Treatment of AIDS-related Kaposi's Sarcoma With Low-dose Radiotherapy - Follow-up on 2,305 Tumours.

BACKGROUND/AIM: We aimed to report our experience obtained by treating AIDS-related Kaposi's sarcoma (KS) with radiotherapy before the era of antiretroviral therapy. PATIENTS AND METHODS: This investigation was performed as a quality control of KS patients treated with low-dose radiotherapy at our department. KS patients referred to our section from 1983 up until 1990, were treated three times with radiotherapy (29-50 kV, 2-4 Gy), once every second week. RESULTS: Initially, 74 skin KSs were treated three times with 2 Gy, of which 70% were treated successfully. Hereafter, other 2,066 KSs on the skin were treated three times with 4 Gy with a very high success rate of 93%. Additional 165 mucous KSs were treated three times with 4 Gy, of which 91% were treated successfully. CONCLUSION: Low-dose radiotherapy is effective for the treatment of many AIDS-related KS patients.

Clinical and pathological features and treatment of AIDS-related cutaneous Kaposi's sarcoma in Chinese Han patients.

This retrospective study aimed to observe the clinicopathological features and immunological phenotypes, and explore effective treatment and prognosis for 12 Chinese Han patients with acquired immunodeficiency syndrome-related cutaneous Kaposi's sarcoma. All 12 patients were human immunodeficiency virus-positive, and underwent the standard highly active antiretroviral therapy (HAART). Skin lesions mainly presented as purple, or rufous papules, or plaques; skin biopsy showed diffuse or flaky infiltration of spindle cells, active proliferation of slit-like vasculature, erythrocyte exudation, hemosiderin deposition, and inflammatory cell infiltration. Immunohistochemical analysis showed the expression of Ubiquitin C-terminal hydrolase L1 (+), and CD31 (+) in T-cells; factor VIII (+) and HHF-35 (+) in the proliferating vascular endothelial cells; vimentin (+) and S-100 protein (-) in the vessel wall; and CD34 (+++) in the spindle cells of 6 cases, with 1 case of negative CD34 expression. Four patients with confined lesions underwent surgery and microwave therapy, and received a favorable prognosis. Two patients with limited lesions underwent microwave therapy, and the lesions subsided. Of six patients with widely distributed sarcomas, five underwent microwave therapy and one received combined chemotherapy; five attained significant efficacy, and one died. There were no significant differences in the clinicopathological features and immunological phenotypes between the Chinese Han patients and those from other populations. Along with basal HAART, patients in early stages, with sarcomas <2 cm in diameter should undergo surgery and microwave therapy, while patients with sarcomas >2 cm in diameter should undergo chemotherapy and microwave therapy.

Antimicrobial photodynamic therapy in the treatment of oral candidiasis in HIV-infected patients.

OBJECTIVE: Antimicrobial photodynamic therapy (aPDT) has been used to combat local infections, and it consists of the combination of a photosensitizer, a light source, and reactive oxygen species (ROS) to kill microbial cells. In this study, we evaluated the effectiveness of aPDT in the treatment of candidiasis in HIV-infected patients. METHODS: Twenty-one patients were divided into three groups. Control group (CG) was treated with the conventional medication for candidiasis (fluconazole 100 mg/day during 14 days). Laser group (LG) was subjected to low-level laser therapy (LLLT), wavelength 660 nm, power of 30 mW, and fluence of 7.5 J/cm(2), in contact with mucosa during 10 sec on the affected point. An aPDT group (aPDTG) was treated with aPDT, that is, combination of a low-power laser and methylene blue 450 µg/mL. Pre-irradiation time was 1 min. Parameters of irradiation were the same ones as for the LG, and patients were single irradiated. Patients were clinically evaluated and culture analysis was performed before, immediately after, and 7, 15, and 30 days after the treatment. RESULTS: Our results showed that fluconazole was effective; however, it did not prevent the return of the candidiasis in short-term. LLLT per se did not show any reduction on Candida spp. aPDT eradicated 100% of the colonies of this fungus and the patients did not show recurrence of candidiasis up to 30 days after the irradiation. CONCLUSIONS: These findings suggest that aPDT is a potential approach to oral candidiasis treatment in HIV-infected patients.

Hypofractionated radiation therapy in the treatment of epidemic Kaposi sarcoma--a prospective randomized trial.

PURPOSE: To compare a conventional fractionation regimen with a hypofractionated regimen in the treatment of Epidemic Kaposi sarcoma with radiation therapy. MATERIALS AND METHODS: Sixty patients were randomized to receive a standard regimen of 24 Gy in 12 fractions (ARM A) or the study regimen of 20 Gy in five fractions (ARM B). Radiation technique was individualized. Treatment response, local control and toxicity were recorded. RESULTS: Thirty five sites were treated in ARM A and 30 sites in ARM B. Treatment arms were similar for gender, ECOG performance score, treated site, antiretroviral therapy usage, T stage, I stage and S stage. The overall survival using the Kaplan Meier method was 37% at 1 year. Complete responses were recorded at 28 sites (13 Arm A,15 Arm B), partial responses at 19 sites (8 Arm A,11 Arm B) and stable disease at three sites (2 Arm A,1 Arm B). The mean time to maximum objective response was 3 months (range: 1-14 months). Response rates and local control were equal in the two arms (p=0.73 and 0.77, respectively, log rank test). Acute skin toxicity (p=0.77) and late skin toxicity (p=0.24) were equal in the two arms. CONCLUSION: The two treatment regimens produced equivalent results for treatment response, local recurrence-free survival and toxicity.

