Effect of highly active antiretroviral therapy on survival in patients with AIDS-associated pulmonary Kaposi's sarcoma treated with chemotherapy

Kaposi's Sarcoma: Evaluation of Clinical Features, Treatment Outcomes, and Prognosis in a Single-Center Retrospective Case Series

Kaposi's sarcoma (KS) is a rare angioproliferative tumor classified in four different clinical-epidemiological forms. The diagnosis is based on histopathological and immunohistochemical analyses. The treatment is heterogeneous and includes several local and systemic therapeutic strategies. Methods: This is a retrospective cohort study including 86 KS patients treated between 1993 and 2022 at the University Hospital of Padua (AOPD) and at the Veneto Institute of Oncology (IOV). The data were extracted from an electronic database. Survival curves were generated using the Kaplan-Meier method, and Cox regression models were employed to explore associations with overall and disease-free survival. The male sex (89.53%), classical variant (43.02%), and cutaneous involvement (77.9%) were predominant. More than 61.6% of patients received a single treatment. Surgery, antiretroviral therapy, and chemotherapy were the mostly adopted approaches. A persistent response was observed in approximately 65% of patients, with a 22% relapse rate (at least 2 years). The overall survival ranges from 90 to 70% at 2 to 10 years after the diagnosis. Iatrogenic KS demonstrated a higher mortality (52.9%). This study reflects our experience in the management of KS. Comorbidities are very frequent, and treatments are heterogeneous. A multidisciplinary approach involving multiple referral specialists is essential for the appropriate management of this disease during diagnosis, treatment, and follow-up.

Impact of valganciclovir therapy on severe IRIS-Kaposi Sarcoma mortality: An open-label, parallel, randomized controlled trial

INTRODUCTION

High HHV-8 viral load (VL) in Kaposi Sarcoma (KS) has been associated with Severe Immune Reconstitution Inflammatory Syndrome (Severe-IRIS-KS), which can occur after initiating cART, and leads to high mortality, particularly in patients with pulmonary involvement. We investigate if valganciclovir (as an anti-HHV-8 agent) initiated before cART reduces the mortality associated with Severe-IRIS-KS and the incidence of Severe-IRIS-KS.

METHODS

Open-label parallel-group randomized clinical trial in AIDS cART naïve patients with disseminated KS (DKS) as defined by at least two of the following: pulmonary, lymph-node, or gastrointestinal involvement, lymphedema, or ≥30 skin lesions. In the experimental group (EG), patients received valganciclovir 900 mg BID four weeks before cART and continued until week 48; in the control group (CG), cART was initiated on week 0. Non-severe-IRIS-KS was defined as: an increase in the number of lesions plus a decrease of ≥one log10 HIV-VL, or an increase of ≥50cells/mm3 or ≥2-fold in baseline CD4+cells. Severe-IRIS-KS was defined as abrupt clinical worsening of KS lesions and/or fever after ruling out another infection following cART initiation, and at least three of the following: thrombocytopenia, anemia, hyponatremia, or hypoalbuminemia.

RESULTS

40 patients were randomized and 37 completed the study. In the ITT analysis, at 48 weeks, total mortality was the same in both groups (3/20), severe-IRIS-KS attributable mortality was 0/20 in the EG, compared with 3/20 in the CG (p = 0.09), similar to the per-protocol analysis: 0/18 in the EG, and 3/19 in the control group (p = 0.09). The crude incidence rate of severe-IRIS-KS was four patients developed a total of 12 episodes of Severe-IRIS-KS in the CG and two patients developed one episode each in the EG. Mortality in patients with pulmonary KS was nil in the EG (0/5) compared with 3/4 in the CG (P = 0.048). No difference was found between groups in the number of non-S-IRIS-KS events. Among survivors at week 48, 82% achieved >80% remission.

CONCLUSIONS

Although mortality attributable to KS was lower in the EG the difference was not statistically significant.

Recent advances in HIV-associated Kaposi sarcoma

Kaposi sarcoma (KS) is a mesenchymal tumour caused by KS-associated herpesvirus and is an AIDS-defining illness. Despite a decline in incidence since the introduction of combination anti-retroviral therapy, KS remains the most common cancer in people living with HIV in sub-Saharan Africa, where it causes significant morbidity and mortality. This review reflects on recent epidemiological data as well as current management, unmet needs and future perspectives in the treatment of HIV-associated KS with particular emphasis on the potential role of immune checkpoint inhibitors.

Immune reconstitution inflammatory syndrome-associated disseminated Kaposi's sarcoma in a patient infected with human immunodeficiency virus: Report of an autopsy case

Immune reconstitution inflammatory syndrome is a collection of inflammatory disorders associated with paradoxical worsening of preexisting infectious processes following the initiation of highly active antiretroviral therapy (HAART) in individuals infected with human immunodeficiency virus (HIV). It involves a wide range of pathogens, neoplasms such as Kaposi's sarcoma (KS) and some autoimmune diseases. We describe an autopsy report of a 40-year-old man infected with HIV. He experienced a rapid dissemination of KS resulting in death within 6 months after starting HAART. His serum viral load had significantly decreased 4 log10 within 32 days and his CD4+ T-cell count increased 4-fold. He presented with multiple skin lesions over the chin and anterior neck, which rapidly spread over the trunk, 4 extremities, perianal region, and penis. Finally, he developed acute dyspnea and a plain chest radiograph showed bilateral pulmonary infiltrations. Despite treatment, he died of acute respiratory failure. At autopsy, multiple KS lesions were noted in the bilateral lungs, liver, kidneys, and gastrointestinal tract. Increased inflammatory cytokines during immune reconstruction from HAART-reactive human herpes virus type-8 infection, linked to the tumorigenesis of KS, finally led to rapid dissemination and death.

