Management of AIDS-Associated Kaposi’s Sarcoma: A Multidisciplinary Perspective

Since the first cases of AIDS-associated Kaposi’s sarcoma (AIDS/KS) were described in the medical literature in 1981,[1] various local and systemic therapies have been used in efforts to control this most common HIV-associated neoplasm. Many reviews have been published about the treatment of AIDS/KS, but almost all of them have been written by authors representing a single medical specialty, whether it be medical oncology, dermatology, or radiation oncology.

Not surprisingly, the content and focus of these reviews have reflected the authors’ own training and expertise; although such articles often mentioned other types of treatments, they usually emphasized the therapeutic approaches of their primary disciplines. To date, few, if any, attempts have been made to develop a multidisciplinary consensus about the optimal means of managing the various manifestations of AIDS/KS or to provide a cross-disciplinary perspective on the relative merits of various therapeutic strategies.

As a means of addressing this limitation in the literature, we were invited to organize a roundtable symposium about AIDS/KS therapeutics that would generate published proceedings. Rather than employing the usual format, with each participant presenting a separate paper about his or her particular area of expertise, we used this opportunity to convene a multidisciplinary group to discuss the management of AIDS/KS in a case presentation format.

To obtain broad representation, we invited a dermatologist and a radiation oncologist, both of whom had extensive experience in AIDS/KS treatment. We also invited several medical oncologists who not only had expertise in the use of several types of standard and investigational systemic drug and biological therapies for AIDS/KS, but who also differed somewhat from one another in their opinions about when in the course of AIDS/KS to begin systemic therapy. Finally, we asked an infectious diseases specialist experienced in the management of HIV infection and its non-neoplastic complications to provide the perspective of a clinician who often establishes the initial diagnosis of AIDS/KS, makes decisions about when and to whom to refer such patients for therapy, and must often coordinate antiretroviral and opportunistic infection management in patients undergoing treatment of KS.

Several weeks in advance of the roundtable, we compiled and distributed to the participants a list of various clinical presentations of AIDS/KS, ranging from a few skin lesions, to extensive cutaneous disease, to edema and visceral disease (Table 1). The clinical scenarios also varied according to the rate of new lesion development, cosmetic impact of lesion location, and CD4 lymphocyte count. We also asked participants to consider the impact on their treatment recommendations of HIV viral load, concomitant therapy, the presence of KS-associated pain, the existence of comorbid conditions (such as wasting or cytomegalovirus [CMV] infection), and individual patient goals and treatment preferences.

On March 10, 1997, we convened in New York to discuss these cases in an open roundtable format, hoping to determine in which cases a management consensus could be reached and in which cases it could not, as well as which treatment approaches were supported by sufficient data and which would benefit from additional research.

The content of this roundtable discussion is presented in these proceedings. For the purposes of organizational clarity and clinical usefulness, we have arranged the content based on severity of clinical presentation, from the least severe form—limited cutaneous KS—to the most severe presentation—visceral, systemic KS.

References:

1. Centers for Disease Control: Kaposi’s sarcoma and Pneumocystis pneumonia among homosexual men—New York City and California. Morbid Mortal Weekly Rep 30:305-308, 1981.