Comparison of clinical and prognostic characteristics of patients with classic and AIDS-related Kaposi sarcoma: A single-center experience.

1. Introduction

Kaposi sarcoma (KS) is an angioproliferative disease caused by human herpesvirus-8 (HHV-8) infection. The disease was first described in 1872 by Moritz Kaposi, a dermatologist at the University of Vienna, as “idiopathic multiple pigmented sarcoma of the skin” and was later named KS. [ 1 ]

KS is epidemiologically classified into 4 main groups; classic KS (the type originally described by Kaposi, occurring in middle and old age), endemic KS (several forms described in sub-Saharan African populations prior to the acquired immunodeficiency syndrome [AIDS] epidemic), iatrogenic or organ transplant-associated KS (a type associated with immunosuppressive drug therapy, typically seen in renal allograft recipients), and AIDS-related KS. [ 2 ]

Classic KS is 3 to 10 times more common in men than in women and is most common in Mediterranean countries, Central and Eastern Europe and Uyghur Autonomous Region of China. [ 3 ] The median age at diagnosis in patients with classic KS is in the 7th decade and only 4% to 8% of patients have an age at diagnosis below 50 years. [ 4 ] HHV-8 infection is required for the development of classic KS, but not all infected individuals develop the disease. For example, 1 study found that only 1 to 3 per thousand people over the age of 50 infected with HHV-8 per year develop KS. [ 5 ]

Risk factors for classic KS include high levels of HHV-8 antibodies in the blood, inherited variations in immunomodulatory genes, immunosuppression, male gender, association with other malignancies such as multiple myeloma, leukemia, lymphoma, certain environmental factors such as exposure to volcanic soil and smoking. [ 6 , 7 ]

Classic KS lesions are characterized by the appearance of purplish, reddish-blue or dark brown/black macules, plaques and nodules on the skin and usually occur on the distal extremities, especially the lower legs and feet. These lesions may remain unchanged for months to years, or they may grow and spread rapidly within a few weeks. [ 4 ]

Mucosal involvement of the oral and gastrointestinal (GI) tracts are the most common extracutaneous lesions, occurring in <10% of patients. Involvement of internal organs outside the GI tract (e.g., lung, liver, bone, and bone marrow) is extremely rare. [ 8 ]

There are many options for local control of limited skin lesions. If there is a single symptomatic lesion (e.g., bleeding or chafing against clothing), excision alone may provide local tumor control, but new lesions often develop elsewhere. [ 9 ] All forms of KS, including classic KS, are very sensitive to radiotherapy (RT). Although permanent local lesion control and symptom relief can be achieved with RT in >90% of cases, off-site recurrences are common. [ 10 , 11 ] Other options for local control of lesions include cryotherapy, laser therapy, intralesional therapy, and topical treatments. Systemic therapy is recommended for patients with advanced disease with symptomatic visceral or mucosal involvement, or with diffuse symptomatic cutaneous lesions. Pegylated liposomal doxorubicin (PLD) is preferred as first-line treatment, with paclitaxel as an alternative to PLD in patients for whom PLD is contraindicated (e.g., cardiac comorbidity). [ 8 , 12 , 13 ]

AIDS-related KS has a variable clinical course, ranging from stable disease to rapidly progressive disease with significant morbidity. Skin involvement in AIDS-related KS are most common on the lower extremities, face (especially the nose), oral mucosa and genitalia. Extracutaneous involvement is more common in AIDS-related KS than in classic KS, with the oral cavity, GI tract, lungs, and lymph nodes are more frequently involved. Epidemiological studies suggest that there has been a marked decrease in new cases of KS since the widespread use of antiretroviral therapy (ART). [ 14 ]

Although KS has been reported in all risk groups with HIV infection, it is most common in homosexual or bisexual men. AIDS-related KS is much less common in heterosexual injecting drug users, transfusion recipients and patients with hemophilia. [ 15 ]

In patients with AIDS-related KS, CD4 cell count is an important factor associated with the development of KS: patients with a CD4 cell count < 200 are approximately 19 times more likely to develop AIDS-related KS than patients with a CD4 count > 500. [ 16 ]

