Outcomes Of Kaposi Sarcoma Research Articles

Evaluating Kaposi Sarcoma in Kidney Transplant Patients: A Systematic Review and Meta-Analysis.

Kaposi's sarcoma (KS) is a malignancy that commonly appears as lesions on the skin or mucosal surfaces but can also develop in other organs. This cancer is usually caused by the human herpesvirus 8 (HHV-8), recently known as Kaposi's sarcoma-associated herpesvirus (KSHV). KS is rare in the general population but can develop in kidney transplant recipients with varying incidence due to immunocompromised status from immunosuppression. The main aim of the present systematic review was to identify the prevalence and treatment of KS in kidney transplant patients. PubMed, Cochrane Library, and Google Scholar databases were searched for studies until October 2023. Full-text studies with similar research objectives were included, while non-English articles, reviews, case reports, ongoing clinical trials, and studies evaluating KS in HIV patients or after other solid organ transplants were excluded. All studies were observational; therefore, methodological quality was assessed using the Newcastle-Ottawa Scale. The statistical analyses were performed with the Comprehensive Meta-Analysis (CMA) software (Biostat, Inc.Englewood, NJ). The pooled analysis from the 15 studies includedshowed that KS develops in 1.5% of kidney transplant recipients and is more prevalent in African (1.7%) and Middle Eastern (1.7%) recipients than in Western recipients (0.07%). KS was also significantly more prevalent among male recipients than female recipients (OR: 2.36; p < 0.0001). Additionally, cyclosporine-based immunosuppression accounts for most KS incidences (79.6%) compared to azathioprine-based immunosuppression (28.2%). Furthermore, reduction or withdrawal of immunosuppression alone resulted in 47.8% KS complete remissions. Post-kidney transplantation KS is more frequent among males and patients of Middle Eastern and African origin. However, the gender difference may be attributed to most patients undergoing kidney transplants being male. Therefore, if gender balance is considered in future studies, then the difference might be insignificant. Based on our results, we can concur that the mainstay treatment for post-transplant KS is reduction or withdrawal of immunosuppression. However, the patients should be closely monitored to avoid KS recurrence and kidney rejection. Furthermore, there is an increased risk for KS with the use of cyclosporine-based immunosuppression. However, this does not mean that the withdrawal of this immunosuppression agent might result in improved KS outcomes because the withdrawal of azathioprine with or without cyclosporine reduction has also led to improved outcomes.

BI11 Cutaneous presentation of Kaposi sarcoma following allogeneic haematopoietic stem cell transplantation for myeloma

Abstract Iatrogenic Kaposi sarcoma (KS) is a relatively frequent occurrence following solid-organ transplants (0–5%), in part due to prolonged immunosuppression. However, its occurrence after haematopoietic stem cell transplantation (HSCT) is rare, with only 15 cases described in the literature. We report a case of KS presenting in the skin of a patient who had received a matched unrelated donor allogeneic HSCT for IgG kappa myeloma. A 55-year-old HIV-negative white man with myeloma underwent an allogeneic HSCT from a matched, unrelated donor following conditioning chemotherapy with fludarabine–melphalan and antithymocyte globulin. Post-transplant, he was maintained on ciclosporin as graft-versus-host disease (GVHD) prophylaxis. On day 14 post-transplant, he developed a widespread eczematous eruption that rapidly evolved into an erythroderma; a skin biopsy was consistent with acute GVHD. He was managed with superpotent topical steroids and a 5-day course of oral prednisolone. He began extracorporeal photopheresis (ECP) on day 33 post-transplant, having failed to respond adequately to systemic steroids. He also completed four cycles of rituximab. Ciclosporin was stopped by day 130 post-transplant. He had completed 14 cycles of ECP by day 139 post-transplant, with resolution of cutaneous GVHD; however, he had developed a rapidly growing solitary dusky-red nodule on his right neck that was excised due to diagnostic uncertainty. Histology revealed a dermal haemorrhagic exophytic vascular tumour composed of lobules and sheets of epithelioid cells with an eosinophilic cytoplasm and pleomorphic nuclei. Immunoperoxidase staining was negative for S100, MNF-116 and AE1/AE3. The same cells were strongly and diffusely positive for the vascular markers CD31, CD34 and ERG. The lesional cells were positive for human herpesvirus (HHV)-8 confirming a diagnosis of Kaposi sarcoma. He subsequently developed a second lesion on his left forearm, despite being off all immunosuppression. A repeat bone biopsy confirmed that he remains in morphological remission from his myeloma. Positron emission tomography–computed tomography has not identified extracutaneous disease. KS following HSCT is rare, but it can be fatal. Skin lesions are the dominant clinical presentation. HHV-8 has an important role in the pathogenesis, and transplant-related KS may occur secondary to reactivation of the virus as a result of significant immunosuppression following HSCT. However, it could also occur as primary infection or be transmitted with donor cells. The outcome of KS after HSCT is variable. A watch and wait strategy can be applied if immune recovery is expected. In our patient, it developed 5 months after HSCT; shortly after immunosuppression had been tapered, he remains well and will be closely monitored for further suspicious lesions.

