What is the role of chemotherapy in the treatment of Kaposi sarcoma (KS)?

Updated: Apr 11, 2019
  • Author: Jessica Katz, MD, PhD, FACP; Chief Editor: Edwin Choy, MD, PhD  more...
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Systemic therapy for epidemic Kaposi sarcoma

Chemotherapy is the preferred first-line therapy for refractory/relapsed limited cutaneous disease and advanced disease. It  is indicated for symptomatic visceral or rapidly progressive mucocutaneous disease for which a rapid response is desirable. It is used in disseminated disease not amenable to local modalities.

Cytotoxic agents are approved by the Food and Drug Administration (FDA) for AIDS-related Kaposi sarcoma and include the following:

  • Liposomal doxorubicin (Doxil)
  • Liposomal daunorubicin (DaunoXome)
  • Paclitaxel (Taxol)
  • Oral etoposide (Vepesid)

Current National Comprehensive Cancer Network (NCCN) guidelines recommend liposomal doxorubicin (or liposomal daunorubicin) or paclitaxel in the first-line setting. [71] The liposomal technology has resulted in higher response rates with less cardiac and myelotoxicity for both liposomal doxorubicin and liposomal daunorubicin because of their more targeted nature. [12, 13, 14] Response rates of up to 80% can be seen with either of these drugs.

The same is true for paclitaxel, which can be safely administered to severely immunocompromised patients whose diseaserefractory to other chemotherapeutic agents. [75] Response rates of 50-71% were reported in two phase II trials. [88, 89]

Several trials have compared pegylated-liposomal doxorubicin with combination chemotherapy and have found it to be as effective as or superior to conventional combination chemotherapy, with higher response rates and lower toxicity. In a randomized phase III trial of 258 patients receiving pegylated-liposomal doxorubicin or doxorubicin/bleomycin/vincristine (ABV) the overall response rate was 46% in the liposomal doxorubicin arm versus 25% in the ABV arm. The median time to treatment failure was similar to both arms, with decreased grade 3-4 adverse events in the liposomal doxorubicin arm. Therefore, single-agent regimens are commonly preferred.

In AIDS-associated Kaposi sarcoma, the problem has been balancing the immunosuppressive effects of chemotherapy with its potential benefit. This has required a great deal of finesse in the era of HAART, which can itself cause regression of Kaposi sarcoma. Treatment duration should be to a response plateau with lengthening of the treatment interval to approximately 6 weeks, a period in which Kaposi sarcoma will progress if treatment is not being administered. Also, recurrence of Kaposi sarcoma after chemotherapy does not necessarily mean resistance, making retreatment with the same regimen a reasonable option.

In refractory or relapsed cases that progressed despite one or both first-line therapies, options include the following:

  • Pomalidomide,
  • Bevacizumab
  • Etoposide
  • Gemcitabine
  • Imatinib
  • Thalidomide
  • Vinorelbine

However data for these agents are limited and derived from studies with small treatment populations.

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