With ART for AIDS-related KS, tumor regression is observed in 50% of tumors and some patients can be given ART alone. [ 17 ] Treatment options for limited cutaneous involvement in AIDS-related KS include surgical excision, RT, cryotherapy, intralesional chemotherapy (vinblastine), and topical alitretinoin. Initial treatment with both systemic chemotherapy and ART is recommended for patients with advanced or rapidly progressing KS. The first choice of initial systemic therapy is PLD. Other options include paclitaxel, bleomycin, vinblastine, vincristine and etoposide. [ 11 , 18 , 19 ]

We aimed to compare the clinical and prognostic characteristics of patients with classic and AIDS-related KS followed in our clinic.

2. Methods

We retrospectively reviewed the electronic and written records of 74 patients with KS who were followed up at our clinic between January 2014 and December 2023. One of these 74 patients was excluded from the study due to organ transplant-associated KS.

Fifty-seven patients had classic KS and 16 patients had AIDS-related KS. Inclusion criteria were as follows: Age older than 18 years and histologically confirmed KS. Basic clinicodemographic data including age, gender, presence of comorbidities, Eastern Cooperative Oncology Group (ECOG) performance status, tumor location and response to treatment were recorded.

A complete response was defined as the absence of detectable lesions for at least 8 weeks, while a major response was defined as a ≥ 50% reduction in the number of measurable lesions and the absence of new cutaneous lesions for at least 8 weeks. The sum of complete and major responses was the overall response rate (ORR). A minor response was defined as a 25% to 50% reduction in the number of lesions. Progressive disease was defined as the appearance of new lesions or a > 25% increase in previous lesions, and stable disease was defined as any response that did not meet the above criteria. [ 12 ]

As there is no globally accepted system for response assessment, we preferred the revised World Health Organization criteria. [ 20 ] Response to treatment assessment included a detailed clinical examination, physical observation and review of old photographs of the disease.

This study has been approved by the Ethics Committee of Istanbul Prof Dr Cemil Taşcioğlu City Hospital (approval number: 2024/239). Informed consent was not obtained due to the retrospective nature of the study.

Categorical variables are presented as numbers (percentages). Continuous variables are expressed as median (range). Continuous variables of 2 independent groups were compared using the Mann–Whitney U test. The chi-squared test or Fisher exact test was used to compare proportions between groups when appropriate. Patient survival was calculated from the time of diagnosis using Kaplan–Meier analysis. Factors influencing survival were analyzed using the log-rank test. An overall P -value of <.05 was considered statistically significant. Progression-free survival (PFS) was calculated from the start of chemotherapy until disease progression or death from any cause. Statistical analyses were performed using IBM SPSS Statistics for Windows, version 26 (IBM Corp., Armonk).

3. Results

In this retrospective study of 73 patients diagnosed with KS between 2014 and 2023, 78.1% (57) were classic KS and 21.9% (16) were AIDS-related KS. The median age of all patients was 63 years (23–92) and 63 (86.3%) were male. Table 1 shows the clinical characteristics of patients with classic and AIDS-related KS at diagnosis. The median age of patients with classic KS was 67 years (43–92), 82.5% were male, 77% had comorbidities and 94% had a good performance status (ECOG score 0–1). Patients with AIDS-related KS had a median age of 41 years (23–52) and all 16 patients were male. 25% of patients had comorbidities and only 1 patient had poor performance status (ECOG score ≥ 2).

The number of nonsmokers was higher in both classic and AIDS-related KS patients. 60% of classic KS patients had never smoked, 10% were active smokers, and 30% were ex-smokers. The rates of never smokers, active smokers and ex-smokers in AIDS-related KS patients were 62%, 32%, and 6%, respectively. While 5% of patients with classic KS and 38% of patients with AIDS-related KS were alcohol users.

