KS in the HAART era includes patients with high CD4 and suppressed viral load: importance of KS chemotherapy for some patients in addition to ART

1 June 2012. Related: Conference reports, Coinfections and complications, BHIVA 18th Birmingham 2012.

Simon Collins, HIV i-Base

An overview of Kaposi’s Sarcoma (KS) in the HAART era was given by Mark Bower from the Chelsea and Westminster Hospital who focused on the continued use for KS chemotherapy and included recent cases of KS in patients with high CD4 counts (>350 cells/mm3) and who have undetectable viral load.

While the incidence of KS has dramtically reduced since 1997 and 80% of patients diagnosed with early stage KS (T0) and with good immunity (CD4>150) commonly don’t need additional treatment to ART [2] more advanced staging (T1 – any tumour-associated oedema or ulceration, extensive oral KS or non-nodal visceral KS) and reduced immune function (CD4 <150) should be treatment with liposomal anthracycline in addition to ART (or paclitaxel for refractory KS).

The Chelsea and Westminster Hospital cohort from 1996 to 2012 now includes 521 first cases of KS. Most are men (94%) with 17% (86/521) in black Africans. Median age and CD4 counts at presentation are 38 years (range 16-71) and 168 cells/mm3 (range 0-1200) with 66% (n=342) at stage T0 and 34% (n=177). Survival rates in the T0 and T1 groups at 14 years (Kaplan-Meier) are approximately 80% and 65%, respectively. These differences were driven mainly by an early impact <3 years of visceral involvement and presence of oedema/ulceration (later impact > 6 years), rather than oral involvement.

Of note, 15% of new diagnoses (80/521) were in people on established ART (> 3 months), 6% (n=32) had an undetectable viral load and 4% (n=20) had both undetectable viral load and a CD4 count >350 cells/mm3.

The Chelsea and Westminster group has also reported KS as an IRIS-related complication (defined as rapid KS progression during the 2-4 month window after starting ART) in 7% of patients (10/150) who started ART with a KS diagnosis, but higher rates have been reported (20%) in cohorts that only use ART and not concomitant KS treatment. Recurrent KS has also been reported in virologically suppressed patients with similarly good immune responses.

As well as efficacy in addition to ART reported in a recent randomised clinical study (though not greater survival in an African setting) [4], the importance of KS chemotherapy is also supported by mimimal toxicity or prolonged negative impact on CD4 responses. This is now primarily for any patient with stage T1 disease and for the management of KS related to IRIS or in suppressed patients.

References:

1. Bower M. Kaposi’s Sarcoma in the era of HAART. BHIVA invited lecture. 18th BHIVA Conference, 18-20 April 2012, Birmingham. View webcast. Download slides.
2. Bower M et al. The effect of HAART in 254 consecutive patients with AIDS-related Kaposi’s sarcoma. AIDS 24 August 2009, 23:1701-6.
   http://journals.lww.com/aidsonline/Fulltext/2009/08240/
   The_effect_of_HAART_in_254_consecutive_patients.9.aspx
3. Bower M et al. Immune Reconstitution Inflammatory Syndrome associated with Kaposi’s Sarcoma. J Clin Oncol 23:5224-5228 (2005).
   http://jco.ascopubs.org/content/23/22/5224.full.pdf (PDF)
4. Mosam A et al. A randomized controlled trial of HAART versus HAART and chemotherapy in therapy-naive patients with HIV-associated Kaposi sarcoma in South Africa. JAIDS 2012 (19 March) epub.
   http://www.ncbi.nlm.nih.gov/pubmed/22395672