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Slaught C, Williams V, Grover S, Bigger E, Kayembe M, Chiyapo S, Jackson NJ, Dryden-Peterson S, Kovarik CL, Wanat KA. A retrospective review of patients with Kaposi's sarcoma in Botswana. Int J Dermatol 2019; 58:707-712. [PMID: 30460985 PMCID: PMC6923797 DOI: 10.1111/ijd.14305] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 10/14/2018] [Accepted: 10/24/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Despite widespread antiretroviral coverage in Botswana, Kaposi's sarcoma (KS) remains among the most common malignancies. To date, adult KS in Botswana is not well characterized. The diagnosis relies on clinical suspicion that is often confirmed by histopathology given the implications of treatment; however, this poses a significant resource burden. METHODS We conducted a retrospective review of the cohort of patients biopsied for possible KS at Princess Marina Hospital, the main dermatology referral site in Botswana, from September 2008 through June 2015 to describe the demographics, human immunodeficiency virus (HIV) characteristics, and clinical presentations of these patients. Histopathologic diagnoses were reviewed, and positive predictive value (PPV) was used to characterize the accuracy of clinical suspicion of KS. RESULTS A total of 441 patients received 450 biopsies where KS was on the differential diagnosis, and 239 patients (54%) were ultimately diagnosed with KS. The KS cohort was more likely to be male (58% vs. 37%, P < 0.001), HIV positive (94% vs. 85%, P < 0.05), and have lower CD4 counts at the time of biopsy (274 cells/μl vs. 362 cells/μl, P < 0.05). The PPV of clinical suspicion of KS was 58%. When KS was not histopathologically diagnosed, clinically benign diseases were found in 17%, medically significant conditions requiring alternative therapies in 78%, and life-threatening diseases in 5%. DISCUSSION Our study reinforces the risk factors in development of KS. The poor PPV supports the important role of histology in KS diagnosis to both ensure appropriate treatment and prevent overtreatment. Improved accessibility to biopsy and augmentation of local dermatopathologic services would likely improve diagnostic accuracy and treatment.
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Affiliation(s)
- Christa Slaught
- Department of Dermatology, Oregon Health and Sciences University, Portland, OR, USA
| | - Victoria Williams
- Ministry of Health of Botswana, Gaborone, Botswana
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Oncology, Princess Marina Hospital, Gaborone, Botswana
| | - Elizabeth Bigger
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Mukendi Kayembe
- Department of Anatomical Pathology, National Health Laboratory, Gaborone, Botswana
- Department of Pathology, University of Botswana School of Medicine, Gaborone, Botswana
| | - Sebathu Chiyapo
- Department of Oncology, Princess Marina Hospital, Gaborone, Botswana
| | - Nicholas J. Jackson
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Scott Dryden-Peterson
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, MA, USA
- Botswana Harvard AIDS Institute, Gaborone, Botswana
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Carrie L. Kovarik
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Karolyn A. Wanat
- Department of Dermatology and Pathology, University of Iowa, Iowa City, IA, USA
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Mtonga W, Mujajati A, Munkombwe D, Kalungia A, Muungo LT, West J, Wood C, Ngalamika O. Therapeutic Outcomes in AIDS-Associated Kaposi's Sarcoma Patients on Antiretroviral Therapy Treated with Chemotherapy at Two Tertiary Hospitals in Lusaka, Zambia. Curr HIV Res 2018; 16:231-236. [PMID: 29992888 PMCID: PMC8103568 DOI: 10.2174/1570162x16666180711103610] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 06/19/2018] [Accepted: 07/04/2018] [Indexed: 12/18/2022]
Abstract
The incidence of HIV-associated Kaposi's sarcoma (KS) remains high in Zambia in the antiretroviral therapy era. The most efficacious treatment regimen for KS has yet to be established. In both developed and developing countries, treatment regimens have had limited efficacy. Late presentation in Africa affects therapeutic outcomes. OBJECTIVE The aim of this study was to determine therapeutic outcomes of epidemic KS patients on combination antiretroviral therapy (cART) after completion of six cycles of Adriamycin, Bleomycin, and Vincristine (ABV) chemotherapy. METHODS This was a descriptive cross-sectional study. Study participants were drawn from a study database of confirmed incident KS patients seen at the Skin Clinic of the University Teaching Hospitals (UTH) during the period between August, 2015 and September, 2016. RESULTS Of the 38 successfully recruited study participants, a complete response was documented in 18 (47%) after 6 cycles of ABV whereas 20 (53%) experienced a partial response. KS recurrence was observed in 8 (44%) of the individuals that experienced an initial complete response. At the time of the study, clinical assessment revealed that KS lesions had completely regressed in 21 (55%) of all the patients. CONCLUSION ABV chemotherapy appears ineffective in long-term resolution of epidemic KS patients on ART. Recurrence rates are high after chemotherapy in patients that experience initially favorable responses to treatment. There is a need to diagnose KS earlier, and to develop more efficacious treatment options in order to reduce recurrence rates for epidemic KS.
