Kaposi's sarcoma medical therapy: Difference between revisions

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{{Kaposi's sarcoma}}
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==Overview==
==Overview==
Patients with Kaposi's sarcoma have many treatment options. The selection depends on the stage of the tumor. The options are local therapy, [[radiation therapy]], [[chemotherapy]], biologic drugs treatment, or a combination of these methods. Before treatment starts, ask your health care team about possible side effects and how treatment may change your normal activities. Because cancer treatments often damage healthy cells and tissues, side effects are common. [[Side effect]] may not be the same for each person, and they may change from one treatment session to the next.
The optimal therapy for Kaposi's sarcoma depends on multiple factors. Management strategies varies depending on the specific variant of Kaposi's sarcoma. Classic Kaposi's sarcoma management may range from no treatment to either [[radiotherapy]], local [[therapeutic]] interventions, or [[surgical]] [[excision]]. [[Iatrogenic]] Kaposi's sarcoma management focuses on modifying [[immunosuppressive therapy]] in addition to local [[therapeutic]] interventions. [[Endemic]] Kaposi's sarcoma is primarily managed by systemic [[chemotherapy]]. However, there is no curative treatment for [[epidemic]] Kaposi's sarcoma; the mainstay management for such patients is [[Highly active antiretroviral therapy|HAART therapy]] which aims for the control of Kaposi's sarcoma progression.


==Medical Therapy==
==Medical Therapy==
* The optimal [[therapy]] for Kaposi's sarcoma depends on multiple factors which include:<ref name="pmid22677687">{{cite journal| author=Fatahzadeh M| title=Kaposi sarcoma: review and medical management update. | journal=Oral Surg Oral Med Oral Pathol Oral Radiol | year= 2012 | volume= 113 | issue= 1 | pages= 2-16 | pmid=22677687 | doi=10.1016/j.tripleo.2011.05.011 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22677687  }} </ref><ref name="pmid24585567">{{cite journal| author=Masur H, Brooks JT, Benson CA, Holmes KK, Pau AK, Kaplan JE et al.| title=Prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: Updated Guidelines from the Centers for Disease Control and Prevention, National Institutes of Health, and HIV Medicine Association of the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2014 | volume= 58 | issue= 9 | pages= 1308-11 | pmid=24585567 | doi=10.1093/cid/ciu094 | pmc=PMC3982842 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24585567  }} </ref>
:* The [[anatomy|anatomical]] location of the [[tumor]]
:* The specific variant of Kaposi's sarcoma
:* The rate of distribution and progression of Kaposi's sarcoma [[lesions]]
:* The patients [[clinical]] presentation
:* The [[efficacy]] and potential [[side effect]]s of [[therapy]]
:* The presence or absence of [[HIV]] [[infection]]
:* The degree of [[immune]] suppression
:* The presence of other [[comorbidities]]
:* The preference and [[prognosis]] of the patients
* Management strategies varies depending on the specific variant of Kaposi's sarcoma such as:


Kaposi's sarcoma is not curable, in the usual sense of the word, but it can often be effectively palliated for many years and this is the aim of treatment. In KS associated with [[immunodeficiency]] or [[immunosuppression]], treating the cause of the immune system dysfunction can slow or stop the progression of KS. In 40% or more of patients with [[AIDS]]-associated Kaposi's sarcoma, the Kaposi lesions will shrink upon first starting highly active antiretroviral therapy ([[HAART]]). However, in a certain percentage of such patients, Kaposi's sarcoma may again grow after a number of years on HAART, especially if [[HIV]] is not completely suppressed. Patients with a few local lesions can often be treated with local measures such as radiation therapy or [[cryotherapy]]. Surgery is generally not recommended as Kaposi's sarcoma can appear in wound edges.
:*Classic Kaposi's sarcoma management may range from no treatment to either [[radiotherapy]], local [[therapeutic]] interventions, or [[surgery|surgical excision]].
:*[[Iatrogenic]] Kaposi's sarcoma management focuses on modifying the patients [[immunosuppressive therapy]] in addition to local [[therapeutic]] interventions.
:*[[Endemic]] Kaposi's sarcoma is primarily managed by systemic [[chemotherapy]]
:* There is no curative treatment for epidemic Kaposi's sarcoma; the mainstay management for such patients is [[Highly active antiretroviral therapy|HAART therapy]] which aims for the control of Kaposi's sarcoma progression.