Academic medical center access and outcomes in Kaposi sarcoma.

e21582 Background: Kaposi sarcoma (KS) is a soft tissue tumor commonly affecting the skin. It is seen in patients in immunosuppressed states, such as those with HIV/AIDS or organ transplant history. Treatment may include excision, chemotherapy, or radiotherapy depending on the location and spread of lesions. Prior studies indicate that treatment at academic facilities, which offer higher treatment volume, and access to specialized care, clinical trials, and a greater number of ancillary services, is associated with improved survival in other skin cancers, such as melanoma. In this study we aim to compare the survival and sociodemographic factors for KS patients between academic and non-academic facilities, using the largest dataset of these patients yet examined. Methods: We conducted a retrospective analysis of the National Cancer Database from 2004 to 2019 for subjects with KS, identified by ICD code 9140 (n=5,233). Factors were compared between patients seen at non-academic (NAC) (n=2,278) versus academic centers (AC), (n=2,955). Overall survival (OS) was estimated using Kaplan Meier analysis with pairwise log-rank tests for significance. Multivariate analysis was performed using binary logistic regression. Results: Most individuals in the study were White (70.1%), male (87.1%), not of Spanish or Hispanic origin (82.7%), and had government insurance (54.3%). Treatment at AC was associated with improved survival compared to NAC (median OS 184 vs. 98 months, p&lt;0.001). AC patients were younger compared to NAC patients (mean age 56.1 vs. 60.9 years old, p&lt;0.001). On adjusted logistic regression, AC were more likely to treat minority patients, including Black patients (OR 1.23, 95% CI 1.06-1.43, p=0.005) and Spanish/Hispanic patients (OR 1.26, 95% CI 1.06-1.48, p=0.007). AC were more likely to manage uninsured patients compared to patients with private (OR 0.48, 95% CI 0.39-0.60, p&lt;0.001) or government insurance (OR 0.69, 95% CI 0.55-0.86, p=0.001). Compared to the East Coast, patients in the Central U.S. (OR 0.81, 95% CI 0.71-0.93, p=0.003) and West Coast (OR 0.83, 95% CI 0.71-0.96, p=0.015) were less likely to use AC. Patients residing in high education zip codes were less likely to be treated at academic centers (p&lt;0.001). Patients in the top income quartile were more likely to be treated at AC (OR 1.42, 95% CI 1.15-1.75, p=0.001). Conclusions: Treatment at AC is associated with improved overall survival compared to NAC in KS. AC were more likely to treat younger patients, and those from racial and ethnic minorities, as well as those in the top income quartile. Less academic center use was seen in areas of higher educational attainment and by individuals with government or private insurance. While specialized care and clinical trial access may play a role in this survival benefit, access to AC may also be a surrogate marker of social determinants of health that play a role in KS outcomes. Our study supports the ongoing need for access to comprehensive care in KS.

Evaluation of a training intervention to improve cancer care in Zimbabwe: Strategies to Improve Kaposi Sarcoma Outcomes (SIKO), a prospective community-based stepped-wedge cluster randomized trial.