Clinical characteristics, predictors of immune reconstitution inflammatory syndrome and long-term prognosis in patients with Kaposi sarcoma

Objective

To investigate the predictive factors for the development of Kaposi sarcoma-related immune reconstitution inflammatory syndrome (KS-IRIS) and long-term prognosis in patients starting combined antiretroviral therapy (cART).

Methods

We studied a retrospective-cohort of consecutive antiretroviral-naïve patients with KS initiating cART from January 2005 to December 2011 and followed through June 2013. KS-IRIS was defined as ≥2 of the following: abrupt increase in number of KS lesions, appearance or exacerbation of lung-opacities or lymphedema, concomitantly with an increase in CD4+ cell-count ≥50 cells/mm³ and a decrease of >1 log in viral-load once started cART. We compared individuals who met KS-IRIS criteria with those that did not and described the long-term follow-up.

Results

We included 89 patients, 88 males; 35 (39%) developed KS-IRIS at a median of 10 weeks (IQR 4–16). KS-IRIS patients had more pulmonary-involvement (60% vs. 16.6% of patients; p < 0.0001), eight died attributed to pulmonary-KS. Thrombocytopenia <100,000/mm³ at follow-up occurred in 36% of KS-IRIS vs. 4% in non-KS-IRIS patients (p = 0.0002), 45% KS-IRIS patients with thrombocytopenia died, non without KS-IRIS. Chemotherapy (bleomicyn–vincristine) was more frequently prescribed in KS-IRIS patients (88.6% vs. 29.6%) with no differences in outcome; 80% of all patients achieve KS complete remission, 52% of them never received chemotherapy. No difference between groups in the long-term follow-up (mean 52.4 ± 27.4 months) was found, only one patient developed a secondary malignancy (1.12%).

Conclusions

Lung-involvement was predictive of IRIS development. Thrombocytopenia in KS-IRIS patients at week 12 follow-up after cART initiation was associated with high mortality. Over a third of patients with KS achieve remission without chemotherapy. Individuals that survive the initial period of KS-IRIS adhere to cART had a good long-term prognosis.

Electronic supplementary material

The online version of this article (doi:10.1186/s12981-017-0156-9) contains supplementary material, which is available to authorized users.

A retrospective cohort study on the mortality of AIDS patients in Guangxi, China (2001-2011)

The purpose of this article is to describe mortality trends in different highly active antiretroviral therapy (HAART) periods and associated factors among AIDS patients in Guangxi, China. We prospectively analyzed AIDS patients in Guangxi between 2001 and 2011; demographic characteristics were compared among AIDS patients diagnosed in three treatment periods (pre-HAART: 2001-2004, early-HAART: 2005-2008, and late-HAART: 2009-2011). AIDS mortality was calculated by person-years, and treatment coverage was defined as the proportion of time that patients who were eligible for treatment received treatment. Factors of AIDS mortality were determined by a Cox proportional hazard regression. Of 19,020 AIDS patients, overall mortality declined from 41.1 per 100 person-years in 2001 to 13.3 per 100 person-years in 2011 with treatment coverage increasing from zero to 72.1%. The overall median survival figure was 5.6 years (95% CI: 4.4-6.8) with 60.3% for 5-year survival rate. After AIDS diagnosis, the mortality rate peaked in the first year, and 37.4% patients were still active in the ninth year. Protective factors for mortality were AIDS patients diagnosed from 2009 to 2011 (AHR=0.75, 95% CI: 0.58-0.89), having received HAART (AHR=0.71, 95% CI: 0.50-0.87), and having a CD4 count of higher than 350 cells/μl at AIDS diagnosis (AHR=0.79, 95% CI: 0.60-0.92). Risk factors for mortality included being male (AHR=1.28, 95% CI: 1.07-1.43), living in a rural area (AHR=1.40, 95% CI: 1.18-1.94), and being aged ≥60 years at AIDS diagnosis (AHR=1.36, 95% CI: 1.18-1.73). A decline in AIDS mortality was observed in Guangxi with a concomitant increase in treatment coverage. Some subpopulations of AIDS patients, such as males, rural residents, and the old, require more medical care.

Clinical Characteristics of Gastrointestinal Lymphomas Associated with AIDS (GI-ARL) and the Impact of HAART

PURPOSE

The gastrointestinal (GI) tract is the most common site of extranodal disease in patients with systemic non-Hodgkin's lymphoma (NHL). Patients with systemic NHL and GI involvement associated with AIDS (GI-ARL) have a significantly worse prognosis than those without AIDS. We studied whether the introduction of HAART is associated with improved survival in patients with GI-ARL.

PATIENTS AND METHOD

36 patients with GI-ARL were identified from the tumor registries of a large municipal hospital in New York City and a tertiary care facility in western New York State. Of these, 28 patients did not receive HAART and 8 were treated with HAART. The primary endpoint was survival, which was defined as time from date of diagnosis of NHL until death from any cause.

RESULTS

Patients were analyzed based on whether or not they were treated with HAART. Kaplan-Meier analysis showed significantly better survival in patients with GI-ARL who were concurrently treated with HAART (p =.014). Median survival was 5 months for the no-HAART group and 30 months for the HAART group.

CONCLUSION

In patients with GI-ARL who were treated with chemotherapy, concurrent therapy with HAART therapy was associated with improved survival.

Use of boosted protease inhibitors reduces Kaposi sarcoma incidence among male veterans with HIV infection

BACKGROUND

Kaposi sarcoma (KS) incidence has decreased since combination antiretroviral therapy (cART). However, effects of cART type and duration on KS remain difficult to interpret secondary to KS-associated immune reconstitution inflammatory syndrome (IRIS).

METHODS

We performed a retrospective study of Veterans Affairs Human Immunodeficiency Virus Clinical Case Registry data from 1985 to 2010. We analyzed the relationship between cART regimens and KS using multivariable Poisson regression, stratified or adjusted for timing around cART initiation. KS was identified by ≥ 1 inpatient or ≥ 2 outpatient International Classification of Diseases, Ninth Revision codes (176.0-9). Percent of cART on specific regimen and total duration on specific regimen were examined.