===Therapies===
* '''Local/regional therapy recommended for the management of Kaposi's sarcoma patients may include:'''<ref name="pmid17762570">{{cite journal |vauthors=Dittmer DP, Krown SE |title=Targeted therapy for Kaposi's sarcoma and Kaposi's sarcoma-associated herpesvirus |journal=Curr Opin Oncol |volume=19 |issue=5 |pages=452–7 |date=September 2007 |pmid=17762570 |pmc=2855645 |doi=10.1097/CCO.0b013e3281eb8ea7 |url=}}</ref>
*Local therapy:
**Topical treatment: This is the treatment to put medicine directly on the lesions.
**[[Cryosurgery]]: During this procedure, the doctor use a probe cooled with liquid nitrogen to freeze the lesions.
**Intralesional chemotherapy: In this procedure, the chemotherapy drug is injected directly into the Kaposi's sarcoma lesions.


*Radiation therapy: This is a cancer treatment to kill cancer cells or keep them from growing by using high-energy x-rays or other types of radiation.
:* Intralesional vinca-alkaloids, [[bleomycin]], and [[interferon-alpha]]
:* Topical 0.1% [[alitretinoin]]
:* [[Imiquimod]] cream
:*[[Radiotherapy]]
:* [[Laser therapy]]


*Chemotherapy: More widespread disease, or disease affecting internal organs, is generally treated with systemic therapy with [[interferon]] alpha, [[liposomal]] [[anthracycline]]s (such as Doxil) or [[paclitaxel]].
* '''HAART therapy regimens recommended for the management of Kaposi's sarcoma patients may include:'''<ref name="pmid14752065">{{cite journal |vauthors=Krown SE |title=Highly active antiretroviral therapy in AIDS-associated Kaposi's sarcoma: implications for the design of therapeutic trials in patients with advanced, symptomatic Kaposi's sarcoma |journal=J. Clin. Oncol. |volume=22 |issue=3 |pages=399–402 |date=February 2004 |pmid=14752065 |doi=10.1200/JCO.2004.08.064 |url=}}</ref><ref name="pmid18453853">{{cite journal |vauthors=Nguyen HQ, Magaret AS, Kitahata MM, Van Rompaey SE, Wald A, Casper C |title=Persistent Kaposi sarcoma in the era of highly active antiretroviral therapy: characterizing the predictors of clinical response |journal=AIDS |volume=22 |issue=8 |pages=937–45 |date=May 2008 |pmid=18453853 |pmc=2730951 |doi=10.1097/QAD.0b013e3282ff6275 |url=}}</ref>


*Biologic therapy: This treatment uses chemicals such as interferon alpha to help the immune system attack cancer cells.
:*[[NNRTI|Non nucleoside reverse transcriptase]] ([[NNRTI|NNRT]])-based [[therapy]]
:* [[Protease inhibitor]] (PI)-based [[therapy]]


===Antimicrobial Regimen===
* '''Chemotherapy regimens recommended for the management of Kaposi's sarcoma patients may include:'''<ref name="pmid2435150">{{cite journal |vauthors=Gelmann EP, Longo D, Lane HC, Fauci AS, Masur H, Wesley M, Preble OT, Jacob J, Steis R |title=Combination chemotherapy of disseminated Kaposi's sarcoma in patients with the acquired immune deficiency syndrome |journal=Am. J. Med. |volume=82 |issue=3 |pages=456–62 |date=March 1987 |pmid=2435150 |doi= |url=}}</ref>


