Kaposi’s Sarcoma after Repeated Surgical Procedures in an Immunocompetent Patient: The Lymphatic Hypothesis

Abstract

A 63-year-old Swiss patient developed acquired nodules on his right palm after 3 localized surgeries, called ‘needle fasciotomy’, for Dupuytren’s disease. Kaposi’s sarcoma (KS) was diagnosed in a biopsy of a nodule. A positive immunolabeling and serology for human herpesvirus 8 has been found, but human immunodeficiency virus and hepatitis C identification remained negative. The nodules were limited to the surgically traumatized area. This first report of a nonimmunocompromised patient developing a KS after repeated surgeries in a unique peculiar localized area with a dense lymphatic network sustains the hypothesis that tissue alterations involving the lymphatic system could play a central role in the occurrence of KS.

Kaposi’s Sarcoma Restricted to an Immunocompromised District

“…In summary, the case reported by Kostaki et al [1] features a typical example of an immunocompromised district due to repeated surgical procedures that impaired both lymph circulation and immune control in the traumatized area. Bearing in mind that an immunocompromised district may harbor opportunistic and immunity-related disorders -such as infections, tumors and immune reactions [2] -the onset of KS lesions is not at all surprising here, since KS has an infectious etiology (HHV-8), a tumor morphology (angiogenic neoplasm), and an immune pathogenesis (immunosuppression often confined to acral body regions [3][4][5][6][7][8][9][10] ).…”

“…We read with interest, albeit a lack of surprise, the case of Kaposi's sarcoma (KS) that appeared on a surgically traumatized area in an immunocompetent patient reported by Kostaki et al [1] . In particular, the authors described the onset of KS nodules solely on the right palm of a 63-year-old man who had undergone repeated and minimally invasive surgical procedures (needle fasciotomy) for Dupuytren's disease.…”

“…However, our lack of surprise originates in the common knowledge that, even in the absence of systemic immunodeficiency, numerous and varied immunity-related disorders (infections, tumors, immune reactions) can appear on and remain limited to body regions that have been immunologically destabilized by chronic lymph stasis, herpetic infections, ionizing radiation, burn, or trauma (even the minimal trauma occurring with vaccinations) [2] . In their report, Kostaki et al [1] , by noticing that KS developed after repeated surgeries in a unique peculiar localized area with a dense lymphatic network, put forward the hypothesis that tissue injuries involving the lymphatic routes could play a central role in the occurrence of KS [1] . A large body of evidence that has been accumulated over the last three decades [3][4][5][6][7][8][9][10] strongly supports this concept, which is much more than a hypothesis.…”

Kaposi’s sarcoma: Etiology and pathogenesis, inducing factors, causal associations, and treatments: Facts and controversies

“…64,65 Also a localized trauma may be responsible for facilitating the onset of KS lesions selectively on the traumatized area. 66,67 Environmental cofactors and risk for KS In cancer pathogenesis, the possibility exists that following an initial stable, genetic damage (initiation event), a transient post-initiation insult (promotion event), nonsufficient by itself to induce a cancer, could contribute to increase cancer incidence. 68 Viruses, like chemicals, can act both as initiators as well as promoters, depending on their prevalent effects either mutagenic (eg, herpesviruses) or epigenetic (eg, papillomaviruses).…”