No visceral organ involvement was observed in classic KS (missing data in 8 patients), whereas 1 patient with AIDS-related KS had pathologically confirmed brain involvement (missing data in 1 patient). Oral mucosal involvement was not observed in patients with classic KS (missing data in 8 patients), whereas oral mucosal involvement was observed in 4 patients with AIDS-related KS (missing data in 1 patient) ( P = .002). Lymph node involvement confirmed by imaging modalities (PET-computerized tomography [CT], thorax-abdominal-pelvic CT or ultrasonography for superficial lymph nodes) was present in 11% (6) of patients with classic KS (missing data in 5 patients) and 50% (8) of patients with AIDS-related KS ( P = .003). All patients with classic KS and AIDS-related KS had skin involvement.

The number of HHV-8 positive patients was 49 in the classic KS group (missing data in 8 patients) and 14 in the AIDS-related group (missing data in 2 patients). HHV-8 positivity was analyzed by immunohistochemistry (IHC).

The localization of skin lesions is shown in Table 2 . Skin lesions were more common in the lower extremities in patients with both classic KS and AIDS-related KS (in 60% of patients with classic KS and 40% of patients with AIDS-related KS). Other sites of skin lesions in patients with classic KS were the upper extremities in 24%, the head and neck in 10%, and the trunk in 6%. Other locations of skin lesions in patients with AIDS-related KS are 24% on the upper extremities, 10% on the head and neck, and 6% on the trunk. During the follow-up period, skin lesions were seen in multiple localizations were observed in 9 patients with classic KS, whereas this number was 2 in patients with AIDS-related KS. Data on the localization of skin lesions were not available for 8 patients with classic KS.

Of the 38 patients who received first-line systemic therapy, 27 were in the classic KS group and 11 in the AIDS-related KS group. Table 3 shows the treatment characteristics of patients with classic and AIDS-related KS. All patients with AIDS-related KS received ART. In both groups, 3 patients were followed up without any systemic or local treatment (surgery, RTor cryotherapy). A total of 24 (42%) patients with classic KS and 2 (12%) patients with AIDS-related KS received only local treatment. The proportion of patients with classic and AIDS-related KS receiving systemic therapy alone was 30% and 56%, respectively. The number of patients receiving both systemic and local treatment was 10 in the classic KS group and 2 in the AIDS-related KS group. In the classic KS group, treatment information was not available for 3 patients. Due to progression, 3 patients with classic KS and 1 patient with AIDS-related KS received second-line systemic therapy.

Among 27 patients with classic KS who received first-line systemic chemotherapy, 52% received paclitaxel, 44% oral etoposide and 4% liposomal doxorubicin. In the AIDS-related KS group of 11 patients receiving first-line systemic therapy, 82% received paclitaxel and 18% liposomal doxorubicin.

The treatment responses of patients with classic KS and AIDS-related KS who received first-line systemic therapy are shown in Table 4 . Of the 27 patients with classic KS who received first-line systemic therapy, 13 had a complete response and 7 had a major response. Complete response was observed in 8 (57%) of 14 patients receiving paclitaxel, 4 (33%) of 12 patients receiving oral etoposide and 1 patient receiving liposomal doxorubicin. In the AIDS-related KS group, 11 patients received first-line systemic therapy and 7 had a complete response and 2 had major response. Complete response was observed in 5 (55%) of 9 patients receiving paclitaxel and in all 2 patients receiving liposomal doxorubicin. Complete response was obtained with PLD in both groups. In the classic KS group, the ORR was 78% with paclitaxel and 66% with oral etoposide, while in the AIDS-related group, the ORR was 78% with paclitaxel. No disease progression was observed after first-line systemic therapy.

KS herpesvirus inflammatory cytokine syndrome (KICS), which is very rare in AIDS-related KS patients and presents with fever, edema, neuropathy, GI, and respiratory symptoms, was present in 1 of 16 AIDS-related KS patients and this patient died very shortly after diagnosis. No other patient in the AIDS-related group died during follow-up, with a median follow-up of 20 months (3–101 mo).