IntroductionMost Zimbabweans access medical care through tiered health systems. In 2013, HIV care was decentralized to primary care clinics; while oncology care remained centralized. Most persons in Zimbabwe with Kaposi sarcoma (KS) are diagnosed late in their disease, and the prognosis is poor. Little is known about whether educational interventions could improve KS outcomes in these settings.MethodsInterventions to improve KS detection and management were evaluated at eight Zimbabwe primary care sites (four rural/four urban) that provided HIV care. Interventions included a standardized KS clinical evaluation tool, palliative care integration, standardized treatment and improved consultative services. Interventions were implemented between February 2013 and January 2016 using a randomized stepped‐wedge cluster design. Sites were monitored for KS diagnosis rates and KS outcomes, including early diagnosis (T0 vs. T1 tumour stage), participant retention and mortality. Analyses controlled for within‐clinic correlations.ResultsA total of 1102 persons with suspected KS (96% HIV positive) were enrolled: 47% incident (new diagnosis), 20% prevalent (previous diagnosis) and 33% determined as not KS. Early (T0) diagnosis increased post‐intervention, though not significant statistically (adjusted odds ratio [aOR] = 1.48 [95% confidence interval (95% CI): 0.66–3.79], p = 0.37). New KS diagnosis rates increased 103% (95% CI: 11–273%), p = 0.02) post‐intervention; although paired with an increased odds of incorrectly diagnosing KS (aOR = 2.08 [95% CI: 0.33–3.24], p = 0.001). Post‐intervention, non‐significant decreases in 90‐day return rates (adjusted hazard ratio [aHR] = 0.69 [95% CI: 0.38–1.45], p = 0.21) and survival (aHR = 1.36 [95% CI: 0.85–2.20], p = 0.20) were estimated.ConclusionsKS training interventions at urban and rural Zimbabwe decentralized primary care clinics significantly increased overall and incorrect KS diagnosis rates, but not early KS diagnosis rates, 90‐day return rates or survival.

Mortality disparities among patients with HIV-associated Kaposi's sarcoma in the southern United States.

To describe risk factors for mortality in HIV-associated Kaposi's sarcoma in an urban population in Dallas, Texas. Retrospective electronic medical record review of patients with HIV-associated Kaposi's sarcoma. Electronic medical records were reviewed from 1 January 2009 to 31 December 2018 for patients with a diagnosis of HIV and Kaposi's sarcoma by ICD-9 or ICD-10 codes. Demographics, HIV history, Kaposi's sarcoma history, treatment, and mortality data were collected. Mortality data was supplemented by an inquiry from the National Death Index (NDI). Survival analyses were performed using Cox proportional hazards analysis to determine independent predictors of mortality. Black patients had higher mortality than white or Hispanic patients (hazard ratio 2.07, 95% confidence interval 1.12-3.82), even after adjusting for covariates. This mortality difference correlates with higher rates of advanced Kaposi's sarcoma disease and KS-IRIS in black patients compared with other groups and is not explained by differences in CD4+ cell count, HIV viral load, engagement in care, or ART adherence at the time of cancer diagnosis. Despite nationwide trends showing decreased incidence and decreased mortality in Kaposi's sarcoma in the ART era, a high number of Kaposi's sarcoma cases and disparities in Kaposi's sarcoma outcomes persist in certain populations in the United States.

Prospective cohort study of Kaposi sarcoma treated under real-world conditions in Malawi.

