What is the clinical course of an HIV (Human Immunodeficiency Virus) patient with visceral Kaposi's sarcoma (KS) and pulmonary involvement, who also had malignancy and received corticosteroids, which potentially exacerbated the KS?

From the Guidelines

I strongly advise against the use of steroids in HIV patients with visceral Kaposi sarcoma and pulmonary involvement, as it can lead to a significant worsening of the condition, as evidenced by the potential for life-threatening Kaposi sarcoma exacerbation resulting from stimulatory effects of glucocorticoids on Kaposi sarcoma spindle cells 1. When managing HIV patients with visceral Kaposi sarcoma, particularly those with pulmonary involvement, it is crucial to prioritize antiretroviral therapy (ART) to optimize immune function and viral suppression, as this can lead to remissions or stable disease in cases of limited cutaneous disease 1. Key considerations in such cases include:

• The potential for immune reconstitution inflammatory syndrome (IRIS) within 3 to 6 months after initiating ART, which may be more likely in patients with pulmonary involvement or those who have recently used glucocorticoids 1
• The importance of coordinating care with an HIV specialist to manage potential complications and optimize treatment outcomes
• The need to avoid additional immunosuppression, including the use of glucocorticoids, which are generally contraindicated in Kaposi sarcoma due to their potential to exacerbate the condition 1 In cases where malignancy is also present, treatment should focus on optimizing ART and considering chemotherapy options, such as liposomal doxorubicin or paclitaxel, for the management of Kaposi sarcoma, while avoiding the use of steroids whenever possible.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Visceral Kaposi Sarcoma with Pulmonary Involvement

• Visceral Kaposi sarcoma (KS) is a multicentric angioproliferative cancer of endothelial cells caused by Human Herpesvirus 8 (HHV8) 2
• Clinical presentation varies from an indolent slowly progressive behavior, generally limited to the skin, to an aggressive and rapidly progressing disease 2
• In more than 50% of cases, the skin lesions are often associated with a more or less important visceral involvement, particularly to the oral cavity and the gastrointestinal tract 2

Treatment of Visceral Kaposi Sarcoma

• Highly Active Antiretroviral Therapy (HAART) represents the first treatment in patients with moderate lesions limited to skin, and it can be sufficient to reduce significantly the size of lesions and, often, the complete disappear in 35% of cases after 3-9 months of treatment 2
• In case of a rapidly progressive disease with extensive cutaneous and/or visceral involvement systemic drugs are used such as the liposomal anthracyclines pegylated liposomal doxorubicin (PLD) and daunorubicin citrate liposome (DNX), the combined treatment adriamycin-bleomycin-vincristine (ABV) and bleomycin-vincristine (BV), Paclitaxel and Interferon-alfa 2
• HAART plus chemotherapy may be beneficial in reducing disease progression compared to HAART alone in patients with severe or progressive Kaposi's sarcoma 3, 4

Steroids and Kaposi Sarcoma

• There is no direct evidence in the provided studies that steroids made Kaposi sarcoma worse, however, it is known that immune suppression can exacerbate KS 5

Pulmonary Involvement

• Pulmonary involvement in KS can be severe and life-threatening, and treatment should be tailored to the individual patient's needs 5
• There is limited information in the provided studies about the specific treatment of pulmonary KS, but it is likely that a combination of HAART and chemotherapy would be used 3, 4, 6