In the classic group with a median follow-up of 44 months (3–157 mo), 14 of 57 patients died. The median overall survival (OS) was not reached. 1-year OS in patients with classic KS is 96.5%, 3-year 84.0%, 5-year 74.6%. Figure 1 shows the survival curves for patients with classic and AIDS-related KS.

While the median PFS was 26 months in the classic KS group in which 27 patients received first-line systemic therapy, the median PFS was not reached in the AIDS-related KS group in which 11 patients received first-line systemic therapy. The 1-, 2- and 3-year PFS in the classic group was 86.2%, 61.6%, and 49.3%, respectively, while the 1-, 2- and 3-year PFS in the AIDS-related group was 90.9%, 79.5%, and 79.5%, respectively. There was no statistical difference in PFS between the 2 groups ( P > .27),

4. Discussion

This study is a retrospective review of 73 patients with KS who were followed up over a 10-year period (January 2014–December 2023) at our hospital, a tertiary care hospital in Istanbul, the largest city in Turkey, where middle- and low-income people are frequently admitted. Our study provides real-life data on patients with KS treated in a developing country. About 48% of patients with classic KS and 68% of patients with AIDS-related KS received systemic chemotherapy. Paclitaxel was the most commonly used agent in both the classic and AIDS-related groups. These findings are valuable in terms of real-world data in a disease such as KS, which is rare and where prospective studies -and therefore treatment options- are limited. It should also be noted that there are difficulties in accessing new and standard drugs (especially liposomal doxorubicin and immunotherapies for KS) in Turkey.

Classic KS and AIDS-related KS have many differences in terms of clinicodemographic characteristics and there are very few studies in the literature directly comparing these 2 groups.

There is a significant difference in the rate of classic KS between men and women. In our study, we found a male:female ratio of 4.7:1, which is similar to the literature. [ 21 ] AIDS-related KS is also common in men; all 16 AIDS- related KS patients in our study were males.

It has been reported in the literature that the median age at diagnosis in patients with AIDS-related KS and classic KS is approximately 35 and 60 years, respectively. [ 22 , 23 ] In our study, the median age at diagnosis was 67 years in the classic KS group and 41 years in the AIDS-related KS group. It should be stressed again that classic KS is a geriatric disease.

Studies from different parts of the world have shown that KS is most common in the lower extremities, particularly the distal lower extremities. [ 24 – 26 ] In recent studies conducted in Peru and China, lower extremity involvement was found to be 60% to 80% in the classic KS group and 30% to 50% in the AIDS-related KS group. [ 21 , 25 , 27 ] In our study, the most common site of involvement was the lower extremity (60% in the AIDS-related group and 40% in the classic group). The second most common site was the upper extremity, and the third most common site was the head and neck.

Regional lymph node involvement is rarely seen in classic KS. In a study conducted in Greece, regional lymph node involvement was reported to be 15%. [ 28 ] In a Peruvian study comparing the classic and AIDS-related groups, lymph node involvement was found to be 13% and 49%, respectively. [ 21 ] In a similar study conducted in the Xinjiang-Uygur Autonomous Region of China, lymph node involvement was found to be 6.5% in the classic group and 18% in the AIDS-related group. [ 25 ] In our study, lymph node involvement was found to be 10.5% in the classic KS group and 50% in the AIDS-related KS group (similar to the Peruvian study).

Mucosal involvement of the GI tract (including oral mucosa) is the most common extracutaneous involvement in KS. It has been reported in the literature that GI and oral mucosal involvement is more common in patients with AIDS-related KS. [ 21 , 25 ] In our study, GI system involvement was not found clinically in both groups. It should be noted that endoscopy was not routinely performed (in the absence of symptoms) in the patients included in the study. In agreement with the literature, we found that oral mucosal involvement was more common in patients with AIDS-related KS.

In the literature, visceral organ involvement is more common in patients with AIDS-related KS. [ 21 ] In our study, visceral organ involvement was not detected clinically or radiologically in patients with classic KS. One of the patients with AIDS-related KS had diffuse organ involvement and was diagnosed with KICS. This patient died shortly afterwards.