RESULTS

There were 341 KS cases among 25 529 HIV-infected male veterans (incidence rate = 2.02/1000 person-years). Stratified by years after starting cART, every additional 10% time on boosted protease inhibitors (BPIs) was associated with reduced KS incidence in the third year of cART (incidence rate ratio [IRR] = 0.79; 95% confidence interval [CI], .69-.90). Months on BPIs was associated with lower KS incidence (P = .02). KS incidence was lower at 12-23 (IRR = 0.47; 95% CI, .23-.95) and ≥ 36 (IRR = 0.14; 95% CI, .02-1.00) months on BPIs compared with <6 months. Longer duration on other regimens was not associated with decreased KS incidence.

CONCLUSIONS

Lower KS incidence was observed with longer BPI use, after accounting for potential IRIS and other factors. Future research should evaluate newer cART regimens and long-term benefits of PI-based cART on KS in other cohorts and prospective studies.

KSHV LANA--the master regulator of KSHV latency

Kaposi's sarcoma associated herpesvirus (KSHV), like other human herpes viruses, establishes a biphasic life cycle referred to as dormant or latent, and productive or lytic phases. The latent phase is characterized by the persistence of viral episomes in a highly ordered chromatin structure and with the expression of a limited number of viral genes. Latency Associated Nuclear Antigen (LANA) is among the most abundantly expressed proteins during latency and is required for various nuclear functions including the recruitment of cellular machineries for viral DNA replication and segregation of the replicated genomes to daughter cells. LANA achieves these functions by recruiting cellular proteins including replication factors, chromatin modifying enzymes and cellular mitotic apparatus assembly. LANA directly binds to the terminal repeat region of the viral genome and associates with nucleosomal proteins to tether to the host chromosome. Binding of LANA to TR recruits the replication machinery, thereby initiating DNA replication within the TR. However, other regions of the viral genome can also initiate replication as determined by Single Molecule Analysis of the Replicated DNA (SMARD) approach. Recent, next generation sequence analysis of the viral transcriptome shows the expression of additional genes during latent phase. Here, we discuss the newly annotated latent genes and the role of major latent proteins in KSHV biology.

Consensus of the Brazilian Society of Infectious Diseases and Brazilian Society of Clinical Oncology on the management and treatment of Kaposi's sarcoma

Kaposi's sarcoma is a multifocal vascular lesion of low-grade potential that is most often present in mucocutaneous sites and usually also affects lymph nodes and visceral organs. The condition may manifest through purplish lesions, flat or raised with an irregular shape, gastrointestinal bleeding due to lesions located in the digestive system, and dyspnea and hemoptysis associated with pulmonary lesions. In the early 1980s, the appearance of several cases of Kaposi's sarcoma in homosexual men was the first alarm about a newly identified epidemic, acquired immunodeficiency syndrome. In 1994, it was finally demonstrated that the presence of a herpes virus associated with Kaposi's sarcoma called HHV-8 or Kaposi's sarcoma herpes virus and its genetic sequence was rapidly deciphered. The prevalence of this virus is very high (about 50%) in some African populations, but stands between 2% and 8% for the entire world population. Kaposi's sarcoma only develops when the immune system is depressed, as in acquired immunodeficiency syndrome, which appears to be associated with a specific variant of the Kaposi's sarcoma herpes virus.

There are no treatment guidelines for Kaposi's sarcoma established in Brazil, and thus the Brazilian Society of Clinical Oncology and the Brazilian Society of Infectious Diseases developed the treatment consensus presented here.

Paclitaxel for AIDS-associated Kaposi’s sarcoma

Treatment options are limited for patients with advanced acquired immunodeficiency syndrome-related Kaposi's sarcoma (AIDS-KS). The management of early stage cutaneous AIDS-KS has been revolutionized by the introduction of highly active antiretroviral therapy and for most patients highly active antiretroviral therapy alone will control early stage AIDS-KS. However, patients with advanced stage Kaposi's sarcoma with visceral disease, tumor-associated edema or extensive oral disease require systemic chemotherapy in addition to antiretrovirals. The standard first-line therapy for these affected individuals is a liposomal anthracycline, and response rates of around 70% are usually achieved. For patients with refractory or recurrent AIDS-KS, treatment algorithms are less well defined. The use of paclitaxel in these circumstances is reviewed.

Prospective stage-stratified approach to AIDS-related Kaposi's sarcoma

PURPOSE

Combination antiretroviral therapy (cART) is standard of care for patients with HIV diagnosed with Kaposi's sarcoma (KS), but the current role of systemic chemotherapy is undefined.

PATIENTS AND METHODS

Since 1998, a prospective stage-stratified approach has been adopted for 469 patients with HIV with KS. Patients with early-stage (T0) KS are treated with cART alone; patients with advanced-stage (T1) KS receive cART plus liposomal anthracycline chemotherapy. Clinical characteristics, overall survival, and KS progression-free survival were analyzed according to stage at presentation and treatment received.

RESULTS

A total of 303 patients presented with T0 stage KS, including 237 who were not receiving cART, and 166 patients had T1 stage KS. Patients with T0 KS had higher CD4 cell counts (P < .001); 90% of patients with T0 KS who were not receiving cART and 84% of those with T1 KS were treated in accordance with the stage-stratified approach. Median follow-up was 4.6 years, and 5-year overall survival was 89%; 54 patients have died, 15 as a result of KS. Overall 5-year survival was 92% for T0 KS and 83% to T1 KS (P = .0024). On-treatment analysis of 213 cART-naive patients with T0 KS treated with cART alone revealed 5-year overall survival of 95% and progression-free survival of 77%. For 140 patients with T1 disease treated with cART and liposomal anthracycline chemotherapy, 5-year overall survival was 85%.

