How would you suggest to radiate a Kaposi's sarcoma?

Would certain patient/disease characteristics make you choose RT therapy over chemotherapy or other locally ablative therapies? What dose/fraction would you suggest and what margin would you place on the visible lesion? Also, would you differ your approach between a HIV-associated vs classic/endemic Kaposi's sarcoma

5 Answers

Mednet Member

Radiation Oncology · Rush University Medical Center

Answered on

Although you already have some excellent answers, I would like to add a note about Non HIV KS of the feet and hands (so called endemic variety) as sometimes seen in older men of Mediterranean origin.

The challenge in this situation is to offer a therapy that produces durable control w/o serious toxicity (acute or late). A nice option reported in the Red Journal in 1986 is to do 150cGy daily x 10, interrupt for 10-14 days and repeat.

The split course eliminates acute toxicity concerns, which is important for the feet. The results are durable and without long term toxicity.

Best Regards,

Ross

Mednet Member

Radiation Oncology · VA New Jersey Healthcare System - East Orange Campus

Answered on

Great question. This entity is not seen as often since the intervention of HAART for these epidemic dx'ed folks. In the VA, I still see at least couple of cases per year of both epidemic and classical KS.

I have found regardless of HIV status, for purely cutaneous lesions, 800cGy x 1 is great, with a repeat dose within 3 weeks or so, if needed. This has worked quite well in the clinic for my patients.

I have also seen larger bulky lesions where I like to fractionate with 250cGy per session to a total of 35-40Gy. This has worked well, too.

Back in the mid 1980s, when HIV/AIDS was more common, some folks used other fractionation schemes. Of course, this can depend upon your practice setting to dictate what you do.

Mednet Member

Radiation Oncology · VA New Jersey Healthcare System - East Orange Campus

Answered on · Updated on

Hi @Dr. First Last. A nice systemic management perspective.

However, the things/issues you described I have not seen in a long time, compared to my experience with these cases before the modern era of HIV care. Large plague lesions, which were very prevalent then, often led to the issues you raised. It was in this period is when I saw some of the complications that you mentioned. I can say that I have NOT seen any serious post RT treatment issues since the mid to late 80s though. Perhaps in less developed nations with less medical and radiotherapy resources one can see these highly disfiguring lesions which will lead to complications with RT intervention or not.

By the way, because most KS lesions I see are usually skin based and local, we rarely require whole limb RT. Hence we don't see the RT induced extremity edema issue you raised. My most common mode of RT delivery is with Electron beams w/ or w/o skin bolus. Photons are used for bones and / or large soft tissue masses.

Thanks for the input.

References:

JNMA 2006; 98(7):1136-9. "Radiotherapy in the Management of Kaposi Sarcoma: 8Gy versus 6Gy."

Ann Palliative Medicine 2016. Oct;5(4):298-302."Radiotherapy for Skin Kaposi Sarcoma."

Mednet MemberInvited Expert

Radiation Oncology · University of Washington

Answered on

A randomized trial at the University of Washington among AIDS patients with Kaposi's sarcoma conducted before the era of HAART showed higher complete response rates and lower risk of local failure with higher doses of radiation than with shorter treatment regiments (8 Gy x 1, 20 Gy in 10 fractions, 40 Gy in 20 fractions). However, almost half of patients developed regional failure with the 40 Gy dose.

I interpret this to mean that there is a dose response and accordingly choose a dose based on the patient's comorbidities and expected life span. (Stelzer KJ, Griffin TW, A randomized prospective trial of radiation therapy for AIDS related Kaposi's sarcoma. Int J Radiat Oncol Biol Phys 1993, Dec 1, 27(5), 1057-61.)

Mednet Member

Radiation Oncology · VA New Jersey Healthcare System - East Orange Campus

Answered on · Updated on

Hi @Dr. First Last. I agree with the data you note concerning protracted course of RT used for epidemic KS lesions pre-HAART era. Indeed a protracted course was often used then. However, as it relates to resource poor countries, where KS lesions are the leading cancers in HIV affected men and women, treating KS lesions remain problematic in light of high cost of effective treating agent(s) like chemotherapy(Vincristine), and the lack of reliable electrical infrastructure/grids to facilitate delivery of reliable / electricity radiotherapy (IMHO, self-inflicted in a lot of cases (brain drain, financial malfeasance, corruption.... to name a few.). Here, in resource rich nations, the issue is not if we can treat such lesions, compared to that faced by resource poor nations, but rather what we face is how to treat these lesions efficiently, and effectively. And, until those countries develop a reliable medical and electrical infrastructure to deliver effective care, patients afflicted with largely preventable, and / or treatable lesions, will continue to bear the burden of excess morbidity and mortality burden that has been greatly reduced in resource rich nations, for the most part.

1. Kaposi's Sarcoma. Union for International Cancer Control.

2014 Review of Cancer Medicines on the WHO list of Essential Medicines.

2. Low- to Middle-Income Nations: Resource Rich in People but Resource Poor in Reliable Utility (electrical grid) Infrastructure for Effective Delivery of High-Impact Supportive Care Modalities—Some Thoughts on the Radiotherapy Perspective

@Dr. First Last

Journal of Global Oncology 2018 :4, 1-2

How would you suggest to radiate a Kaposi's sarcoma?

What RT dose scheme(s) do you use for skin KS?