Chemotherapy is used in patients with disseminated KS to reduce the number and size of lesions and to relieve severe disease-related symptoms that affect quality of life. [ 29 ] In our study, 47.5% of patients with classic KS and 68.7% of patients with AIDS-related KS received first-line systemic therapy and all patients with AIDS-related KS were received concomitant ART. In a recent similar study, the proportion of patients receiving systemic therapy was 32% in the classic KS group and 76% in the AIDS-related group, and 91% of patients in the AIDS-related group were receiving ART. [ 21 ]

PLD is the first-line drug recommended by the guidelines for the systemic treatment of KS (both classic and AIDS-related). In cases where PLD is unavailable or contraindicated, the alternative agent is paclitaxel. Paclitaxel is an effective treatment option with an acceptable safety profile for patients with advanced classic. [ 13 ] Approaches to systemic treatment vary from country to country. This is mainly due to problems of access to medicines.

In our study, paclitaxel was the most preferred first-line systemic treatment agent in patients with both classic KS and AIDS-related KS. Paclitaxel was received by 52% of patients in the classic group and 82% of patients in the AIDS-related group who received first-line systemic therapy. Very few patients received liposomal doxorubicin. This is similar to studies in other developing countries. [ 21 , 30 ] Oral etoposide was the second most preferred agent in patients with classic KS.

The ORR achieved with paclitaxel in both the classic and the AIDS-related KS groups was 78%, similar to the literature. However, studies differ in terms of complete response to paclitaxel. For example, in a Turkish study of patients with classic KS, the complete response rate to paclitaxel was 15%. [ 13 ] In a Peruvian study, this rate was reported to be 47% in the classic group and 56% in the AIDS-related group. [ 21 ] The complete response rate to paclitaxel was 60% in a study of patients with classic KS in Italy. [ 31 ] In our study, the complete response rate to paclitaxel was 57% in the classic group and 56% in the AIDS-related group.

After oral etoposide, the second most commonly used agent in patients with classic KS, we found an ORR of 66% and a complete response rate of 33%. The ORR was consistent with the literature, but the complete response rate was about 3 times higher than the studies in the literature. [ 32 ]

Most patients received paclitaxel or oral etoposide in the first-line setting, and very few patients received liposomal doxorubicin. Despite promising results, no patients could be treated with immunotherapy. This situation highlights the problems of access to medicines, as in other developing countries.

Among patients with classic KS, 42% received local treatment (surgery, cryotherapy, or RT) alone and 18% with CT; among patients with AIDS-related KS, 12% received local treatment (surgery, cryotherapy, or RT) alone and 12% with CT. These results are consistent with a recent similar study. [ 21 ]

To the best of our knowledge, there are no direct studies comparing PFS in patients with classic and AIDS-related KS receiving first-line systemic therapy. In the first-line setting, 27 patients in the classic KS group and 11 patients in the AIDS-related group received systemic treatment. In the classic group, median PFS was 26 months and 3-year PFS was 49%. In the AIDS-related group, median PFS was not reached and 3-year PFS was 79%. There was no statistically significant difference between the 2 groups.

Studies show that 5-year OS in patients with classic KS is over 80%. [ 21 , 33 ] In our study, we found an OS of 75% in the classic group. After the introduction of ART, OS rates among patients with AIDS-related KS have increased. In western studies, 5-year OS has increased to almost 90%. [ 34 ] In our study, only 1 patient in the AIDS- related group died and the 5-year OS was over 90%. There was no statistically significant difference between the 2 groups in terms of OS.

The retrospective nature of our study is one of the most important limitations. Some parameters could not be reached due to lack of data in medical records. The reasons leading to this situation are inadequacies in the archive and patients not coming to follow-up.

Despite these limitations, the most important aspect of our study is that it presents real life data from a developing country in patients with classic KS and AIDS-related KS.

5. Conclusion

This single-center, real-world experience provides a perspective on the preferred treatment agents and the impact of treatments on PFS and OS in patients with KS in a developing country. This study shows that patients with classic and AIDS-related KS have similar clinical and demographic characteristics to patients in other countries, and are treated with chemotherapeutic agents similar to those in developing countries but different from those in the Western world. Improving access to standard first-line drugs and new immunotherapeutic agents should be a priority.

