Kaposi Sarcoma
Definition:
Kaposi sarcoma (KS) is a vascular neoplasm first described in 1872 by Moritz Kaposi as “idiopathic multiple pigmented sarcoma of the skin.” Historically, it was seen primarily in elderly men of Mediterranean, Eastern European, or Ashkenazi descent. Although sporadically observed in organ transplant recipients and in African populations, KS gained major attention during the AIDS epidemic as a defining illness. All clinical forms of KS are associated with human herpesvirus 8 (HHV-8), also known as Kaposi sarcoma-associated herpesvirus (KSHV).
Epidemiology:
KS manifests in four clinical variants:
- Classic KS: Primarily affects elderly men of Mediterranean or Eastern European descent; typically slow-growing and indolent.
- African endemic KS: Common among children and adults in Sub-Saharan Africa; includes aggressive lymphadenopathic forms.
- Iatrogenic KS: Occurs in immunosuppressed individuals, especially post-organ transplantation or with chronic immunosuppressive therapies (e.g., corticosteroids, calcineurin inhibitors). Lesions may regress upon reduction of immunosuppression.
- AIDS-related (epidemic) KS: Predominantly affects individuals with HIV/AIDS. It was particularly prevalent in the 1980s but has declined with the advent of highly active antiretroviral therapy (HAART).
Etiology:
KS originates from endothelial cells of blood vessels and lymphatics, though the exact lineage remains mixed. HHV-8 infection plays a central role by altering endothelial cells, promoting lymphangiogenic and mesenchymal features through endothelial to mesenchymal transition. The virus encodes homologs of cellular genes that stimulate proliferation, inhibit apoptosis, and promote angiogenesis. Immunosuppression, cytokine release, and chronic inflammation further contribute to tumor development. Transmission of HHV-8 occurs primarily through saliva but can also involve sexual and possibly arthropod vectors. The virus may remain latent and reactivate under conditions of immune dysfunction.
Clinical Features:
- Classic KS: Presents as slowly enlarging, pink to red-violet macules on the lower extremities that may evolve into plaques or nodules. Lesions can be unilateral initially but often become multifocal over time.
- AIDS-related KS: Characterized by widespread, violaceous plaques and nodules affecting the skin, mucous membranes, gastrointestinal tract, and lymph nodes. Lesions can worsen during immune reconstitution inflammatory syndrome (IRIS).
- Iatrogenic KS: Typically resolves with reduction of immunosuppressive therapy.
- African endemic KS: Manifests in nodular, florid, infiltrative, or lymphadenopathic forms, with the lymphadenopathic type primarily affecting children. Lymphedema and visceral involvement (oral cavity, gastrointestinal tract, lungs) are common in advanced disease.
Diagnosis:
Diagnosis is clinical but confirmed by histopathology showing spindle-shaped endothelial cells, slit-like vascular spaces, and HHV-8 positivity by immunohistochemistry or PCR.
Management:
Management depends on the clinical variant and disease extent:
- HIV-associated KS: Initiation of HAART is critical and often leads to lesion regression.
- Localized disease: Options include cryotherapy, radiotherapy, or intralesional chemotherapy.
- Extensive disease: Systemic chemotherapy (liposomal doxorubicin, paclitaxel) is indicated.
- Iatrogenic KS: Reduction or modification of immunosuppressive therapy may lead to lesion regression.
Written by:
Raneem Alahmadi, Medical Intern.
Revised by:
Naif Alshehri, Medical Intern
Resources:
Bolognia 5th edition
Dermnet