11569 Background: Kaposi sarcoma (KS) is the leading cancer in Malawi (34% of cancers). Outside of clinical trials, prospective KS studies from sub-Saharan Africa (SSA) are few and limited by loss to follow up. We conducted a prospective KS cohort study of standard of care bleomycin/vincristine (BV) at Lighthouse HIV clinic, in Lilongwe, Malawi. Methods: We enrolled pathologically confirmed, newly diagnosed, HIV+ KS patients from Feb 2017 to Jun 2019. We collected clinical and treatment characteristics, toxicity, and outcomes of KS with follow-up censored Jun 2020. Patients were treated with bleomycin (25 mg/m2) and vincristine (0.4 mg/m2) every 14 days for a planned maximum of 16 cycles. STATA v13.0 was used to calculate descriptive statistics and Kaplan Meier survival analysis. Toxicity was graded using NCI CTCAE v5.0. Results: We enrolled 138 participants, median age 36 (IQR 32-44) and 110 (80%) male. By ACTG staging, 107 (78%) were T1 (tumour severity), 46 (33%) were S1 (illness severity) and 46 (33%) had Karnofsky performance status ≤70. Presenting symptoms included edema in 69 (53%), visceral disease in 9 (7%), and oral involvement in 43 (33%). Prior to KS diagnosis, 70 (51%) participants were aware of being HIV+ for median 17 months (IQR 6-60) and had been on ART for median 16 months (IQR 6-60). Median CD4 count was 197 (IQR 99-339), median HIV-viral load was 2.6 log copies/mL (IQR 1.6 – 4.8) and 57% were HIV-suppressed ( &lt; 1000 HIV copies/ml). The median number of cycles was 16 (IQR 7-16). 62 (45%) participants missed at least one dose due to stock out. Amongst patients with missed doses, the median number was 3 (IQR 2-4) for bleomycin and 2 (IQR 1-3) for vincristine. 14 (10%) participants experienced at least one reduced dose due to toxicity. 5 (4%) participants suffered grade ≥3 anaemia, 13 (9%) grade ≥3 neutropenia, and one participant had grade 4 bleomycin-induced dermatitis. There was no reported grade ≥3 bleomycin lung toxicity or vincristine-induced neuropathy. Of 115 evaluable participants, responses at the end of therapy were: complete response in 52 (45%), partial response in 27 (23%) stable disease in 5 (4%), and progressive disease in 31 (28%). Median duration of follow-up was 20 months. At censoring, 69 (50%) were alive, 36 (26%) dead, and 33 (24%) lost to follow-up. Overall survival is shown Table as crude and worst-case scenario; worst-case assumes all participants lost to follow up died. Conclusions: Here, we present one of the most complete characterizations of KS presentation and treatment from SSA. As in other studies from the region, the majority of patients presented with advanced disease, chemotherapy stock-outs and loss to follow up were common, and mortality was high. Studies are planned to understand the virologic characteristics, improve therapies, and better implement existing therapies.[Table: see text]

328. Kaposi Sarcoma in High Population ART Utilization Setting: An Observational Study in Botswana

BackgroundDespite population antiretroviral treatment (ART) utilization exceeding UNAIDS 90-90-90 targets, Kaposi sarcoma (KS) remains one of the most prevalent malignancies in Botswana. We sought to examine the characteristics and outcomes of KS in the context of high ART utilization.MethodsConsenting patients at one of four oncology centers for KS treatment were enrolled prospectively (October 2010 to March 2019) and followed quarterly for 5 years. Survival was estimated using Kaplan–Meier estimator and predictors assessed with Cox proportional hazards modeling.ResultsA total of 408 KS patients were enrolled and of those, 396 (97%) were HIV-positive and included in analyses. Median age at diagnosis was 40 years (IQR: 34.1, 46.7) and 247 patients (62%) were male. The median CD4 cell count at the time of KS diagnosis was 253 cells/mL (IQR: 134, 364) and 279 (73%) were receiving ART at the time of KS diagnosis. Among those on ART, the median duration of ART prior to KS diagnosis was 11.9 months (IQR: 2.7, 46.7). The proportion receiving ART prior to KS increased during the surveillance period from 58% to 80% (P < 0.001). Of the 248 (62.6%) patients with recent measurement, 91% had HIV-1 RNA < 1000 copies/mL. Five-year overall survival was 73% (95% CI 68–78%). In multivariable analysis, Female sex and higher income were associated with improved survival, but not age or CD4 cell count. The duration of ART was significantly associated with survival (P = 0.02), with improved survival for individuals on ART < 6 months compared with longer ART (HR 0.54; 95% CI 0.29–0.98). The incidence of KS cases declined by nearly 50%, but has remained relatively stable since 2015.ConclusionSurvival rates in this cohort were comparable to other KS cohorts. While KS treatment initially declined with ART expansion, KS remains a significant disease burden in Botswana with 80% of cases occurring among individuals receiving ART. Disclosures All authors: No reported disclosures.