Author contributions

Conceptualization: Okan Aydin, Mert Erciyestepe, Ahmet Emin Öztürk.

Data curation: Okan Aydin, Gülhan Dinç.

Formal analysis: Okan Aydin, Emre Uysal.

Funding acquisition: Okan Aydin.

Investigation: Okan Aydin, Mert Erciyestepe, Ahmet Emin Öztürk, Gülhan Dinç.

Methodology: Okan Aydin, Muhammed Mustafa Atci.

Project administration: Okan Aydin, Emir Çelik.

Resources: Okan Aydin, Ahmet Emin Öztürk.

Software: Okan Aydin, Emre Uysal.

Supervision: Okan Aydin, Emir Çelik.

Validation: Okan Aydin, Mert Erciyestepe, Muhammed Mustafa Atci, Kayhan Ertürk, Emir Çelik.

Visualization: Okan Aydin, Kayhan Ertürk, Emir Çelik.

Writing – original draft: Okan Aydin, Muhammed Mustafa Atci, Emir Çelik.

Writing – review & editing: Okan Aydin, Kayhan Ertürk, Emir Çelik.

Abbreviations: AIDS acquired immunodeficiency syndrome ART antiretroviral therapy CT computerized tomography ECOG Eastern Cooperative Oncology Group GI gastrointestinal HHV-8 human herpesvirus-8 KS Kaposi sarcoma ORR overall response rate OS overall survival PFS progression-free survival PLD pegylated liposomal doxorubicin RT radiotherapy

This retrospective study was approved by the Medical Ethics Committee of the University of Health Sciences (file no: 2024/239).

The authors have no conflicts of interest to disclose.

The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request.

How to cite this article: Aydin O, Erciyestepe M, Öztürk AE, Dinç G, Uysal E, Atci MM, Ertürk K, Çelik E. Comparison of clinical and prognostic characteristics of patients with classic and AIDS-related Kaposi sarcoma: A single-center experience. Medicine 2025;104:31(e43576).

References

[1] Clinicians MKCACJ for, 1982 undefined . Idiopathic multiple pigmented sarcoma of the skin. Wiley Online Library M Kaposi CA . 1982 ; 32 : 342 – 7 .

[2] Cesarman E Damania B Krown SE Martin J Bower M Whitby D . Kaposi sarcoma. Nat Rev Dis Primers . 2019 ; 5 : 1 – 21 . 30705286 10.1038/s41572-019-0060-9 PMC6685213

[3] Kaldor JM Coates M Vettom L Taylor R . Epidemiological characteristics of Kaposi’s sarcoma prior to the AIDS epidemic. Br J Cancer . 1994 ; 70 : 674 – 6 . 7917916 10.1038/bjc.1994.370 PMC2033414

[4] Di Lorenzo G . Update on classic Kaposi sarcoma therapy: new look at an old disease. Crit Rev Oncol Hematol . 2008 ; 68 : 242 – 9 . 18657433 10.1016/j.critrevonc.2008.06.007

[5] Vitale F Briffa DV Whitby D , . Kaposi’s sarcoma herpes virus and Kaposi’s sarcoma in the elderly populations of 3 Mediterranean islands. Int J Cancer . 2001 ; 91 : 588 – 91 . 11251987 10.1002/1097-0215(200002)9999:9999<::aid-ijc1089>3.0.co;2-8

[6] Brown EE Whitby D Vitale F . Virologic, hematologic, and immunologic risk factors for classic Kaposi sarcoma. Cancer . 2006 ; 107 : 2282 – 90 . 16998933 10.1002/cncr.22236

[7] Goedert JJ Vitale F Lauria C . Risk factors for classical Kaposi’s sarcoma. J Natl Cancer Inst . 2002 ; 94 : 1712 – 8 . 12441327 10.1093/jnci/94.22.1712

