Reply to “Successful treatment of nodular human immunodeficiency virus–associated Kaposi sarcoma of the foot utilizing combination intralesional bleomycin and cryotherapy.”

Abstract

To the Editor: The recently published paper by Erickson et al, “Successful treatment of nodular human immunodeficiency virus–associated Kaposi sarcoma of the foot utilizing combination intralesional bleomycin and cryotherapy,” reported on the efficacy of intralesional bleomycin in a case of refractory Kaposi sarcoma (KS) nodule on the foot, arguing for its introduction in the routine therapeutic arsenal against KS.1Erickson M.K. Choi J.N. Successful treatment of nodular human immunodeficiency virus-associated Kaposi sarcoma of the foot utilizing combination intralesional bleomycin and cryotherapy.JAAD Case Rep. 2021; 10: 25-27https://doi.org/10.1016/j.jdcr.2021.01.034Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Even if notable improvement was documented as early as 3 weeks since treatment initiation, complete response was achieved only after about a year. Numerous visits were required, for repeated intralesional drug administration and cryotherapy. The final outcome was deemed satisfactory both functionally and esthetically.1Erickson M.K. Choi J.N. Successful treatment of nodular human immunodeficiency virus-associated Kaposi sarcoma of the foot utilizing combination intralesional bleomycin and cryotherapy.JAAD Case Rep. 2021; 10: 25-27https://doi.org/10.1016/j.jdcr.2021.01.034Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar We came across a very similar case, which was managed by means of curettage nodulectomy, significantly reducing time to remission and number of follow-up visits needed. A 55-year-old man with longstanding HIV-negative KS presented with several angiomatous nodules on the upper and lower extremities. Notably, a 2-cm nodule on the little finger of the right hand was documented (Fig 1, A), which had been source of great psychologic distress and hindered daily activities. After local anesthesia with lidocaine and tourniquet application for adequate bleeding control, surgical curettage was performed in order to debulk the lesion. The presence of a clear cleavage plane allowed complete removal of the nodule’s base. Subsequently, hemostasis was obtained using 35% hydrogen peroxide solution. Histopathologic evaluation was consistent with KS, exhibiting neoplastic, human herpes virus 8-positive spindle cells and slit-like vascular spaces in the dermis. Complete remission of the lesion was achieved. No postoperative complications were encountered. The final esthetic outcome was excellent, with imperceptible scarring at 4 weeks (Fig 1, B). After 6 months of follow up, no recurrences were noted. KS is a multifocal neoplastic disorder of lymphatic endothelial origin caused by human herpes virus 8. Its management includes both local and systemic options. The former can either be adopted alone for localized lesions or combined with the latter in disseminated KS.2Brambilla L. Genovese G. Berti E. et al.Diagnosis and treatment of classic and iatrogenic Kaposi's sarcoma: Italian recommendations.Ital J Dermatol Venerol. 2021; 156: 356-365https://doi.org/10.23736/S2784-8671.20.06703-6Crossref PubMed Scopus (7) Google Scholar Cryotherapy/cryosurgery can be employed for superficial lesions but often results in hypopigmented sequelae and/or scarring. Likewise, classic surgical excision of KS lesions presents a number of disadvantages, such as residual scarring, possible functional impairment, and high rates of recurrence.2Brambilla L. Genovese G. Berti E. et al.Diagnosis and treatment of classic and iatrogenic Kaposi's sarcoma: Italian recommendations.Ital J Dermatol Venerol. 2021; 156: 356-365https://doi.org/10.23736/S2784-8671.20.06703-6Crossref PubMed Scopus (7) Google Scholar Conversely, intralesional chemotherapy is usually characterized by good response rates and has been regarded as one of the preferred treatment modalities for KS nodules. Intralesional vincristine is less painful than both intralesional vinblastine and bleomycin, is inexpensive, well tolerated, leads to excellent therapeutic response - with full healing in most cases, and has negligible systemic absorption.3Brambilla L. Bellinvia M. Tourlaki A. Scoppio B. Gaiani F. Boneschi V. Intralesional vincristine as first-line therapy for nodular lesions in classic Kaposi sarcoma: a prospective study in 151 patients.Br J Dermatol. 2010 Apr; 162: 854-859https://doi.org/10.1111/j.1365-2133.2009.09601.xCrossref PubMed Scopus (52) Google Scholar However, intralesional treatment of large KS nodules, especially those located on the foot, poses the risk of paradoxical enlargement and inflammatory lesional change.3Brambilla L. Bellinvia M. Tourlaki A. Scoppio B. Gaiani F. Boneschi V. Intralesional vincristine as first-line therapy for nodular lesions in classic Kaposi sarcoma: a prospective study in 151 patients.Br J Dermatol. 2010 Apr; 162: 854-859https://doi.org/10.1111/j.1365-2133.2009.09601.xCrossref PubMed Scopus (52) Google Scholar In the writers’ experience, removal of such nodular, bulky lesions is best done by curettage followed by 35% hydrogen peroxide solution application.4Tourlaki A. Bellinvia M. Brambilla L. Recommended surgery of Kaposi's sarcoma nodules.J Dermatolog Treat. 2015; 26: 354-356https://doi.org/10.3109/09546634.2014.971698Crossref PubMed Scopus (9) Google Scholar Other hemostatic agents such as 20% aluminum chloride or Monsel solution could be used, but these have the disadvantage of potentially causing permanent discoloration.5Farhang S.X. Weiss E. Hydrogen peroxide as a hemostatic agent during dermatologic surgery.Cutis. 2019; 104: 366-367PubMed Google Scholar In conclusion, our approach was simple, inexpensive, and caused minimal scarring, while sparing the need for numerous visits. None disclosed.