Incidence and outcome of Kaposi sarcoma after hematopoietic stem cell transplantation: a retrospective analysis and a review of the literature, on behalf of infectious diseases working party of EBMT.

The incidence, the clinical characteristics, and the outcome of Kaposi sarcoma (KS) in patients after hematopoietic stem cell transplantation (HSCT) were assessed. During the period 1987-2018, 13 cases of KS were diagnosed, 3 females and 10 males, median age of 50 years, median time from HSCT of 7 months. KS had an incidence of 0.17% in allogeneic and 0.05% in autologous HSCT. HHV-8 was documented in eight of nine tumor tissue samples assessed. The organ involvement was: skin in nine, lymph nodes in six, oral cavity in four, and visceral in three patients, respectively; seven patients had >1 organ involved. Five patients had immunosuppression withdrawn, whereas four and three patients received radiotherapy and chemotherapy, respectively. Eight patients are alive (median follow-up 48 months, range 5-128), whereas five patients died after a median time of 8 months from the diagnosis of KS. However, no death was caused by KS. We conclude that the incidence of KS after HSCT is very low. Although KS can be managed with the reduction of immunosuppression, visceral forms may require chemotherapy and/or radiotherapy. The low prevalence of KS indicates that screening for HHV-8 serology and surveillance for HHV-8 viremia are not indicated in HSCT patients.

MDM2 gene polymorphisms and risk of classic Kaposi's sarcoma among Iranian patients.

A single-nucleotide polymorphism (SNP) in the promoter region of MDM2 (SNP309T>G, rs2279744) has been shown to increase the expression of the MDM2 protein in various cancer types. However, only one study has analyzed the role of the MDM2 polymorphism in the development of Kaposi's sarcoma (KS). The association of MDM2 SNP309 with classic KS risk was evaluated in 79 Iranian patients with classic KS and 123 healthy controls. The MDM2 SNP309 was genotyped using PCR and restriction fragment length polymorphism methods. No significant correlation was found between the SNP309 polymorphism in MDM2 promoter and classic KS risk. There was no significant correlation between gender and disease stage. However, a significant association was found between SNP309 GG genotype and younger age (≤50years) (odds ratio 9.5, 95% confidence intervals 1.5-60, p = 0.03). Our findings support no major role for the MDM2 SNP309 in KS development although it might influence the clinical outcome of KS in younger patients.

Demographic Characteristics and Preliminary Outcomes in a Cohort of HIV-Positive Patients With Kaposi's Sarcoma in a High ART Coverage Setting: A Report from Botswana

Abstract 50 Objective: Despite antiretroviral treatment coverage exceeding 90% by government estimates, Kaposi sarcoma (KS) remains the most prevalent malignancy in Botswana. Incidence has decreased minimally over the last decade. We sought to explore reasons for persistent high incidence and describe KS outcomes. Methods: Since 2010, consenting patients presenting to one of three oncology centers for KS treatment were enrolled prospectively and followed quarterly. Baseline HIV testing performed and records abstracted through April 2015. Results: 207 KS patients enrolled, 60% (125) with clinical diagnosis, 34% (71) with pathologic diagnosis, and 11 (6%) with radiologic/other diagnosis. Median age at diagnosis was 37 years (IQR: 11.9) and 63% (133) male. At presentation, 65% (134) had cutaneous and 24% (49) had disseminated disease. Revised ACTG staging was 8% (17) stage I, 54% (112) stage II, 35% (73) stage III. Nearly all, 98% (199), were HIV-infected with median nadir CD4 190 cells/μL (IQR: 208). Among HIV-infected patients, 68% (109) were not on ART at time of KS diagnosis and 26% (42) were diagnosed within first six months of ART. Of those not yet on ART, 72% (47) of men and 28% (18) of women had CD4 &lt;250 cells/μL, p=.0004. Few cases, 6 (10%), developed in patients on ART for &gt;6 months. Patients not on ART were referred to start. 71% (146) received chemotherapy and 7% (15) required radiation. After median follow-up 19 months, 21% (43) patients had died. Estimated 3-year OS was 76% (95% CI: 69-82%). Gender, ART duration, disease extent, and stage did not significantly predict survival. Conclusions: With high population ART coverage, KS development among individuals with CD4&lt;250 cells/μL accounts for majority of cases referred for oncologic treatment. ART delay, particularly among men, also contributed to persistent KS burden. Overall survival with KS in Botswana is similar to US and Europe. Initiation of ART at higher CD4 thresholds is needed to control the KS epidemic. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST: Shekinah N. Elmore No relationship to disclose Elizabeth S. Bigger No relationship to disclose Mukendi K.A. Kayembe No relationship to disclose Zola Musimar No relationship to disclose Gita Suneja No relationship to disclose Jason A. Efstathiou Honoraria: Medivation/Astellas, Bayer Healthcare Pharmaceuticals Consulting or Advisory Role: Medivation/Astellas, Bayer Healthcare Pharmaceuticals Scott Dryden-Peterson Patents, Royalties, Other Intellectual Property: UpToDate