[8] Lebbe C Garbe C Stratigos AJ . Diagnosis and treatment of Kaposi’s sarcoma: European consensus-based interdisciplinary guideline (EDF/EADO/EORTC). Eur J Cancer . 2019 ; 114 : 117 – 27 . 31096150 10.1016/j.ejca.2018.12.036

[9] Tourlaki A Bellinvia M Brambilla L . Recommended surgery of Kaposi’s sarcoma nodules. J Dermatolog Treat . 2015 ; 26 : 354 – 6 . 25283737 10.3109/09546634.2014.971698

[10] Kandaz M Bahat Z Guler OC Canyilmaz E Melikoglu M Yoney A . Radiotherapy in the management of classic Kaposi’s sarcoma: a single institution experience from Northeast Turkey. Dermatol Ther . 2018 ; 31 : e12605 . 29633477 10.1111/dth.12605

[11] Wulf HC Heerfordt IM . Treatment of AIDS-related Kaposi’s Sarcoma with low-dose radiotherapy - follow-up on 2,305 tumours. Anticancer Res . 2021 ; 41 : 3871 – 4 . 34281848 10.21873/anticanres.15181

[12] Di Trolio R Di Lorenzo G Delfino M De Placido S . Role of pegylated lyposomal doxorubicin (PLD) in systemic kaposi’s sarcoma: a systematic review. Int J Immunopathol Pharmacol . 2006 ; 19 : 253 – 63 . 16831292 10.1177/039463200601900202

[13] Paksoy N Khanmammadov N Doǧan I . Weekly paclitaxel treatment in the first-line therapy of classic Kaposi sarcoma: a real-life study. Medicine (Baltimore) . 2023 ; 102 : e32866 . 36749246 10.1097/MD.0000000000032866 PMC9901949

[14] Dezube BJ . Acquired immunodeficiency syndrome-related Kaposi’s sarcoma: clinical features, staging, and treatment. Semin Oncol . 2000 ; 27 : 424 – 30 . 10950369

[15] Beral V Peterman TA Berkelman RL Jaffe HW . Kaposi’s sarcoma among persons with AIDS: a sexually transmitted infection? Lancet . 1990 ; 335 : 123 – 8 . 1967430 10.1016/0140-6736(90)90001-l

[16] Lodi S Guiguet M Costagliola D Fisher M De Luca A Porter K ; CASCADE Collaboration . Kaposi sarcoma incidence and survival among HIV-infected homosexual men after HIV seroconversion. J Natl Cancer Inst . 2010 ; 102 : 784 – 92 . 20442214 10.1093/jnci/djq134 PMC2879418

[17] Krell J Stebbing J . Broader implications of a stage-guided stratified therapeutic approach for AIDS-related Kaposi’s sarcoma. J Clin Oncol . 2014 ; 32 : 373 – 5 . 24378412 10.1200/JCO.2013.53.7126

[18] Gbabe OF Okwundu CI Dedicoat M Freeman EE . Treatment of severe or progressive Kaposi’s sarcoma in HIV-infected adults. Cochrane Database Syst Rev . 2014 ; 8 : CD003256 . 25313415 10.1002/14651858.CD003256.pub2

[19] Séverin D Bessaoud F Meftah N . A comparative study of classic and HIV-viremic and aviremic AIDS Kaposi sarcoma. AIDS . 2021 ; 35 : 399 – 405 . 33181532 10.1097/QAD.0000000000002744

[20] Therasse P Arbuck SG Eisenhauer EA . New guidelines to evaluate the response to treatment in solid tumors. European Organization for Research and Treatment of Cancer, National Cancer Institute of the United States, National Cancer Institute of Canada. J Natl Cancer Inst . 2000 ; 92 : 205 – 16 . 10655437 10.1093/jnci/92.3.205

[21] Valcarcel-Valdivia B Enriquez-Vera D Piedra LE Holguín A De la Cruz Ku G . Treatment outcomes of patients with classic and AIDS-related Kaposi sarcoma: a single-center real-world experience. Clin Exp Med . 2023 ; 23 : 5463 – 71 . 37940724 10.1007/s10238-023-01246-3