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Affiliation(s)
- Watson Mtonga
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - Aaron Mujajati
- Department of Medicine, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Derick Munkombwe
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - Aubrey Kalungia
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - Lungwani Tyson Muungo
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - John West
- Nebraska Center for Virology, University of Nebraska, Lincoln, USA
| | - Charles Wood
- Nebraska Center for Virology, University of Nebraska, Lincoln, USA
| | - Owen Ngalamika
- Dermatology and Venereology Section, Adult Hospital of University Teaching Hospitals, Lusaka, Zambia
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Singogo E, Keegan TJ, Diggle PJ, van Lettow M, Matengeni A, van Oosterhout JJ, Sodhi S, Joshua M, Taylor BM. Differences in survival among adults with HIV-associated Kaposi's sarcoma during routine HIV treatment initiation in Zomba district, Malawi: a retrospective cohort analysis. Int Health 2017; 9:281-287. [PMID: 28911125 DOI: 10.1093/inthealth/ihx027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 08/21/2017] [Indexed: 11/13/2022] Open
Abstract
Background The HIV epidemic is a major public health concern throughout Africa. Malawi is one of the worst affected countries in sub-Saharan Africa with a 2014 national HIV prevalence currently estimated at 10% (9.3-10.8%) by UNAIDS. Study reports, largely in the African setting comparing outcomes in HIV patients with and without Kaposi's sarcoma (KS) indicate poor prognosis and poor health outcomes amongst HIV+KS patients. Understanding the mortality risk in this patient group could help improve patient management and care. Methods Using data for the 559 adult HIV+KS patients who started ART between 2004 and September 2011 at Zomba clinic in Malawi, we estimated relative hazard ratios for all-cause mortality by controlling for age, sex, TB status, occupation, date of starting treatment and distance to the HIV+KS clinic. Results Patients with tuberculosis (95% CI: 1.05-4.65) and patients who started ART before 2008 (95% CI: 0.34-0.81) were at significantly greater risk of dying. A random-effects Cox model with Log-Gaussian frailties adequately described the variation in the hazard for mortality. Conclusion The year of starting ART and TB status significantly affected survival among HIV+KS patients. A sub-population analysis of this kind can inform an efficient triage system for managing vulnerable patients.