* '''Human herpesvirus 8 (KSHV)'''
:*[[Liposomal doxorubicin]]: [[Liposomal]] [[doxorubicin]] is the preferred first-line systemic [[therapy]]. An [[echocardiogram]] must be obtained prior to the start of [[therapy]] given the risk for [[anthracycline]]-induced [[cardiomyopathy]]. This [[medication]] can also cause [[mucositis]] and [[cytopenias]]. [[Liposomal]] [[doxorubicin]] is typically reserved for advanced [[cutaneous]], [[visceral]], or nodal Kaposi's sarcoma, rather than limited [[cutaneous]] Kaposi's sarcoma. This medication is given at a dose of 20mg/m2 IV every 3 weeks. If a patient develops relapse after treatment with [[liposomal]] [[doxorubicin]] and the initial response lasted for 3 months or greater, a repeat trial of [[liposomal]] [[doxorubicin]] can be done. If the initial response lasted less than 6 months, another agent such as [[Paclitaxel]] should be given.
:* 1. '''Mild to moderate Kaposi sarcoma'''<ref>{{ cite web | title = Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents | url = https://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultOITablesOnly.pdf }}</ref>
:* [[Paclitaxel]]: [[Paclitaxel]] is the preferred second-line [[systemic therapy]]. [[Paclitaxel]] is typically reserved for advanced [[cutaneous]], [[visceral]], or nodal Kaposi's sarcoma, rather than limited [[cutaneous]] Kaposi's sarcoma. This [[medication]] is given at a dose of 100mg/m2 IV every 2 weeks and required [[premedication]] with [[dexamethasone]] 10mg give the risk for [[hypersensitivity reaction]] with [[paclitaxel]] [[infusion]]. One major [[adverse effect]] of [[paclitaxel]] is [[peripheral neuropathy]].
::* Preferred regimen: initiate or optimize ART
:* [[Etoposide]]: [[Etoposide]] is used in the relapsed/[[refractory]] setting. This is a [[Topoisomerase inhibitor|topoisomerase I inhibitor]] and is used at a dose of 50mg daily for 7 days of each 21-day cycle.
:* [[Pomalidomide]]: [[Pomalidomide]] is an [[immunomodulatory]] agent that is used in the relapsed/[[refractory]] setting. [[Pomalidomide]] is the preferred therapy in the relapsed/[[refractory]] setting compared to the other agents. The dose is 5mg daily for 21 days of a 28-day cycle. [[Adverse effects]] include increased risk for [[thrombosis]], [[cytopenias]], and [[secondary]] [[malignancies]]. [[Thalidomide]] can also be used though the dose is 200mg daily and the [[adverse effect]] profile is worse.


:* 2. '''Advanced Kaposi sarcoma (ACTG Stage T1, including disseminated cutaneous or visceral Kaposi sarcoma)'''
* '''Immune modulators recommended for the management of Kaposi's sarcoma patients may include:'''<ref name="pmid16760382">{{cite journal |vauthors=Rezaee SA, Cunningham C, Davison AJ, Blackbourn DJ |title=Kaposi's sarcoma-associated herpesvirus immune modulation: an overview |journal=J. Gen. Virol. |volume=87 |issue=Pt 7 |pages=1781–804 |date=July 2006 |pmid=16760382 |doi=10.1099/vir.0.81919-0 |url=}}</ref>
::* Preferred regimen: chemotherapy (per oncology consult) {{and}} ART
:* [[Interferon-alpha]]


:* 3. '''Primary effusion lymphoma'''
* '''Targeted therapies recommended for the management of Kaposi's sarcoma patients may include:'''<ref name="pmid19489649">{{cite journal |vauthors=Sullivan RJ, Pantanowitz L, Dezube BJ |title=Targeted therapy for Kaposi sarcoma |journal=BioDrugs |volume=23 |issue=2 |pages=69–75 |date=2009 |pmid=19489649 |pmc=2707492 |doi= |url=}}</ref>
::* Preferred regimen: chemotherapy (per oncology consult) {{and}} ART
::* Note: [[Valganciclovir]] PO or [[Ganciclovir]] IV can be used as adjunctive therapy.


:* 4. '''Multicentric Castleman's disease'''
:* Anti-[[herpes]] [[therapy]]
::* Preferred regimen (1): [[Valganciclovir]] 900 mg PO bid for 3 weeks
:*[[VEGF]] inhibitors ([[bevacizumab]])
::* Preferred regimen (2): [[Ganciclovir]] 5 mg/kg IV q12h for 3 weeks
:*[[Tyrosine kinase inhibitors]] ([[imatinib]])
::* Preferred regimen (3): [[Valganciclovir]] 900 mg PO BID {{and}} [[Zidovudine]] 600 mg PO q6h for 7–21 days
:*[[Matrix metalloproteinases]]
::* Alternative regimen: [[Rituximab]] 375 mg/m2 given weekly for 4–8 weeks (may be an alternative to or used adjunctively with antiviral therapy)