CONCLUSION

This stage-stratified approach to the management of KS achieves high survival in patients with advanced KS and reduces exposure to chemotherapy in patients with early-stage KS.

NANOMATERIALS FOR PROTEIN MEDIATED THERAPY AND DELIVERY

There has been a significant amount of research done on liposomes and nanoparticles as drug carriers for protein drugs. Proteins and enzymes have been used both as targeting moieties and for their therapeutic potential. High specificity and rapid reaction rates make proteins and enzymes excellent candidates for therapeutic treatment, but some limitations exist. Many of these limitations can be addressed by a well studied nanotechnology based delivery system. Such a system can provide a medium for delivery, stabilization of the drugs, and enable site specific accumulation of drugs. Nanomedicines such as these have great potential to revolutionize the pharmaceutical industry and improve healthcare worldwide.

Brain localization of Kaposi's sarcoma in a patient treated by combination antiretroviral therapy

Background

Central nervous system is a very rare site of Kaposi’s sarcoma in acquired immunodeficiency syndrome. Kaposi’s sarcoma, a neoplasm of endothelial origin, occurs mainly in the skin, but can involve many tissues, especially in patients with a poor immunity. Combination antiretroviral therapy, highly active against human immunodeficiency virus type-1, has caused a dramatic reduction of cutaneous and visceral involvements. No report of central nervous system localization of Kaposi’s sarcoma is described since the introduction of combination antiretroviral therapy in the late 90’s.

Case presentation

A 42 year-old Caucasian man affected by human immunodeficiency virus type-1 infection treated with combination antiretroviral therapy and showing relatively preserved immunity with low viral load presented gingival squamous cell carcinoma and visceral (lungs and lymph nodes) Kaposi’s sarcoma. Chemotherapy and radiotherapy were performed with improvement of both neoplasms. Afterwards, a magnetic resonance imaging showed focal lesions of the brain. Despite new chemotherapy and radiotherapy the patient died. Histology after autopsy revealed brain lesions due to Kaposi’s sarcoma with the detection of Human Herpesvirus 8 on tissue samples.

Conclusions

This is the first report in the combination antiretroviral therapy era of a very rare complication of Kaposi’s sarcoma, such as that of brain localization, in a patient with a relatively good control of human immunodeficiency virus infection. Therefore, Kaposi’s sarcoma should be considered in differential diagnosis with other intracranial mass lesions that can occur in human immunodeficiency virus infected-patients focusing the issue of appropriate treatment for central nervous system involvement.

Trends in Kaposi's Sarcoma in Miami Beach from 1987 to 2007

Purpose. Kaposi's sarcoma (KS) is a rare low-grade vascular tumor associated with the human herpes virus 8. By analyzing the epidemiology, staging, and treatment of KS, we hoped to improve the quality of care at our institution. Methods. Review of the Mount Sinai Medical Center tumor registry database in Miami Beach, FL, USA, identified 143 cases of KS between January 1, 1987 and December 31, 2007. Results. The majority of patients were non-Hispanic whites, non smoking males diagnosed between 1987 and 1996. Most of the patients were HIV positive, with an equal percentage diagnosed with local or distant disease. Most patients received no chemotherapy or radiation. There were no significant differences in patient survival based on sex, HIV status, or radiation received. There was a trend toward improved survival among older patients who smoked, received no chemotherapy, and had localized stage at diagnosis. Multivariate analysis revealed that non-Hispanic whites had a significant worse survival than Hispanic whites (HR = 0.55, 95% CI (0.33, 0.90), P = 0.02). Patients diagnosed between 1987 and 1996 had a worse survival than those between 1997 and 2007 (HR = 0.33 (95% CI 0.19, 0.55), P < 0.0001). Conclusion. This large retrospective study provides further insight into KS. Ethnicity and date of diagnosis are important predictors of long-term survival.

Role of endogenous biological response modifiers in pathogenesis of infectious diseases

Biologic response modifiers (BRMs) interact with the host immune system and modify the immune response. BRMs can be therapeutically used to restore, augment, or dampen the host immune response. Although they have been used for decades, their clinical applications have been expanded in the past decade for diagnosis and treatment of many diseases including cancers, immunologic disorders, and infections. This article discusses endogenous biological response modifiers (ie, naturally occurring immunomodulators as a part of the host immune system), which play vital roles as regulators of both innate and adaptive immune responses.

The effect of HAART in 254 consecutive patients with AIDS-related Kaposi's sarcoma

OBJECTIVE

A prospective cohort study was performed to evaluate the clinical outcomes of patients with histologically confirmed AIDS-related Kaposi's sarcoma diagnosed since the introduction of HAART.

METHODS

Two hundred and fifty-four consecutive patients (96% men) diagnosed with Kaposi's sarcoma between 1996 and 2008 are included. Clinicopathological and treatment details were prospectively collected. The median follow-up is over 4 years and maximum 12 years.

RESULTS

The mean age at Kaposi's sarcoma diagnosis was 39 years and average duration of known HIV seropositivity was 4 years. At Kaposi's sarcoma diagnosis, only 19% patients were on HAART and only 7% patients had an undetectable plasma HIV viral load. Seventy-nine (31%) patients had AIDS clinical Trial Group stage T1 disease at Kaposi's sarcoma diagnosis and 122 (48%) had AIDS clinical Trial Group stage I1 disease (CD4 cell count < 150 cells/microl). Nodular grade Kaposi's sarcoma represented 28% of the tumours and was significantly associated with black African ethnicity and AIDS clinical Trial Group T1 stage disease. The overall 5-year survival is 89% (95% confidence interval 84-93). One hundred and sixty-three patients were treated with HAART alone for T0 stage Kaposi's sarcoma; only one died of Kaposi's sarcoma and only 37 (22%) required chemotherapy, giving a systemic treatment-free survival at 5 years of 74% (95% confidence interval 67-82) and the overall survival at 5 years is 91% (95% confidence interval 87-95).