[22] Herce ME Kalanga N Wroe EB , . Excellent clinical outcomes and retention in care for adults with HIV-associated Kaposi sarcoma treated with systemic chemotherapy and integrated antiretroviral therapy in rural Malawi. J Int AIDS Soc . 2015 ; 18 : 19929 . 26028156 10.7448/IAS.18.1.19929 PMC4450240

[23] Oyucu Orhan S Bilgehan Sahin A Cubukcu E . Efficacy of chemotherapeutics on classic and non-classic Kaposi sarcoma: a single-center retrospective real-world study. Bosn J Basic Med Sci . 2021 ; 21 : 746 – 51 . 33596402 10.17305/bjbms.2020.5329 PMC8554703

[24] Dogan M Dogan L Ozdemir F . Fifty-one Kaposi sarcoma patients. Clin Transl Oncol . 2010 ; 12 : 629 – 33 . 20851804 10.1007/s12094-010-0568-7

[25] Wu XJ Pu XM Kang XJ . One hundred and five Kaposi sarcoma patients: a clinical study in Xinjiang, Northwest of China. J Eur Acad Dermatol Venereol . 2014 ; 28 : 1545 – 52 . 25350316 10.1111/jdv.12349

[26] Mohanna S Ferrufino JC Sanchez J Bravo F Gotuzzo E . Epidemiological and clinical characteristics of classic Kaposi’s sarcoma in Peru. J Am Acad Dermatol . 2005 ; 53 : 435 – 41 . 16112349 10.1016/j.jaad.2005.05.041

[27] Yang HL He F Jielili A . A retrospective study of Kaposi’s sarcoma in Hotan region of Xinjiang, China. Medicine (Baltimore) . 2023 ; 102 : E35552 . 37832074 10.1097/MD.0000000000035552 PMC10578766

[28] Stratigos JD Potouridou I Katoulis AC . Classic Kaposi’s sarcoma in Greece: a clinico-epidemiological profile. Int J Dermatol . 1997 ; 36 : 735 – 40 . 9372346 10.1046/j.1365-4362.1997.00284.x

[29] Valantin MA Royston L Hentzien M . Therapeutic perspectives in the systemic treatment of Kaposi’s Sarcoma. Cancers (Basel) . 2022 ; 14 : 484 . 35158752 10.3390/cancers14030484 PMC8833559

[30] Krown SE Moser CB MacPhail P . Treatment of advanced AIDS-associated Kaposi sarcoma in resource-limited settings: a three-arm, open-label, randomised, non-inferiority trial. Lancet . 2020 ; 395 : 1195 – 207 . 32145827 10.1016/S0140-6736(19)33222-2 PMC7236082

[31] Tourlaki A Germiniasi F Rossi LC Veraldi S Brambilla L . Paclitaxel as first- or second-line treatment for HIV-negative Kaposi’s sarcoma: a retrospective study of 58 patients. J Dermatolog Treat . 2020 ; 31 : 183 – 5 . 30897011 10.1080/09546634.2019.1590520

[32] Tas F Sen F Keskin S Kilic L . Oral etoposide as first-line therapy in the treatment of patients with advanced classic Kaposi’s sarcoma (CKS): a single-arm trial (oral etoposide in CKS). J Eur Acad Dermatol Venereol . 2013 ; 27 : 789 – 92 . 22188463 10.1111/j.1468-3083.2011.04404.x

[33] Armstrong AW Lam KH Chase EP . Epidemiology of classic and AIDS-related Kaposi’s sarcoma in the USA: incidence, survival, and geographical distribution from 1975 to 2005. Epidemiol Infect . 2013 ; 141 : 200 – 6 . 22404880 10.1017/S0950268812000325 PMC9152052

[34] Bower M Dalla Pria A Coyle C . Prospective stage-stratified approach to AIDS-related Kaposi’s sarcoma. J Clin Oncol . 2014 ; 32 : 409 – 14 . 24378415 10.1200/JCO.2013.51.6757