Kaposi's sarcoma medical therapy

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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:

• The 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 effects 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:

• 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 the patients immunosuppressive therapy in addition to local therapeutic interventions.
• Endemic Kaposi's sarcoma is primarily manage by systemic chemotherapy
• 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.

• Local/regional therapy recommended for the management of Kaposi's sarcoma patients may include:

• Intralesional vinca-alkaloids, bleomycin, and interferon-alpha
• Topical 0.1% alitretinoin
• Imiquimod cream
• Radiotherapy
• Laser therapy

• HAART therapy regimens recommended for the management of Kaposi's sarcoma patients may include:

• Non nucleoside reverse transcriptase (NNRT)-based therapy
• Protease inhibitor (PI)-based therapy

• Chemotherapy regimens recommended for the management of Kaposi's sarcoma patients may include:

• Liposomal doxorubicin: Liposomal doxorubicin is the preferred first-line systemic therapy. An echocardiograph 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.
• 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.
• Etoposide: Etoposide is used in the relapsed/refractory setting. This is a 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.

• Immune modulators recommended for the management of Kaposi's sarcoma patients may include:

• Interferon-alpha

• Targeted therapies recommended for the management of Kaposi's sarcoma patients may include:

• Antiherpes therapy
• VEGF inhibitors (bevacizumab)
• Tyrosine kinase inhibitors (imatinib)
• Matrix metalloproteinases