1158Significance of HIV Viral Load and CD4 Count on Kaposi Sarcoma in the Era of Highly-Active-Antiretroviral Therapy

. Approximately 20% of patients with HIV will have Kaposi Sarcoma (KS) and about half will die within 3 months of diagnosis. Incidence and outcomes of KS have traditionally been linked to CD4 counts <350. More recently, KS has been increasingly described in higher CD4 counts and variable presentations in the era of HighlyActive-Antiretroviral-Therapy (HAART). No studies have established the role of Viral Load (VL) on KS.

Abstract 3649: Significance of HIV viral load and CD4 count on Kaposi sarcoma in the era of highly active antiretroviral therapy

Abstract Background: Approximately 20% of patients with HIV will have Kaposi Sarcoma (KS) and about half will die within 3 months of diagnosis. Incidence and outcomes of KS have traditionally been linked to CD4 counts &amp;lt;350. More recently, KS has been increasingly described in higher CD4 counts and variable presentations in the era of Highly-Active-Antiretroviral-Therapy (HAART). No studies have established the role of Viral Load (VL) on KS. Objective: To determine the effect of CD4 count and HIV VL on KS presentation and outcomes. Methods: Retrospective review of KS patients with HIV admitted over 12 years (2000-2012). KS patients without HIV infection were excluded. Patients were divided into 4 groups based on CD4 count (≥200 or 100,000 or &amp;lt;100,000). Groups were analyzed with regards to KS severity (good vs poor risk), extent (soft tissue vs visceral), receipt of HAART and survival (6months). Statistical analysis was done via Chi-Square test. Results: 43 patients were included. KS affected predominantly young (30-40yrs), male (93%) HIV patients with VL &amp;gt;100,000 (85%) and CD4 counts 100,000 had a statistically significant increased incidence for visceral involvement (96%, p100,000 ((66.7% with good risk), increased survival (59.4% survived &amp;gt;6months) and less use of HAART (20%). Although, these differences were statistically insignificant. Conclusion: HIV VL of &amp;gt;100,000 is correlated with increased severity and extent of KS. Though statistically insignificant, CD4 counts &amp;lt;200 showed a trend for less severe disease and increased survival despite less use of HAART. Larger prospective studies are warranted to elucidate on these differences. Citation Format: Gentry T. King, Shivani Garg. Significance of HIV viral load and CD4 count on Kaposi sarcoma in the era of highly active antiretroviral therapy. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 3649. doi:10.1158/1538-7445.AM2014-3649

Relationship of vitamin D insufficiency to AIDS-associated Kaposi's sarcoma outcomes: retrospective analysis of a prospective clinical trial in Zimbabwe