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Affiliation(s)
- Emmanuel Singogo
- Lancaster Medical School, Lancaster University, LA1 4YF, Lancashire, UK
| | - Thomas J Keegan
- Lancaster Medical School, Lancaster University, LA1 4YF, Lancashire, UK
| | - Peter J Diggle
- Lancaster Medical School, Lancaster University, LA1 4YF, Lancashire, UK
| | - Monique van Lettow
- Dignitas International, Zomba, Malawi.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | | | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi.,Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | | | - Benjamin M Taylor
- Lancaster Medical School, Lancaster University, LA1 4YF, Lancashire, UK
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Sengayi MM, Kielkowski D, Egger M, Dreosti L, Bohlius J. Survival of patients with Kaposi's sarcoma in the South African antiretroviral treatment era: A retrospective cohort study. S Afr Med J 2017; 107:871-876. [PMID: 29022531 PMCID: PMC5913753 DOI: 10.7196/samj.2017.v107i10.12362] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND When South Africa (SA) implemented its antiretroviral therapy (ART) programme in 2004, the model for treating HIV-positive Kaposi's sarcoma (KS) patients shifted from symptomatic palliation to potential cure. OBJECTIVE To evaluate survival and changes over time in AIDS-KS patients treated at a tertiary academic hospital oncology unit (the Steve Biko Academic Hospital medical oncology unit) in Pretoria, SA, in the context of ART availability in SA. METHODS We conducted a retrospective review of electronic and paper records of KS patients who accessed cancer care between May 2004 and September 2012. We used Kaplan-Meier survival functions to estimate 1- and 2-year survival, and Cox regression models to identify changes over time and prognostic factors. RESULTS Our study included 357 AIDS-KS patients, almost all of whom were black Africans (n=353, 98.9%); 224 (62.7%) were men. The median age at cancer diagnosis was 37 (interquartile range (IQR) 30 - 43) years, and the median baseline CD4+ count was 242 (IQR 130 - 403) cells/µL. Most patients received ART (n=332, 93.0%) before or after KS diagnosis; 169 (47.3%) were treated with chemotherapy and 209 (58.6%) with radiation therapy. Mortality was 62.7% lower (adjusted hazard ratio (HR) 0.37, 95% confidence interval (CI) 0.19 - 0.73) in the late (2009 - 2012) than in the early (2004 - 2008) ART period. Receiving chemotherapy (adjusted HR 0.3, 95% CI 0.15 - 0.61) and poor-risk AIDS Clinical Trials Group KS stage (adjusted HR 2.88, 95% CI 1.36 - 6.09) predicted mortality. CONCLUSIONS Our results show that large national ART roll-out programmes can successfully reduce KS-related mortality at the individual patient level. If ART coverage is extended, KS-associated morbidity and mortality are likely to drop.
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Affiliation(s)
- M M Sengayi
- National Cancer Registry, National Health Laboratory Service, Johannesburg, South Africa; Graduate School for Cellular and Biomedical Sciences, University of Bern, Switzerland; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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de Witt P, Maartens DJ, Uldrick TS, Sissolak G. Treatment outcomes in AIDS-related diffuse large B-cell lymphoma in the setting roll out of combination antiretroviral therapy in South Africa. J Acquir Immune Defic Syndr 2013; 64:66-73. [PMID: 23797692 PMCID: PMC3797444 DOI: 10.1097/qai.0b013e3182a03e9b] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Long-term survival for patients with AIDS-related diffuse large B-cell lymphoma (DLBCL) is feasible in settings with available combination antiretroviral therapy (cART). However, given limited oncology resources, outcomes for AIDS-associated DLBCL in South Africa are unknown. METHODS We performed a retrospective analysis of survival in patients with newly diagnosed AIDS-related DLBCL treated at a tertiary teaching hospital in Cape Town, South Africa, with cyclophosphamide, doxorubicin, vincristine, and oral prednisone (CHOP) or CHOP-like chemotherapy (January 2004 until December 2010). HIV-related and lymphoma-related prognostic factors were evaluated. RESULTS Thirty-six patients evaluated; median age 37.3 years, 52.8% men, and 61.1% black South Africans. Median CD4 count 184 cells per microliter (in 27.8% this was <100 cells/μL), 80% high risk according to the age-adjusted International Prognostic Index. Concurrent Mycobacterium tuberculosis in 25%. Two-year overall survival (OS) was 40.5% (median OS 10.5 months, 95% confidence interval: 6.5 to 31.8). Eastern Cooperative Oncology Group performance status of 2 or more (25.4% vs 50.0%, P = 0.01) and poor response to cART (18.0% vs 53.9%, P = 0.03) predicted inferior 2-year OS. No difference in 2-year OS was demonstrated in patients coinfected with M. tuberculosis (P = 0.87). CONCLUSIONS Two-year OS for patients with AIDS-related DLBCL treated with CHOP like regimens and cART is comparable to that seen in the United States and Europe. Important factors effecting OS in AIDS-related DLBCL in South Africa include performance status at presentation and response to cART. Patients with comorbid M. tuberculosis or hepatitis B seropositivity seem to tolerate CHOP in our setting. Additional improvements in outcomes are likely possible.
