29% of patients (n/N=30/102). Neutropenia was the most common grade 3/4 event (n/N=17/102, 17%). Twelve months after chemotherapy initiation, 83% of patients (95% CI: 74-89%) were alive, including 88 (77%) retained in care. Overall survival (OS) at 12 months did not differ by initial chemotherapy regimen (p=0.6). Among patients with T1 disease, low body mass index (BMI) (adjusted hazard ratio, aHR=4.10, 95% CI: 1.06-15.89) and 1 g/dL decrease in baseline haemoglobin (aHR=1.52, 95% CI: 1.03-2.25) were associated with increased death or loss to follow-up at 12 months.

CONCLUSIONS

The NKSC model resulted in infrequent adverse events, low loss to follow-up and excellent OS. Our results suggest it is safe, effective and feasible to provide standard-of-care chemotherapy regimens from the developed world, integrated with ART, to treat HIV-KS in rural Malawi. Baseline BMI and haemoglobin may represent important patient characteristics associated with HIV-KS survival in rural sub-Saharan Africa.

Effect of HIV infection on the outcome of cancer therapy in children

SUMMARY

Systematic studies comparing the outcomes of cancer treatment between children with and without HIV are scarce. The literature seems to suggest that, even with present therapeutic advances, prognosis is poor with HIV infection. The aim of this Review was to assess scientific publications from 1990 to present, addressing the difficulties associated with treatment of cancer in children with AIDS and the adaptive changes in therapy. Although much progress has been achieved, further research is needed about antiretroviral and cytotoxic drug interactions, the optimum use of supportive therapy including stem cells and bone marrow transplant, the timing of the initiation of highly active antiretroviral therapy, and the optimum use of protease inhibitors.

AIDS-related Kaposi's sarcoma in Brazil: trends and geopolitical distribution

BACKGROUND

AIDS-related Kaposi's sarcoma (KS) is a unique model of the relationship between viral infection, immunity, environmental, and genetic factors in viral cancers. The goal was to determine the distribution of KS cases among Brazilian geopolitical regions, looking at the ecological relationship with median CD4 cell count.

METHODS

Ecological study using Brazilian National Diseases Reporting Databases: 1982-2009. Subjects ≥ 13 years of age who have KS cited in their AIDS reporting form were selected, and demographic and HIV exposure data were collected.

RESULTS

We found 11,731 KS cases in the period, with a prevalence of 2.4% among AIDS cases; 88% were male, and 68% lived in the Southeast region, which accounted for 59% of AIDS cases. The regional and national prevalence trends were similar, although the highest proportion among women was found in the North region, which has the lowest number of both AIDS and KS cases. Heterosexual transmission accounted for 87% of HIV among women compared to 18% among men. Fifty-seven percent of all KS cases were diagnosed before antiretroviral therapy (ART). Injection drug use accounted for 11% of KS cases. Median survival was 472 days before the ART era and 1482 after it (P < 0.001). Median CD4 counts increased in all regions in the period as ART coverage expanded, and a resulting correlating decline in KS cases was observed.

CONCLUSIONS

Prevalence of KS declined after the introduction of ART in all regions of Brazil, suggesting individual protection conveyed by ART.

Pharyngolaryngeal location of Kaposi's sarcoma with airway obstruction in an HIV-negative patient

Kaposi's sarcoma (KS) is a human herpes virus-8 (HHV-8)-associated angioproliferative disorder, and its occurrence may be favored by human immunodeficiency virus (HIV) infection and iatrogenic immunosuppression. It has also been postulated that a chronic inflammatory disease of the skin can pave the way to its development. KS generally involves mucosal and cutaneous sites, including the head and neck. An oropharyngeal location is quite common, but laryngeal involvement with possible upper airway obstruction and respiratory distress requiring tracheotomy is rare, and no hypopharyngeal locations have yet been reported.

We describe the case of a 68-year-old male patient who developed KS after immunosuppressive treatment for pemphigus vulgaris, an autoimmune bullous disease presenting with blisters and erosions on the skin and the oral mucosa. KS was initially localized to the oral cavity and oropharynx, but subsequent involvement of the laryngeal and hypopharyngeal tract led to acute airway obstruction and the need for tracheotomy. This unique case of pharyngolaryngeal KS suggests that clinicians faced with purple nodular lesions should consider a differential diagnosis of KS in immunocompromised patients, even if they are HIV negative, and should carefully manage the patency of the upper airways.