==References==
==References==
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Latest revision as of 18:05, 9 October 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Shyam Patel [2] Associate Editor(s)-in-Chief: Haytham Allaham, M.D. [3]

Overview

The optimal therapy for Kaposi's sarcoma depends on multiple factors. Management strategies varies depending on the specific variant of Kaposi's sarcoma. Classic Kaposi's sarcoma management may range from no treatment to either radiotherapy, local therapeutic interventions, or surgical excision. Iatrogenic Kaposi's sarcoma management focuses on modifying immunosuppressive therapy in addition to local therapeutic interventions. Endemic Kaposi's sarcoma is primarily managed by systemic chemotherapy. However, there is no curative treatment for epidemic Kaposi's sarcoma; the mainstay management for such patients is HAART therapy which aims for the control of Kaposi's sarcoma progression.

Medical Therapy

  • The optimal therapy for Kaposi's sarcoma depends on multiple factors which include:[1][2]
  • Management strategies varies depending on the specific variant of Kaposi's sarcoma such as:
  • Local/regional therapy recommended for the management of Kaposi's sarcoma patients may include:[3]
  • HAART therapy regimens recommended for the management of Kaposi's sarcoma patients may include:[4][5]
  • Chemotherapy regimens recommended for the management of Kaposi's sarcoma patients may include:[6]
  • Immune modulators recommended for the management of Kaposi's sarcoma patients may include:[7]
  • Targeted therapies recommended for the management of Kaposi's sarcoma patients may include:[8]

References

  1. ↑ Fatahzadeh M (2012). "Kaposi sarcoma: review and medical management update". Oral Surg Oral Med Oral Pathol Oral Radiol. 113 (1): 2–16. doi:10.1016/j.tripleo.2011.05.011. PMID 22677687.
  2. ↑ Masur H, Brooks JT, Benson CA, Holmes KK, Pau AK, Kaplan JE; et al. (2014). "Prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: Updated Guidelines from the Centers for Disease Control and Prevention, National Institutes of Health, and HIV Medicine Association of the Infectious Diseases Society of America". Clin Infect Dis. 58 (9): 1308–11. doi:10.1093/cid/ciu094. PMC 3982842. PMID 24585567.
  3. ↑ Dittmer DP, Krown SE (September 2007). "Targeted therapy for Kaposi's sarcoma and Kaposi's sarcoma-associated herpesvirus". Curr Opin Oncol. 19 (5): 452–7. doi:10.1097/CCO.0b013e3281eb8ea7. PMC 2855645. PMID 17762570.
  4. ↑ Krown SE (February 2004). "Highly active antiretroviral therapy in AIDS-associated Kaposi's sarcoma: implications for the design of therapeutic trials in patients with advanced, symptomatic Kaposi's sarcoma". J. Clin. Oncol. 22 (3): 399–402. doi:10.1200/JCO.2004.08.064. PMID 14752065.
  5. ↑ Nguyen HQ, Magaret AS, Kitahata MM, Van Rompaey SE, Wald A, Casper C (May 2008). "Persistent Kaposi sarcoma in the era of highly active antiretroviral therapy: characterizing the predictors of clinical response". AIDS. 22 (8): 937–45. doi:10.1097/QAD.0b013e3282ff6275. PMC 2730951. PMID 18453853.
  6. ↑ Gelmann EP, Longo D, Lane HC, Fauci AS, Masur H, Wesley M, Preble OT, Jacob J, Steis R (March 1987). "Combination chemotherapy of disseminated Kaposi's sarcoma in patients with the acquired immune deficiency syndrome". Am. J. Med. 82 (3): 456–62. PMID 2435150.
  7. ↑ Rezaee SA, Cunningham C, Davison AJ, Blackbourn DJ (July 2006). "Kaposi's sarcoma-associated herpesvirus immune modulation: an overview". J. Gen. Virol. 87 (Pt 7): 1781–804. doi:10.1099/vir.0.81919-0. PMID 16760382.
  8. ↑ Sullivan RJ, Pantanowitz L, Dezube BJ (2009). "Targeted therapy for Kaposi sarcoma". BioDrugs. 23 (2): 69–75. PMC 2707492. PMID 19489649.

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