CONCLUSION

The high success rate of HAART in a large cohort of AIDS-Kaposi's sarcoma patients over a prolonged period of follow-up will reassure patients and clinicians that this is a well tolerated and effective approach to stage T0 Kaposi's sarcoma.

Ongoing change in the treatment of HIV-associated malignancies in the HAART era

Implementation of highly active antiretroviral therapy (HAART) has changed the epidemiology, clinical outcome and therapeutic approach of HIV-associated malignancies. Whereas Kaposi sarcoma and primary CNS non-Hodgkin lymphoma have decreased dramatically, systemic non-Hodgkin lymphoma incidence seems unchanged, perhaps increasing as with other tumor incidence. Owing to HAART-induced immune function preservation, response rates to chemotherapy and survival times in patients with HIV-associated malignancies have neared those observed in their HIV-negative counterparts. Hence, intensive regimens have been more and more extensively used with promising results. This may also apply to other therapeutic options, such as biotherapy, and procedures, such as stem cell rescue following high-dose chemotherapy or heterologous stem cell transplant, which have so far been precluded to HIV-infected subjects as a matter of fact. A trend toward a full assimilation of HIV-infected people with cancer and the general population with the same pathology is ongoing.

Effect of highly active antiretroviral therapy on survival of HIV infected patients with non-small-cell lung cancer

OBJECTIVE

To evaluate the impact of highly active antiretroviral therapy (HAART) on survival in HIV infected patients with non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

All consecutive HIV infected patients with NSCLC diagnosed between 06/1996 and 03/2007 at two University hospitals in Paris (France) were prospectively followed until death. The association between survival and clinical and biological factors was analyzed by univariate and multivariate models. Survival analysis was performed by Kaplan-Meier estimates and the Cox proportional hazards regression model.

RESULTS

During the study period, NSCLC was diagnosed in 49 consecutive HIV infected patients (median age 46 years); 84% had advanced disease. Median survival was 8.1 months (range 5-10 months). In multivariate analysis, baseline parameters with significant positive impact on survival included performance status (PS) < or =1 (HR=0.2, 95%CI [0.09, 0.46], p=0.0001), stage I-II disease (HR=0.15, 95%CI [0.04, 0.53], p=0.003), and use of HAART (HR=0.4, 95%CI [0.2, 0.9], p=0.027).

CONCLUSION

HAART is a good prognostic factor for survival in HIV infected patients with NSCLC. Stage of disease and PS are two other valid survival prognostic factors.

99mTc-MIBI imaging of AIDS-related Kaposi's sarcoma in the lungs

OBJECTIVE

Pulmonary Kaposi's sarcoma (KS) occurs in more than 10% of patients with acquired immunodeficiency syndrome (AIDS) and has a high mortality rate. Prompt detection, diagnosis, and treatment reduce patient morbidity and mortality. The objective of this study was to determine the efficacy of 99mTc-hexakis-2-methoxy isobutyl isonitrile (99mTc-MIBI) imaging in detecting pulmonary AIDS-related KS.

METHODS

99mTc-MIBI imaging was performed on 72 human immunodeficiency virus-seropositive patients with bronchoscopic diagnosis of pulmonary KS (36 patients), pneumonia (22), normal tracheo-bronchial tree (11), lymphoma (2), and bronchogenic carcinoma (1). Lung uptake and lymph node detection in KS were compared on planar and single photon emission computed tomography (SPECT) scans.

RESULTS

The lung/myocardium ratios on the 1-h planar images were significantly higher in KS and normal lungs than opportunistic infection. Using the lung/myocardium ratio of 1 as cutoff, the sensitivity, specificity, and accuracy of the 1-h planar images for detecting pulmonary KS were 75, 57.58, and 66.67%, respectively. Abnormal lymph node uptake, pleural/pericardial effusions, and ascites were detected more readily on SPECT.

CONCLUSION

Planar 99mTc-MIBI imaging has moderate sensitivity, specificity, and accuracy for detecting pulmonary KS. SPECT is more effective in detecting abnormal lymph nodes, pleural/pericardial effusions, and ascites. 99mTc-MIBI SPECT followed by planar imaging at 40-60 min can be useful in assessing pulmonary KS.

Immune reconstitution inflammatory syndrome in HIV-infected patients receiving antiretroviral therapy : pathogenesis, clinical manifestations and management

The use of antiretroviral therapy (ART) to treat HIV infection, by restoring CD4+ cell count and immune function, is associated with significant reductions in morbidity and mortality. Soon after ART initiation, there is a rapid phase of restoration of pathogen-specific immunity. In certain patients, this results in inflammatory responses that may result in clinical deterioration known as 'the immune reconstitution inflammatory syndrome' (IRIS). IRIS may be targeted at viable infective antigens, dead or dying infective antigens, host antigens, tumour antigens and other antigens, giving rise to a heterogeneous range of clinical manifestations. The commonest forms of IRIS are associated with mycobacterial infections, fungi and herpes viruses. In most patients, ART should be continued and treatment for the associated condition optimized, and there is anecdotal evidence for the use of corticosteroids in patients who are severely affected. In this review, we discuss research relating to pathogenesis, the range of clinical manifestations, treatment options and prevention issues.

Persistent Kaposi sarcoma in the era of highly active antiretroviral therapy: characterizing the predictors of clinical response

OBJECTIVES

To evaluate the role of highly active antiretroviral therapy and chemotherapy on tumor response among persons with AIDS-related Kaposi sarcoma and identify factors associated with response in a clinic setting.

DESIGN

Retrospective cohort.

METHODS

One hundred and fourteen patients from two HIV clinics with a diagnosis of Kaposi sarcoma were identified via a clinical database. Records were reviewed to confirm Kaposi sarcoma diagnosis and abstract clinical and chemotherapy information. Demographics, laboratory values, and highly active antiretroviral therapy use were abstracted electronically. Cox's proportional hazards models identified predictors of Kaposi sarcoma improvement and resolution.

