A comparative study of classic and HIV-viremic and aviremic AIDS Kaposi sarcoma

Abstract

Background: Kaposi sarcoma in people living with HIV (PLHIV) is the most common AIDS-associated malignancy. There is increased interest in Kaposi sarcoma in PLHIV with controlled HIV viremia. Objectives: To describe Kaposi sarcoma occurring in PLHIV despite virological control and to compare their clinical presentations with viremic AIDS-Kaposi sarcoma (AIDS-KS) and classic Kaposi sarcoma (CKS). Methods: This was a monocentric retrospective study, including all Kaposi sarcoma patients registered between the 1 January of 2000 and 31 December 2017 in a comprehensive data bank for all cancers in the Hérault region, South of France. AIDS-KS were also described using chart reviews from the Infectious diseases Department, which followed more than 90% of PLHIV from the same region. We defined aviremic AIDS-KS as Kaposi sarcoma occurring in persons taking HAART with a HIV viral load less than 50 copies for more than 12 months. We compared clinical characteristics of persons with aviremic AIDS-KS, viremic AIDS-KS and CKS, using the Kriegel score and number and topography of skin lesions, and presence of lymphedema. Results: We retrieved 187 Kaposi sarcoma cases, of which 12 occurred in PLHIV with aviremic AIDS-KS. Kriegel score stage I was found in 10 (83%) of the aviremic AIDS-KS, 34 (68%) of CKS and 38 (58.4%) of viremic AIDS-KS cases, with similar clinical presentations between aviremic AIDS-KS and CKS groups, and viremic AIDS-KS persons having more aggressive presentations. One person with aviremic AIDS-KS had visceral involvement. Conclusion: We showed that Kaposi sarcoma in PLHIV with controlled viremia were generally indolent, similarly to CKS. Visceral involvement is, however, possible.

Epidemiology of Kaposi’s Sarcoma

“…The risk is still over 50-fold higher for PLHIV with long-term viral suppression (i.e., >2 years) than for the uninfected population [44]. Moreover, some studies have reported KS occurring in aviremic patients [45][46][47].…”

“…Classic KS are usually indolent and progress slowly while AIDS KS are more aggressive [47]. In a recent retrospective monocentric study of endemic and classic KS (29 and 131, respectively) in France, endemic KS was associated with higher risk of systemic treatment, chemotherapeutic agent or immune-modulating therapies, and initiation than classic KS [82].…”

Kaposi’s Sarcoma in Virally Suppressed People Living with HIV: An Emerging Condition

“…These cases, referred to an expert national panel for cancer treatment advise for PLHIV, probably represented the more severe cases of KS in aviremic HIV-patients in France at that time. A monocentric study from France described all consecutive diagnosed cases of KS in aviremic (12 cases) and viremic (97 cases) HIV-patients diagnosed in a tertiary referral hospital between 2000 and 2017, comparing their clinical presentations with classic KS (also named "Mediterranean KS", in HIV-negative individuals) consecutively diagnosed in the same area and extracted from the Francim cancer databank [8]. Locally skin indolent presentation was the main clinical presentation in 10 of the KS in aviremic patients, although one patient had visceral involvement and one a disseminated mucocutaneous form.…”

“…As KS in aviremic patients may be more commonly indolent [5,8], the use of alternative classifications from non-HIV populations is appealing. A proposed staging system derived from 300 CKS patients based on disease progression was developed [18]: stage I defined by small macules and nodules primarily confined to the lower extremities, stage II by infiltrative plaques mainly involving the lower extremities, sometimes associated with a few nodules, stage III with florid multiple angiomatous plaques and nodules involving the lower extremities that are often ulcerated, and a stage IV with disseminated disease.…”

“…There are very few published case series of virologically controlled patients presenting with KS (Table 1) [5][6][7][8]. There is also no standardized definition of cases in terms of HIV-RNA duration of suppression and HIV-RNA and CD4 thresholds, hindering comparability between studies.…”