The prevalence of vitamin D insufficiency in Africans with AIDS-associated Kaposi sarcoma (AIDS-KS) and the role of vitamin D in AIDS-KS progression are unknown. We hypothesized that a high prevalence of vitamin D deficiency would be found in Zimbabweans with AIDS-KS and that low baseline vitamin D would correlate with progression of AIDS-KS. Ninety subjects were enrolled in a prospective pilot study investigation of the effect of antiretroviral therapy in the treatment of AIDS-KS in Harare, Zimbabwe. Co-formulated abacavir, lamivudine, and zidovudine was initiated; chemotherapy was provided at the discretion of the provider. Participants were followed for 96 weeks. 25-Hydroxyvitamin D was measured in stored specimens collected at study entry. The relationship between vitamin D and clinical response was described by odds ratio and 95% confidence interval. Samples were available for 85 participants; 45 (53%) subjects had inadequate (<75 nmol/l) 25-hydroxyvitamin D. HIV-1 RNA was significantly higher among those with insufficient vitamin D (4.7 vs. 4.5 log, p = 0.04). Tumor response, survival, and KS-IRIS were not associated with vitamin D (p ≥ 0.3). Vitamin D insufficiency was common among Zimbabweans with AIDS-KS but not associated with outcomes after initiation of antiretroviral therapy.

Prognosis, diagnostic delay, and patient characteristics associated with diagnostic delay among Kaposi sarcoma (KS) patients in Uganda.

6578 Background: The incidence and mortality of KS remain high in sub-Saharan Africa. Delaying treatment might explain poor outcomes, but no study has measured the association between delay, characteristics associated with delay, and prognosis for KS patients in low- and middle-income countries. Methods: This is a prospective, cross-sectional study conducted from June-October 2012 at the Uganda Cancer Institute (UCI) in Kampala, Uganda among HIV-infected adults with histologically confirmed KS. The aim was to measure the association between delay and overall KS stage risk at diagnosis. Standardized interviews were conducted in English or Luganda to measure delay, and medical records were abstracted to obtain KS stage at admission to UCI. Multivariable logistic regression was used to assess the relationship between diagnostic delay and poor-risk stage at diagnosis. Results: 161 patients were enrolled; 68.9% were men, mean age was 34.0 years (SD 7.7), 58.1% had income &lt; $2 per day, and 49.4% had ≥primary education. 25.8% had been seen in an HIV clinic within 3 months, 71.6% were on antiretroviral therapy (ART), and 25.5% had visited a traditional healer prior to being seen at UCI. 45.3% delayed seeking care at UCI for ≥3 months from onset of symptoms. Among those who delayed, 35.6% waited 6 months, and 24.7% waited 12 months. The most common reasons for delay were lack of pain (47.9%), no money (31.5%), and distance to UCI (8.2%). In adjusted analysis patients who experienced diagnostic delay were more likely to have poor-risk stage compared to those who did not delay (OR 3.41, p=0.002, 95%CI: 1.46-7.45). After adjusting for patient characteristics, HIV clinic attendance, and ability to pay out-of-pocket costs, visiting a traditional healer was the only characteristic associated with greater likelihood of delay (OR 2.69, p=0.020, 95%CI: 1.17-6.17). Conclusions: Diagnostic delay was independently associated with poor-risk stage at diagnosis, and visiting a traditional healer was the only patient characteristic independently associated with delay. The relationship between traditional and Western medicine presents a critical point of intervention to improve KS outcomes in Uganda.

Sirolimus for the Treatment of Kaposi Sarcoma After Renal Transplantation: A Series of 10 Cases

The incidence of Kaposi sarcoma (KS) has substantially increased among immunocompromised patients, suggesting a role for immunosuppressive drugs. The aim of this study was to evaluate the incidence, features, and outcome of KS among 307 kidney transplantation patients at our center between January 1994 and June 2010. During the study period, the 10 patients who developed KS (3.25%) showed a mean age at transplantation of 35.8 ± 8.7 years (range, 22 to 49 years). The mean interval between transplantation and occurrence of KS was 24.7 ± 21.36 months (range, 6 to 64 months). The mean time of antithymocyte globulin induction was 9.5 days (range, 6 to 13 days). KS was restricted to the skin in 7 cases, among which, one presented with associated Hodgkin lymphoma. Visceral involvement (one lung and one colon) was observed in two cases. One patient presented with a gastric KS without skin lesions. Immunosuppressive treatment was reduced, then withdrawn in three cases, resulting in regression of KS a few weeks later, but with graft loss requiring hemodialysis at 1, 3 and 4 months. Among the remaining 7 cases, we stopped mycophenalate mofetil (MMF) and switched from calcineurin inhibitors to sirolimus. Allograft function remained stable after the switch. Only one patient who already had allograft dysfunction due to biopsy-proven chronic allograft nephropathy. Deteriorated progressively, undergoing hemodialysis at 2 years after KS diagnosis. In conclusion, we observed a relatively high incidence of KS among our cases. The introduction of sirolimus resulted in complete regression of KS lesions with preserved graft function.