RESULTS

Thirty-six months following Kaposi sarcoma diagnosis, the rate of improvement among 64 patients with confirmed Kaposi sarcoma was 77% and that of complete resolution was 51%. In univariate analyses, recent chemotherapy was associated with Kaposi sarcoma improvement, and recent HIV viral load and highly active antiretroviral therapy were associated with both improvement and resolution. No measured baseline characteristics (tumor stage, diagnosis year, CD4 T-cell count, HIV viral load, or prior highly active antiretroviral therapy history) or recent CD4 T-cell counts predicted improvement or resolution. In multivariate analyses, recent chemotherapy (hazard ratio 5.5, 95% confidence interval: 2.7-11.2, P < 0.001) and highly active antiretroviral therapy (hazard ratio 4.1, 95% confidence interval: 1.4-12.6, P = 0.01) were predictors of improvement; only recent highly active antiretroviral therapy was associated with resolution (hazard ratio 6.2, 95% confidence interval: 1.5-26.4, P = 0.01). Response was not associated with type of highly active antiretroviral therapy regimen (non nucleoside reverse transcriptase inhibitor based, protease inhibitor based, or ritonavir-boosted protease inhibitor based).

CONCLUSION

Highly active antiretroviral therapy and chemotherapy are important in clinical Kaposi sarcoma response. Despite widespread availability of these therapies, Kaposi sarcoma continues to be a clinical problem; only half the patients achieved complete resolution of disease. New therapeutic approaches are needed.

Down-regulation of NKG2D and NKp80 ligands by Kaposi's sarcoma-associated herpesvirus K5 protects against NK cell cytotoxicity

Natural killer (NK) cells are important early mediators of host immunity to viral infections. The NK activatory receptors NKG2D and NKp80, both C-type lectin-like homodimeric receptors, stimulate NK cell cytotoxicity toward target cells. Like other herpesviruses, Kaposi's sarcoma-associated herpesvirus (KSHV) down-regulates MHC class I molecules to avoid detection by cytotoxic T lymphocytes but renders cells susceptible to NK cell cytotoxicity. We now show that the KSHV immune evasion gene, K5, reduces cell surface expression of the NKG2D ligands MHC class I-related chain A (MICA), MICB, and the newly defined ligand for NKp80, activation-induced C-type lectin (AICL). Down-regulation of both MICA and AICL requires the ubiquitin E3 ligase activity of K5 to target substrate cytoplasmic tail lysine residues. The common MICA *008 allele has a frameshift mutation leading to a premature stop codon and is resistant to down-regulation because of the loss of lysine residues. K5-mediated ubiquitylation signals internalization but not degradation of MICA and causes a potent reduction in NK cell-mediated cytotoxicity. The down-regulation of ligands for both the NKG2D and NKp80 activation pathways provides KSHV with a powerful mechanism for evasion of NK cell antiviral functions.

Insights into pathogenic events of HIV-associated Kaposi sarcoma and immune reconstitution syndrome related Kaposi sarcoma

A decrease in the incidence of human immune deficiency virus-associated Kaposi sarcoma (HIV-KS) and regression of some established HIV-KS lesions is evident after the introduction of highly active anti-retroviral treatment (HAART), and is attributed to generalized immune restoration, to the reconstitution of human herpesvirus (HHV)-8 specific cellular immune responses, and to the decrease in HIV Tat protein and HHV-8 loads following HAART. However, a small subset of HIV-seropositive subjects with a low CD4+ T cell count at the time of introduction of HAART, may develop HIV-KS as immune reconstitution inflammatory syndrome (IRIS) within 8 weeks thereafter.

Imaging Features of Pulmonary Kaposi Sarcoma–Associated Immune Reconstitution Syndrome

OBJECTIVE

The purpose of this study was to analyze the radiologic features of pulmonary Kaposi sarcoma-associated immune reconstitution syndrome. The syndrome is a phenomenon characterized by clinical deterioration of the condition of HIV-positive patients after initiation of highly active antiretroviral therapy.

MATERIALS AND METHODS

The study included four patients at our institution who fulfilled the diagnostic criteria for pulmonary Kaposi sarcoma-associated immune reconstitution syndrome from 2001 to 2006. All patients were men (mean age, 43 years; range, 31-59 years). Images reviewed included chest radiographs obtained before highly active antiretroviral therapy, radiographs and chest CT scans obtained at appearance of the symptoms of Kaposi sarcoma-associated immune reconstitution syndrome, and follow-up radiographs and chest CT scans during immune reconstitution syndrome.

RESULTS

The radiographic findings of Kaposi sarcoma-associated immune reconstitution syndrome included reticular and reticulonodular opacities (n = 4), areas of consolidation (n = 3), septal lines (n = 3), and pleural effusion (n = 3). The CT findings in all four patients were ill-defined pulmonary nodules and interlobular septal thickening. Three of the patients had a CT halo sign, areas of consolidation, ground-glass opacities, lymphadenopathy, and pleural effusion. The areas of consolidation in three subjects who did not receive chemotherapy increased markedly after 14-20 days. CT performed during the initial symptoms of immune reconstitution syndrome in these three subjects showed less than 5% parenchymal involvement. Follow-up CT showed 26-50% involvement in two patients and more than 50% involvement in one patient.

CONCLUSION

The radiologic findings of pulmonary Kaposi sarcoma-associated immune reconstitution syndrome are similar to the findings described in patients with Kaposi sarcoma without the syndrome, but the extent of abnormalities tends to increase with the development of the syndrome.