Anogenital Lesions: Kaposi's Sarcoma and Its Mimicks

Kaposi's sarcoma (KS) is a low-grade vascular neoplasm associated with human herpes virus-8 (HHV-8) infection, and, in the epidemic form, with the human immunodeficiency virus (HIV). Although HHV-8 is present in all body fluids and is sexually transmitted, there are surprisingly few reports of anogenital KS. Clinically, especially in HIV/KS endemic areas, dark stained skin patches or nodules are prone to misdiagnosis, especially in dark-skinned individuals. Therefore, a biopsy is recommended. The histologic appearance spans a broad spectrum of KS and non-KS lesions; therefore, the final diagnosis should be confirmed by HHV-8 immunohistochemistry. We report a series of 36 anogenital biopsies from a group of 16 documented HIV-positive patients; in 20 the HIV serostatus was unknown. There were ten KS (five in HIV-positive patients), and 26 non-KS (11 in HIV-positive subjects) lesions. In the era of HIV/AIDS, anogenital lesions may be the first manifestation of KS in immunocompromised individuals and should be biopsied. The histological diagnosis should be confirmed by HHV-8 immunohistochemistry.

Clinicopathological Proficiency in the Diagnosis of Kaposi's Sarcoma

Background. The prevalence of Kaposi's sarcoma (KS), an AIDS-defining illness, has increased in parallel with the HIV/AIDS epidemic. The presence of violaceous skin lesions should raise suspicion of KS. However, especially on dark skin, KS mimics a variety of non-KS skin conditions. Histologically, there is a wide range of expressions of KS and a large number of mimickers. For all these reasons, a HHV-8 immunohistochemically biopsy-proven diagnosis of KS should be the gold standard. Methods. Prospective study of 490 consecutive skin biopsies from the general community in the Limpopo Province of South Africa, from April 2010 through December 2011. Results. The clinical discordance rate (over-/underdiagnosis of KS) was 30.5%; the histological discordance rate was 9.2%. Conclusion. Because of the magnitude of diagnostic error, both clinical and histological, all clinical lesions suspicious of KS should be biopsied and HHV-8 LAN-1 immunophenotyped.

Primary cutaneous malignancies in sub-Saharan Africa

Cutaneous malignancies are the most common malignancies in Whites; traditionally considered rare among Blacks, their occurrence in sub-Saharan Africa is yet to be fully characterized.Data on specimens submitted between 1992 and April 2008 on all histologically proven primary cutaneous malignancies were collected from the Pathology Department, including patient age, sex, anatomic site of malignancy, and histologic diagnosis. There were 1900 patients with primary cutaneous malignancies, aged between 8 months and 110 years, with a mean age of 49 years. There were 14 different types of malignancies found, with squamous cell carcinoma representing 45% of the total. A number of the rarer types have not been reported previously, from this region.Cutaneous malignancies in Africa present a number of management challenges including the following: difficulties in early diagnosis in the dark skin, late presentation, access to treatment, and the ability to pay for the appropriate treatment. The current human immunodeficiency virus/acquired immune deficiency syndrome scourge on the continent may lead a significant increase in cutaneous malignancies, posing even bigger challenges.

Gender differences in clinical presentation and outcomes of epidemic Kaposi sarcoma in Uganda

Introduction

The incidence of Kaposi sarcoma (KS) has increased dramatically among women in sub-Saharan Africa since the onset of the HIV pandemic, but data on KS disease in women are limited. To identify gender-related differences in KS presentation and outcomes, we evaluated the clinical manifestations and response in men and women with AIDS-associated KS in Uganda.

Methods and Findings

HIV-infected adults with KS attending the Infectious Diseases Institute (IDI) and Uganda Cancer Institute (UCI) in Kampala, Uganda between 2004 and 2006 were included in a retrospective cohort. Evaluation of KS presentation was based on the clinical features described at the initial KS visit. Response was evaluated as the time to “improvement”, as defined by any decrease in lesion size, lesion number, or edema. The cohort consisted of 197 adults with HIV and KS: 55% (108/197) were women. At presentation, the median CD4 T-cell count was significantly lower in women (58 cells/mm³; IQR 11–156 cells/mm³) than men (124 cells/mm³; IQR 22–254 cells/mm³) (p = 0.02). Women were more likely than men to present with lesions of the face (OR 2.8, 95% CI, 1.4, 5.7; p = 0.005) and hard palate (OR 2.0, 95% CI, 1.1, 3.7; p = 0.02), and were less likely than men to have lower extremity lesions (OR 0.54, 95% CI, 0.3, 0.99; p = 0.05). Women were less likely than men to demonstrate clinical improvement (HR = 0.52, CI 0.31, 0.88; p = 0.01) in multivariate analysis.

Conclusions

The clinical presentation and response of KS differs between men and women in Uganda. These data suggest that gender affects the pathophysiology of KS, which may have implications for the prevention, diagnosis, and treatment of KS in both men and women. Prospective studies are needed to identify predictors of response and evaluate efficacy of treatment in women with KS, particularly in Africa where the disease burden is greatest.