Remission from Kaposi's sarcoma on HAART is associated with suppression of HIV replication and is independent of protease inhibitor therapy

Highly active antiretroviral therapy (HAART) reduces the incidence and improves the prognosis of Kaposi's sarcoma (KS). This study was designed to identify factors associated with KS clinical responses in HIV-infected patients during HAART. We reviewed the files of 138 HIV-1-infected patients with KS. Epidemiologic and HIV-related clinical and biological parameters were recorded at KS diagnosis (baseline) and every 6 months thereafter. In a subset of 73 antiretroviral-naive patients, we compared the clinical outcome of KS according to the use or nonuse of protease inhibitors (PI). After 6 months of follow-up, KS remission was more frequent in patients who were naive of HAART and who were at ACTG stage S0 at baseline (P=0.03 and 0.02). Undetectable HIV viral load was strongly associated with KS remission (P⩽0.004 at all time points), while CD4 cell count was not. Among the 73 antiretroviral-naive patients at baseline, and who were studied for 24 months, KS outcome did not differ between patients who were prescribed PI-containing and PI-sparing regimens. Intercurrent multicentric Castleman's disease was associated with poor outcome after 60 months of follow-up (P⩽0.0001). Fourteen deaths occurred after a median follow-up of 37.5 months, eight of which were KS related. Suppression of HIV replication appears to be crucial to control KS. Non-PI-based regimens were equivalent to PI-based regimens as regards the clinical and virological outcome of antiretroviral-naive HIV-infected patients with KS.

Kaposi sarcoma in kidney transplanted patients.

Newly developed malignancies in kidney transplanted patients are one of the complications attributed to immunosuppression. Kaposi sarcoma is an unusual malignancy in general population, but may develop in kidney transplanted patients with highly varying prevalence. Our aim is to evaluate the prevalence, clinical manifestations, and outcome of Kaposi sarcoma in kidney transplanted patients. Five hundred and eighty cases (330 male, 250 female) with a mean age of 38.2 were followed for 36 months (range 9 months to 10 years), visiting every two months. History taking and physical examination with emphasis on skin and mucosa were taken. Biopsy of suspicious sin, mucosal, and visceral lesions assigned by other paraclinical methods was performed. Except 7 cases which were HLA identical to donors, all patients were managed with cyclosporine, Azathioprine and Prednisolone. Fourteen patients (2.2%) developed Kaposi sarcoma (biopsy documented which constituted 60% of all post-transplantation malignancies. They were 11 males and 3 females with a mean age of 41 years. Sarcoma developed 8 to 31 months after transplantation with an average of 18 months. Of these patients, 13 had skin involvement that one of them had pulmonary involvement too. Another patient had only abdominal involvement. Azathioprine was discontinued all patients, and cyclosporine was reduced in skin affected patients. In patients with visceral involvement cyclosporine was discontinued and then chemotherapy was initiated. All 3 patients with visceral involvement didn't respond to chemotherapy and expired after 6 months. Of 11 patients with skin involvement, one had complete and 2 had incomplete remission of whom, one expired due to acute rejection. Renal function in 8 patients was acceptable, but 2 had impaired renal function, yet didn't need dialysis. Prevalence of Kaposi sarcoma in our patients is more than western countries. Visceral involvement is uncommon. But has poor prognosis. Reducing immunosuppression with discontinuation of azathioprine and significant reducing cyclosporine dosage can cease skin evolvement, with preserving renal function in most of the patients.