Radiotherapy of classic and human immunodeficiency virus-related Kaposi's sarcoma: results in 1482 lesions.

BACKGROUND: The lesions of the various forms of Kaposi's sarcoma (KS), which are relatively radiosensitive, have been treated with different modalities of radiotherapy, with heterogeneous aims and results. OBJECTIVE: To verify the effectiveness and safety of radiotherapy on a large number of lesions endowed (classic KS) with a prolonged follow-up. METHODS: A retrospective study was done on 711 lesions of classic KS and 771 lesions of human immunodeficiency virus (HIV)-related KS, treated with traditional X-ray therapy. RESULTS: In classic KS, a cure rate of 98.7% resulted after 13.5 years from the end of radiotherapy. In three lesions (0.42%) in the same patient, an acute radiodermatitis occurred after traumatic action. In HIV-related KS, a complete remission was obtained in 91.43% of the lesions, partial remission in 6.74% and non-response in 0.51% at 1 to 46 months from the end of radiotherapy. CONCLUSION: Radiotherapy showed to be a safe and effective method, with relevant importance in the therapeutic strategy of KS.

Treatment of Kaposi's sarcoma--an update.

Kaposi's sarcoma (KS) is an angioproliferative disease of multifactorial origin arising in different clinic-epidemiologic forms, which show the same histopathological features. It generally starts as a hyperplastic reactive-inflammatory and angiogenic process, which may evolve into monomorphic nodules of KS cells that can be clonal (late-stage lesions) and resemble a true sarcoma. Infection with the human herpesvirus 8, cytokine- and angiogenic factor-induced growth together with an immuno-dysregulated state represent fundamental conditions for the development of this tumor. Several local therapies are used to eradicate early and confined skin lesions, whereas widely disseminated, progressive or symptomatic disease requires a more aggressive treatment. Although different chemotherapeutic agents have been used to treat aggressive KS, the growing understanding of the pathogenetic factors participating in KS development has provided a strong rationale for using less- or non-cytotoxic agents that block the mechanisms involved in KS pathogenesis. The angiogenic nature of KS makes it particularly suitable for using therapies based on anti-angiogenic agents. Of note on this goal, recent studies indicate that the highly active anti-retroviral therapy, including at least one human immunodeficiency virus (HIV) protease inhibitor (PI), is associated with a dramatic decrease in the incidence of AIDS-KS and with a regression of KS in treated individuals. Consistent with this, results from preclinical studies indicate that PIs have potent and direct anti-angiogenic and anti-KS activities, suggesting that they should be further investigated, alone or combined with other therapies, as a novel treatment for KS in both HIV seropositive or seronegative individuals.

Laser palliation of oral manifestations of human immunodeficiency virus infection.

BACKGROUND: The author describes the use of lasers to palliate the oral manifestations of the human immunodeficiency virus, or HIV, infection. He discusses the advantages to both patients and dentists, but he does not address the use of lasers as a modality to treat or cure HIV infection. CASE DESCRIPTION: Many oral manifestations of HIV infection can be used as markers for degree of immunosuppression. These manifestations may be treated with antibiotics, analgesics and antineoplastics, which may interact and interfere with antiviral agents used to treat the disease and possibly may exacerbate it. The author describes laser palliation of the oral manifestations of three HIV-positive patients. CLINICAL IMPLICATIONS: Dentists will see more patients living longer with HIV as the disease becomes more treatable. Lasers have been shown to be effective instruments in palliation of oral manifestations of HIV infection.

Electron-beam therapy for AIDS-related molluscum contagiosum lesions: preliminary experience.

PURPOSE: To determine the effects of electron-beam therapy on cutaneous molluscum contagiosum lesions in patients with acquired immunodeficiency syndrome (AIDS), because current treatment modalities are limited in their effectiveness and by long-term rates of lesion recurrence. MATERIALS AND METHODS: Five patients with AIDS, with 23 molluscum contagiosum lesion sites, received electron-beam radiation treatment of recurrent molluscum contagiosum lesions. RESULTS: All 23 lesions treated resolved completely and have not recurred during up to 24 months of follow-up. Radiation therapy was well tolerated; mild skin erythema was the only reported side effect. CONCLUSION: The use of electron-beam radiation is a promising alternative to current treatment modalities.

Intracavitary contact X-ray therapy of oral HIV-associated Kaposi's sarcoma.

