KAPOSI SARCOMA

HIV-Associated Kaposi Sarcoma (KS): Local and Systemic Treatments

Treatment for AIDS-Related Kaposi Sarcoma (ARKS) focuses on: goals of comfort (palliation),
prevention of disease progression such as tumour shrinkage and on reducing organ compromise and
psychological stress. The type of treatment is dependent on how severe the progression of the illness is,
how fast the tumour is growing, the HIV-1 viral load CD4 cell count, and overall patient conditions. [10]

Corticosteroids may be used at the discretion of the oncologist to compensate for immune
thrombocytopenia (ITP) and some forms of pneumonia nurses should advocate for oncologist review
with signs and symptoms of ITP and pneumonia are present (lower WBC, crackles, decreased air entry,
fever/infection, etc.) [10]

Intralesional Therapy (Local)

What does it involve? Injection of chemotherapy (usually vinblastine) or an antibiotic (bleomycin)
that results in the destruction of lesions [1, 2]
Treatment Dose: 0.2 to 0.3 mg/mL solution with a volume of 0.1 mL per 0.5 cm2 of lesion
[10]
May use multiple injections if lesions are larger [10]
A second series of injections is often necessary three to four weeks
later [10]
Side Effects: Treatment is considered painful, and can lead to scarring [2]
Things to Consider: Has resulted in eradication of some tumours (that are considered
directly injectable) with approximately 74 % of participates experiencing
a 50 % reduction in lesions [10]
May require use of general or spinal anaesthesia [2]
Nursing Implications: Monitor pain during treatment and administer analgesics if possible/
appropriate or provide non-pharmacological pain management
techniques if possible [9]
Be mindful of which patients would be eligible for this type of treatment
requires advocacy for the patients [2]

Topical Agents (Local)

What does it involve? Involves application of a cream, lotion, or ointment into the skin to reduce
lesions by regulating endothelial growth factors. This treatment is not as
commonly used. [2]
Alitretinoin (Panretin) Dosing: apply gel twice daily to lesions directly and wait 3-5 minutes after
application for gel to dry before putting on clothes, can increase dosing to
3-4 times a day maximum (as tolerated) [2]
Side Effects: pain, paresthesia, skin rash, pruritus (itchiness), edema
(swelling), can cause photosensitivity (aversion to light) [2]
Note: Not typically used due to side effects of inflammation and change in
pigmentation of skin [10]
Nursing Implications: this drug is considered a high alert medication; may
be confused with Pancreatin; not to be administered to patients that have
hypersensitivities or allergic reactions to retinoids; cannot be used if a
person is pregnant [2]

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 KAPOSI SARCOMA

Radiation Therapy (Local)
What does it involve? Requires exposure to primarily an x-ray machine to target cancer cells or
prevent growth. It is used to treat symptomatic disease that is too extensive
to be treated with intralesional chemotherapy [1,2]
External radiation: where the x-ray targets from outside of the body to
inward. There are two main types of external radiations which are:
photon radiation therapy that is considered high energy levels and
electron beam radiation that uses electron (small subatomic particles)
to target cancer cells [5,6]
Internal radiation: where radioactive substances will be inserted into the
body via needle, or catheters (tubing) near or on the cancer cells
directly to destroy them [1,2]
Treatment Dose: Overall radiation doses vary from 6 to 60 Gy, depending on the type of
regimen. Usually, single fractions will be administered from 6 to 12 Gy in a
single treatment session or a larger amount of Gy will be administered in
smaller portions over a longer period of weeks (for example, 30 Gy during
given with 10 fractions or sessions = 3 Gy given per week) [1,4]
Side Effects: Fatigue, skin redness and irritation, swelling of the area, dryness of skin,
chance of blistering or peeling, fatigue and nausea (2,5)

Things to Consider: Side effects from radiation usually resolve within two weeks of treatment;
not to be used with people who have extensive disease progression [10]

Nursing Implications:
Patient education on how to take care of skin during treatment [2]
Emotional support with any body changes or changes in confidence,
production of body image issues/concerns, encourage periodic rest [3]
Monitor for changes in skin during treatment, especially for radiation of
skin concerns outside localized area of treatment [2]
Administer anti-emetics [2,7]

Immunomodulators (Systemic)
What does it involve? It involves the use of Recombinant interferon alpha (IFNa) protein in order
to either boost your natural immune system, create antiviral effects,
prevent the tumour from accessing your blood vessels in order to grow
(angiogenesis), or will stop cancer cells from growing (known as
antiproliferative effects). The exact processes are unknown at this moment
but this therapy is more used with HIV-related Kaposi Sarcoma) [2,8]
Recombinant Interferon Antineoplastic Agent or Interferon
Alfa-2b (IFN) Inhibits DNA and protein synthesis of tumour cells
[4, 8] Increases natural killer cells cytotoxic effects
Inhibits replication of viral DNA
Dosing:
30 million units/m2 3 times weekly until 16 week total treatment
Delay treatment if ANC <500/mm3 or platelets <25,000/mm3
Route: Intramuscular (IM) or subcutaneous (SC)
Absorption:
Bioavailability: IM: 83%; SC: 90%
Half-life: IM, SC: ~2-3 hours Continues on the next page