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.

Investigational agents for treatment of AIDS-related Kaposi's sarcoma

AIDS-related Kaposi's sarcoma (KS) is a neoplasm that results from the co-infection of HIV and KS herpesvirus/human herpesvirus-8 (KSHV/HHV8). Targeting HIV with highly active antiretroviral therapy has attenuated the natural history of this disease. Recent discoveries have elucidated the role of multiple signaling pathways in the pathogenesis of AIDS-related KS. In particular, KSHV/HHV8-specific gene products, including a G-protein-coupled receptor (vGPCR) and a homolog of human IL-6 (vIL-6), have been implicated in the development of tumorigenesis and angiogenesis. In addition, KSHV/HHV8 can modulate cellular growth and angiogenic pathways to augment malignant transformation and potentiate growth. This article discusses the main signaling pathways that are implicated in the pathogenesis of AIDS-related KS, reviews recently completed clinical trials and anticipates the future direction of molecularly targeted agents in this disease.

Management of AIDS-related Kaposi's sarcoma

The advent of highly active antiretroviral therapy (HAART) has lead to a substantial reduction in the prevalence, morbidity, and mortality associated with AIDS-related Kaposi's sarcoma. Similarly, concomitant advances in chemotherapy and supportive-care protocols have allowed for Kaposi's sarcoma to be managed more effectively in comparison with the pre-HAART era. Furthermore, developments in our understanding of the pathogenesis of Kaposi's sarcoma have identified several molecular targets that can potentially provide new therapeutic strategies. This Review discusses the role of conventional chemotherapeutic and immunomodulatory agents in the treatment of Kaposi's sarcoma and summarises the current status and future prospects of novel molecularly targeted agents in the treatment of this disease.

Challenges and opportunities for treatment and research of AIDS-related malignancies in Africa

PURPOSE OF REVIEW

Following our review of AIDS-associated cancer in developing nations in 2004, we sought to update recent publications and review data on the challenges and opportunities for the treatment and research of AIDS malignancies in Africa.

RECENT FINDINGS

It is apparent that the burden of AIDS-related malignancies and other virus-associated tumors is significant and increasing in Africa. Several recent studies report findings on conjunctival squamous cell carcinoma and there is a report that Hodgkin's disease, a non-AIDS-defining neoplasm, is increasing in incidence. International collaborative partnerships dedicated to AIDS malignancies in developing countries are feasible and invaluable for clinical strategies to address this aspect of the pandemic. A departure point is the ongoing work of the East Africa - Case Western Reserve University Collaboration in AIDS malignancies.

SUMMARY

The burden of neoplastic complications of HIV infection and endemic virus-associated tumors are assuming increasing significance in Africa. There is a need to develop nonmyelotoxic therapies and approaches that are hypothesis-driven and pathogenesis-based. The scarcity and shortages in this region demand that our scientific and therapeutic strategies are both suitable and pragmatic for testing in this setting. It is also imperative that African investigators lead us in this important endeavor.

Capacity building for the clinical investigation of AIDS malignancy in East Africa

PURPOSE

To build capacity in the resource-poor setting to support the clinical investigation and treatment of AIDS-related malignancies in a region of the world hardest hit by the AIDS pandemic.

METHODS

An initial MEDLINE database search for international collaborative partnerships dedicated to AIDS malignancies in developing countries failed to identify any leads. This search prompted us to report progress on our collaboration in this aspect of the epidemic. Building on the formal Uganda-Case Western Reserve University (Case) Research Collaboration dating back to 1987, established NIH-supported centers of research excellence at Case, and expanding activities in Kenya, scientific and training initiatives, research capital amongst our institutions are emerging to sustain a international research enterprise focused on AIDS and other viral-related malignancies.

RESULTS

A platform of clinical research trials with pragmatic design has been developed to further enhance clinical care and sustain training initiatives with partners in East Africa and the United States. An oral chemotherapy feasibility trial in AIDS lymphoma is near completion; a second lymphoma trial of byrostatin and vincristine is anticipated and a feasibility trial of indinavir for endemic Kaposi's sarcoma is planned.

CONCLUSIONS

In the absence of published reports of evolving international partnerships dedicated to AIDS malignancy in resource constrained settings, we feel it important for such progress on similar or related international collaborative pursuits to be published. The success of this effort is realized by the long-term international commitment of the collaborating investigators and institutions to sustain this effort in keeping with ethical and NIH standards for the conduct of research; the provision of formal training of investigators and research personnel on clinical problems our East African partners are faced with in practice and the development of pragmatic clinical trials and therapeutic intervention to facilitate technology transfer and enhance clinical practice.