A retrospective study was performed to assess the efficacy and low mucosal toxicity of intracavitary contact X-ray therapy (ICRT), a proposed treatment of small/medium sized lesions of oral HIV-associated Kaposi's sarcoma (HIV-KS). Twenty-six patients with histologically confirmed oral HIV-KS underwent ICRT in the period 1986-1995. No patient received antiblastic or interferon therapy during the radiotherapy or follow-up periods. ICRT was performed according to the usual technical modalities of contact X-ray therapy, but the end of the source of ionizing radiations was introduced into the oral cavity. The total doses administered ranged from 10 to 50 Gy per field, in one or two weekly fractions of 5 Gy each. The follow-up ranged from 1 to 44 months (mean 7.5 months). Complete remission was obtained in 20 cases (76.92%), partial remission in 6 (23.08%) and relapse in one case (3.84%). Pain was relieved in all cases. Mucosal reaction was mild and did not result in any interruption of treatment. Our data suggest that ICRT is an effective and well tolerated treatment. It can be used in the management of oral HIV-KS instead of external radiotherapy, provided that the size and the location of the lesions and the conformation of the palate are suitable to this technique.

Radiation therapy in AIDS-related cutaneous Kaposi's sarcoma.

BACKGROUND: Treatment of cutaneous Kaposi's sarcoma associated with AIDS depends on localization, extension, associated symptoms and the patient's general condition. The most frequent sites of involvement are the face and neck. The aim of this retrospective study was to evaluate the response rate as well as the cosmetic results comparing two different schedules of palliative radiation treatment. METHODS: 251 Skin lesions in 22 patients were treated with irradiation using 100 kV X-ray energy. Applied doses varied between 8 Gy/1 fraction and 30 Gy/10 fractions. The mean age of patients was 38 years (28-59 years). According to Mitsuyasu's staging, 2 patients had stage I, 8 stage II and 12 patients stage IV. The lesions were localized on the face (n = 190), lower extremities (n = 28), upper extremities (n = 24) and the thorax (n = 9). The total given dose was 30 Gy in 68 lesions (27%), 21 Gy in 11 lesions (4.4%), 20 Gy in 2 lesions (0.8%) and 8 Gy in 170 lesions (67.8%). RESULTS: Complete response with or without residual pigmentation was achieved in 95.2% of lesions, while 4.4% had a partial response and 0.4% no response. Pain was completely relieved in all patients. CONCLUSIONS: Radiotherapy can be recommended as palliative treatment to relieve physical discomfort (pain) and to improve the cosmetic results in patients with AIDS-related Kaposi's sarcoma. Doses ranging from 8 Gy/1 fraction to 30 Gy/10 fractions, tailored to the individual patient's need, permit to achieve an excellent local control with minimal toxicity.

Radiation recall skin toxicity with bleomycin in a patient with Kaposi sarcoma related to acquired immune deficiency syndrome.

BACKGROUND: Radiation recall is a recurrence of acute toxicity within a previously quiescent radiation field that occurs with subsequent administration of chemotherapy. METHODS: A patient with acquired immune deficiency syndrome (AIDS)-related Kaposi sarcoma (KS) who had radiation recall is reported. The patient was participating in a randomized prospective trial of radiation treatment regimens for KS. Each lesion was randomized to one of three possible radiation fractionation schemes. All lesions were photographed and measured before treatment with radiation. RESULTS: Two skin sites developed erythema and dry desquamation 18 days after completion of radiation therapy to a dose of 40 Gy in 20 fractions. These reactions took place after the second dose of bleomycin administered intravenously on a weekly basis. The reactions were exacerbated by oral etoposide therapy, which was started 4 days after the recall phenomenon was noted. Other cutaneous sites treated with 8 Gy in a single fraction and 20 Gy in ten fractions during the same time period showed no sign of recall skin toxicity. CONCLUSIONS: The authors believe this to be the first report of radiation recall toxicity after bleomycin therapy and of a radiation dose response related to this phenomenon. The potential for radiation recall toxicity should be considered in treatment decisions pertaining to patients with AIDS-associated KS.

Biology and therapy of epidemic Kaposi's sarcoma.

Kaposi's sarcoma, once a rarely seen neoplasm in the West, now occurs in an epidemic fashion in association with acquired immune deficiency syndrome (AIDS). The pathogenesis of Kaposi's sarcoma is still unclear but it appears to be an endothelial neoplasm. Its clinical presentation may be quite subtle and varied. The natural history of Kaposi's sarcoma is still not fully defined, and its rate of progression may be either relatively indolent or aggressive. Therapies include local radiation, recombinant interferon alfa-2a, and cytotoxic chemotherapy. For a subset of patients with Kaposi's sarcoma who were treated with recombinant interferon alfa-2a, the disease is in complete remission, without opportunistic infection, and they appear to be culture-negative for the etiologic retrovirus that causes their immune deficiency. Interferon alfa-2a appears to have antineoplastic efficacy, (and may have antiretroviral efficacy as well) in this epidemic neoplasm.