Differential improvement in survival among patients with AIDS after the introduction of HAART

We explored changes in the survival of patients with AIDS (PWA) according to the availability of antiretroviral drugs (1994-2002). We tested whether changes in the hazard ratio of progression to death (HR) have been homogeneous among various groups of PWA. We included 4158 PWA diagnosed in Paris, notified to the French National Surveillance Institute by 2002. Four calendar periods were defined: monotherapy (1994-95), bitherapy-HAART transition (1996), early HAART (1997-99), late HAART (2000-October 2002). HR were calculated with Cox models, including the calendar period, modelled as a time dependent covariate. Models were stratified by age, transmission category, CD4 cell count, and AIDS-defining illnesses (ADI) group. Cumulative survival at 60 months increased from 44.0% (before July 1996) to 75.6% (after July 1996) and median survival increased from 31.9 months to >76 months. Adjusted HR reached a minimum in the late HAART period (HR 0.22, 95% CI: 0.19-0.26). No difference in the decrease of the HR has been found by age. HR decreased and was marked during the late HAART period across all HIV transmission categories, including intravenous drug use. HR decreased significantly for all ADIs groups, including tumours. Among PWA diagnosed with tuberculosis, the HR decreased significantly only in the late HAART period. HR decrease was stronger for PWA with a CD4 cell count < or =200/mm(3). Substantial improvements in survival after the introduction of HAART were found for all PWA but varied by specific ADIs and the degree of immunosuppression.

Kaposi sarcoma as a model of oncogenesis and cancer treatment

Kaposi sarcoma is the most common cancer among HIV-infected individuals and one of the most common cancers in sub-Saharan Africa. Kaposi sarcoma lesions are highly vascularized, and comprised of spindle-shaped tumor cells. Kaposi sarcoma herpesvirus is etiologically linked to Kaposi sarcoma development and encodes genes that contribute to cellular transformation, evasion of apoptosis, aberrant angiogenesis and an inflammatory tumor microenvironment. The study of Kaposi sarcoma herpesvirus-driven malignancies has provided a model of oncogenesis and identified some of the key steps and, therefore, therapeutic targets of Kaposi sarcoma development. However, current Kaposi sarcoma treatments are not specific and rely on reconstitution of the immune system and systemic administration of cytotoxic agents. Recent studies have demonstrated that mechanism-based therapeutics, such as vascular endothelial growth factor A or mammalian target of rapamycin inhibitors, are promising therapeutic approaches bridging basic research with clinical practice.

Molecular biology of KSHV in relation to AIDS-associated oncogenesis

KSHV has been established as the causative agent of KS, PEL, and MCD, malignancies occurring more frequently in AIDS patients. The aggressive nature of KSHV in the context of HIV infection suggests that interactions between the two viruses enhance pathogenesis. KSHV latent infection and lytic reactivation are characterized by distinct gene expression profiles, and both latency and lytic reactivation seem to be required for malignant progression. As a sophisticated oncogenic virus, KSHV has evolved to possess a formidable repertoire of potent mechanisms that enable it to target and manipulate host cell pathways, leading to increased cell proliferation, increased cell survival, dysregulated angiogenesis, evasion of immunity, and malignant progression in the immunocompromised host. Worldwide, approximately 40.3 million people are currently living with HIV infection. Of these, a significant number are coinfected with KSHV. The complex interplay between the two viruses dramatically elevates the risk for development of KSHV-induced malignancies, KS, PEL, and MCD. Although HAART significantly reduces HIV viral load, the entire T-cell repertoire and immune function may not be completely restored. In fact, clinically significant immune deficiency is not necessary for the induction of KSHV-related malignancy. Because of variables such as lack of access to therapy noncompliance with prescribed treatment, failure to respond to treatment and the development of drug-resistant strains of HIV, KSHV-induced malignancies will continue to present as major health concerns.

Interactions between HIV-1 Tat and KSHV

Since the advent of the HIV-1 pandemic, a close association between HIV-1 infection and the development of selected types of cancers has been brought to light. The discovery of Kaposi sarcoma-associated herpesvirus (KSHV) has led to significant advances in uncovering the virological and molecular mechanisms involved in the pathogenesis of AIDS-related malignancies. Extensive evidence indicates that HIV-1 trans-activating protein Tat plays an oncogenic role in the development of KSHV-associated neoplasms. Comprehensive knowledge of the functions of Tat-1 together with the KSHV genes will contribute to a better understanding of the pathogenesis of virus-associated cancers and the interaction of viruses with their hosts.

Dermatologic Manifestations of the Immune Reconstitution Inflammatory Syndrome

The immune reconstitution inflammatory syndrome (IRIS) represents a diverse range of immunopathologic reactions resulting in clinical deterioration that may occur as immune function is partially restored in HIV-infected patients receiving highly active antiretroviral therapy. Approximately half of IRIS events are dermatologic, and dermatologic IRIS is described in relation to a wide range of conditions, the commonest being herpes zoster and herpes simplex. Most cases of IRIS result in mild and moderate symptoms, but non-dermatologic manifestations related to IRIS have resulted in death. This article covers certain general issues related to IRIS and then focuses on the spectrum of dermatologic manifestations.

The impact of highly active antiretroviral therapy on the incidence and outcomes of AIDS-defining cancers in Southern Alberta

OBJECTIVES

To determine the impact of highly active antiretroviral therapy (HAART) on the incidence and outcomes of Kaposi's sarcoma (KS), non-Hodgkin's lymphoma (NHL) and invasive cervical cancer/dysplasia in a well-defined geographical HIV-infected population between 1984 and 2005.

METHODS

A clinic database search, chart review and verification with public health records were undertaken for all AIDS-defining cancers diagnosed in Southern Alberta before and after the introduction of HAART.

RESULTS

A total of 2,137 patients with 9,265 person-years of HIV follow-up care were reviewed. One hundred and forty-three cases of KS, 64 cases of NHL and 11 cases of invasive cervical cancer/dysplasia were identified. KS and NHL together accounted for 15% of clinical presentations with an AIDS-defining illness that led to the HIV diagnosis. Following the introduction of HAART, the reduced number of severely immunocompromised patients was associated with 92 and 84% reductions in new diagnoses of KS and NHL, respectively, which were seen mainly in clinic patients declining or failing HAART. Crude reductions of 94 and 65% in mortality from KS and NHL, respectively, were also seen. The prevalences of KS, NHL and invasive cervical cancer/dysplasia have recently stabilized at 3, 1 and 5% of the population, respectively.