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Affiliation(s)
- Pieter de Witt
- Department of Internal Medicine, Stellenbosch University, Cape Town, South Africa, USA
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Chaabna K, Bray F, Wabinga HR, Chokunonga E, Borok M, Vanhems P, Forman D, Soerjomataram I. Kaposi sarcoma trends in Uganda and Zimbabwe: A sustained decline in incidence? Int J Cancer 2013; 133:1197-203. [DOI: 10.1002/ijc.28125] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Accepted: 01/24/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Karima Chaabna
- Section of Cancer Information; International Agency for Research on Cancer; Lyon; France
| | - Freddie Bray
- Section of Cancer Information; International Agency for Research on Cancer; Lyon; France
| | - Henry R. Wabinga
- Kampala Cancer Registry, Department of Pathology; Makerere University; Kampala; Uganda
| | - Eric Chokunonga
- Zimbabwe Cancer Registry; Parirenyatwa Hospital; Harare; Zimbabwe
| | - Margaret Borok
- Zimbabwe Cancer Registry; Parirenyatwa Hospital; Harare; Zimbabwe
| | | | - David Forman
- Section of Cancer Information; International Agency for Research on Cancer; Lyon; France
| | - Isabelle Soerjomataram
- Section of Cancer Information; International Agency for Research on Cancer; Lyon; France
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Current world literature. Curr Opin Oncol 2012; 24:587-95. [PMID: 22886074 DOI: 10.1097/cco.0b013e32835793f1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mosam A, Shaik F, Uldrick TS, Esterhuizen T, Friedland GH, Scadden DT, Aboobaker J, Coovadia HM. A randomized controlled trial of highly active antiretroviral therapy versus highly active antiretroviral therapy and chemotherapy in therapy-naive patients with HIV-associated Kaposi sarcoma in South Africa. J Acquir Immune Defic Syndr 2012; 60:150-7. [PMID: 22395672 DOI: 10.1097/qai.0b013e318251aedd] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The optimal approach to HIV-associated Kaposi sarcoma (HIV-KS) in sub-Saharan Africa is unknown. With large-scale rollout of highly active antiretroviral therapy (HAART) in South Africa, we hypothesized that survival in HIV-KS would improve and administration of chemotherapy in addition to HAART would be feasible and improve KS-specific outcomes. METHODS We conducted a randomized, controlled, open-label trial with intention-to-treat analysis. Treatment-naive patients from King Edward VIII Hospital, Durban, South Africa, a public-sector tertiary referral center, with HIV-KS, but no symptomatic visceral disease or fungating lesions requiring urgent chemotherapy, were randomized to HAART alone or HAART and chemotherapy (CXT). HAART arm received stavudine, lamivudine, and nevirapine (Triomune; CXT arm received Triomune plus bleomycin, doxorubicin, and vincristine every 3 weeks. When bleomycin, doxorubicin, and vincristine were not available, oral etoposide (50-100 mg for 1-21 days of a 28-day cycle) was substituted. Primary outcome was overall KS response using AIDS Clinical Trial Group criteria 12 months after HAART initiation. Secondary comparisons included time to response, progression-free survival, overall survival, adverse events, HIV control, CD4 reconstitution, adherence, and quality of life. RESULTS Fifty-nine subjects were randomized to HAART and 53 to CXT; 12-month overall KS response was 39% in the HAART arm and 66% in the CXT arm (difference, 27%; 95% confidence interval, 9%-43%; P = 0.005). At 12 months, 77% were alive (no survival difference between arms; P = 0.49), 82% had HIV viral load <50 copies per milliliter without difference between the arms (P = 0.47); CD4 counts and quality-of-life measures improved in all patients. CONCLUSIONS HAART with chemotherapy produced higher overall KS response over 12 months, whereas HAART alone provided similar improvement in survival and select measures of morbidity. In Africa, with high prevalence of HIV and human herpes virus-8 and limited resources, HAART alone provides important benefit in patients with HIV-KS.
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Affiliation(s)
- Anisa Mosam
- Department of Dermatology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.
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