CONCLUSIONS

The introduction of HAART has dramatically reduced the incidence of KS and NHL and improved survival from these cancers for most patients in HIV care. However, patients still present with KS and NHL leading to their HIV diagnosis.

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.

Management of patients with HIV in the intensive care unit

Because there are more than one million Americans with HIV, intensive care units continue to see frequent patients with HIV infection. In the era of highly active antiretroviral therapy, clinicians must be aware of drug toxicities and drug interactions. They must also recognize traditional opportunistic infections, as well as newer syndromes such as immune reconstitution syndrome, multicentric Castleman's disease, and primary pleural cell lymphoma.

Pulmonary Kaposi sarcoma in the era of highly active antiretroviral therapy

OBJECTIVE

Since the introduction of highly active antiretroviral therapy (HAART) there has been a dramatic reduction in the incidence of Kaposi sarcoma (KS) and an improvement in survival. We wished to examine whether the outcome in pulmonary KS (pKS) has also altered.

METHODS

In a single-institution cohort of 1140 HIV-positive patients with KS, 305 patients were diagnosed in the HAART era (1996-2004). We examined the clinicopathological features and outcomes of these patients, of whom 25 had pKS and 280 did not.

RESULTS

Patients with pKS had lower CD4 cell counts at the time of KS diagnosis (Mann-Whitney U-test P=0.005). The incidence of pKS was higher in African patients than in non-African patients in this sample (Fisher's test, P=0.001). There were no significant differences in age, gender, plasma HIV-1 viral load or prior HAART treatment at the time of KS diagnosis. Five-year overall survival in the pKS group was 49% [95% confidence interval (CI) 26-73%] as compared with 82% (95% CI 76-87%) for the non-pKS group (log rank, P<0.0001).

CONCLUSION

PKS remains an ominous diagnosis in the era of HAART, with a median survival of just 1.6 years.

A prognostic index for AIDS-associated Kaposi's sarcoma in the era of highly active antiretroviral therapy

BACKGROUND

AIDS-associated Kaposi's sarcoma remains common in individuals with HIV-1 infection in the era of highly active antiretroviral therapy (HAART). We developed a simple model for predicting mortality on the basis of clinical characteristics present at the time of diagnosis of Kaposi's sarcoma.

METHODS

Of 5873 individuals with HIV-1 infection, 326 (6%) developed Kaposi's sarcoma; for 262 (80%) this was their first AIDS-defining illness. We did univariate and multivariate Cox regression analyses to identify covariates predictive of overall survival and validated our model with an independent data set of 446 patients with Kaposi's sarcoma.

RESULTS

In the primary model, we developed a prognostic score from 0 to 15 starting at 10. Having Kaposi's sarcoma as the AIDS-defining illness (-3 points) and increasing CD4 count (-1 point for every complete 100 cells per mm3) improved prognosis; age of 50 years or older (2 points) and having another AIDS-associated illness at the same time (3 points) conveyed a poorer prognosis. In individuals with prognostic scores of 0, 5, 10, and 15, probability of survival at 1-year was 0.993, 0.967, 0.834, and 0.378, and at 5 years was 0.984, 0.918, 0.631, and 0.084, respectively. Increasing prognostic score by 1 increased 1-year death hazard ratio by 40% (95% CI 28-53%; bootstrapped hazard ratio 1.39, 1.25-1.51). The index had concordance of 76.8% (71.7-82.3).

INTERPRETATION

We identified four prognostic factors that can be used to obtain an accurate prognostic index at diagnosis of AIDS-associated Kaposi's sarcoma. This index is widely applicable and can be used to guide therapeutic options.

The presentation and survival of patients with non-cutaneous AIDS-associated Kaposi's sarcoma

BACKGROUND

Acquired immune deficiency syndrome related Kaposi's sarcoma (AIDS-KS) remains a significant cause of morbidity and mortality. We describe for the first time a proportion of patients with AIDS-KS who presented with no evidence of cutaneous disease.

PATIENTS AND METHODS

From our cohort of 5932 individuals infected with the human immunodeficiency virus (HIV-1) treated in the HAART era, 319 were identified with KS. Of these, 11 patients (5.4%) were diagnosed with KS without the presence of any cutaneous disease. We compared their survival, clinical, immunological and virological characteristics to other individuals with KS.

RESULTS

There were no statistically significant differences in survival, CD4 count or HIV viral load at KS presentation. We observed that tumour-associated oedema (P = 0.046) and non-oral gastrointestinal KS (P = 0.042) were significantly more common in patients with non-cutaneous KS. Only one case of non-cutaneous KS was observed prior to the era of highly active anti-retroviral therapy (HAART).

CONCLUSIONS

Non-cutaneous KS is a recognisable condition; patients should be treated with the standard of care as their prognosis is not inferior. This is likely to reflect a strong immune response, in the era of HAART.

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.

Antitumour effects of antiretroviral therapy

Infection by human immunodeficiency virus (HIV) is associated with an increased risk of certain tumours, particularly Kaposi's sarcoma, non-Hodgkin's lymphomas and cervical cancer. However, the incidence of these tumours in HIV-infected patients has decreased significantly since the widespread use of highly active antiretroviral therapy (HAART). This effect cannot be solely explained by the ability of these drugs to suppress HIV replication and thereby reconstitute the immune system. Recent studies have shown that inhibitors of the HIV aspartyl protease, which are widely used in HAART, have direct anti-angiogenic and antitumour effects that are unrelated to their antiviral activity. So these drugs might be used to treat cancer in patients who are not infected with HIV.