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 KAPOSI SARCOMA

Recombinant Interferon Side Effects: Fever, chills, tachycardia, myalgia, headache, chest pain,
Alfa-2b (IFN) depression, confusion, and lack of concentration (cognitive changes),
[4, 8] weight loss, fatigue, alopecia, pruritus, nausea and vomiting, cough,
dyspnea, back pain, weakness, edema, hypertension, urinary tract
infection risks
Nursing Implications:
Patients with pre-existing cardiac abnormalities or in advanced stages
of cancer should have ECGs taken before and during treatment
Monitor for neuropsychiatric changes, especially depression, suicidal
or homicidal ideation, psychosis, or mania; decreased pulmonary
function; or ophthalmic changes
Administer acetaminophen to reduce flu-like symptoms
Monitor vitals (including temperature)
Plan for rest periods for patient
Assist patient with ADLs
Assist with resource implementation or referral to home services (if
needed)

Combined Antiretroviral Therapy (Systemic)

What does it involve? Involves combining numerous or multiple chemotherapy drugs or
antiretroviral medication to meet patient goals. It is the most commonly used
therapy for treatment of ARKS and is considered the most effective [10, 11]
Things to consider: People who receive combined antiretroviral therapy (systemic
chemotherapy) must experience the following symptoms or conditions
related to HIV-Associated KS[10, 11]
Widespread skin involvement (more than 25 lesions) [10]
Extensive Kaposi Sarcoma that is unresponsive to local treatment
regimens, extensive edema [10]
Symptomatic visceral involvement (i.e. organs are experiencing
degradation or painful symptoms) [10]
Can cause Immune Reconstitution Inflammatory Syndrome (IRIS) -
describes a collection of inflammatory disorders associated with
paradoxical worsening of pre-existing infectious processes following the
initiation of highly active antiretroviral therapy (HAART) in HIV-infected
individuals

The next few pages outline some come combined antiretroviral therapy agentsthat are used for
managing HIV-Associated Kaposi Sarcoma, a great resource you may direct your patients to is:
https://www.uptodate.com/contents/kaposi-sarcoma-the-basics?source=see_link which outlines
education on treatment, side effects, and lays out the basics on why treatment causes side effects.

To learn more about all types of antiretroviral medications and treatment regimens follow this link:
https://www.uptodate.com/contents/selecting-antiretroviral-regimens-for-the-treatment-naive-hiv-infected-
patient?source=see_link#H1195155 [10]

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 KAPOSI SARCOMA

Common Combined Antiretroviral Therapy Agents Used to Manage HIV-Associated Kaposi Sarcoma [4]

Therapy Category Dosing, Route and Absorption Side Effects Nursing Implications
- Know baseline CBC, especially platelet
and liver function tests test prior to cycle
- Note signs of radiation (redness, rash)
- Monitor dose toxicity
Fatigue, headache, chest - Obtain ECHO prior to mix with D5W
tightness and pain, skin rash, solution
Pegylated nausea, vomiting, diarrhea, - Can administer Benadryl for allergy-like
2
Liposomal - Antineoplastic - 50 mg/ m every 4 weeks edema, thrombocytopenia, symptoms
Doxorubicin Agent weakness, back pain, - Be mindful of extravasation
(PLD) - Intravenous (IV) pharyngitis, cardiomyopathy, - IV rather than bolus to reduce
- First-line cardiotoxicity, ulcerations, cardiotoxicity
Polyethylene treatment for - Half Life: ~4.7 to 5.2 hours (this means hemorrhage, fever, chills, - Monitor for signs of hand-foot
glycol (PEG) HIV-Associated that the drug will stay in your body lymphorrhea, hypersensitivity, syndrome
with KS actively for at least 9 to 10 hours) increase risk of hand-foot - BM monitoring
doxorubicin syndrome, esophagitis, high - Abdominal focused assessments for
proportion of gastrointestinal GIST
stomal tumor (GIST) - For patients with poorer performance
or extensive comorbidities
- Take caution with handling: use
hazardous drug handling considerations
- Review lab values prior to treatment
- Be mindful of extravasation
Angina pectoris, and - Obtain liver function tests
hypertension, depression of - Adjust dose according to ABC count
- 3.7 mg/m2 or 0.1mg/kg over an hour
- Antineoplastic CNS, headache, dizziness, - Monitor vitals (especially BP, and HR)
Vinblastine agent nausea, weakness, and - Note for signs of depression
- Adjust to account for a WBC count of
Sulfate metallic taste, alopecia, skin - Monitor neurological function
~3000/mm3 every 7 days
- Can be in rash, abdominal pain, - Note that if mixed with bleomycin the
(Velban, or combination anorexia, and stomatitis, risk for pulmonary toxicity increases with
- Can only be given Intravenous (IV)
Velsar) with bleomycin urinary retention, anemia, age >70 years and cumulative lifetime
(an antibiotic) myelosuppression, jaw pain, dose of >400 units
- Half-Life is ~25 hours
leukopenia (lower leukocyte - Take caution with handling- use
count), hair thinning hazardous drug handling considerations
- Review lab values prior to treatment

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Seline Tam, Aja Toste, Rita Vitorino, Yupeng Yan 2017

- 135 mg/m2 over 3 hours every 3
weeks or 100 mg/m2 over 3 hours every
2 weeks
- Premedication with dexamethasone (20
mg orally at 12 and 6 hours prior to the
dose [reduce dexamethasone dose to 10
mg orally with advanced HIV disease]),
Antineoplastic diphenhydramine (50 mg IV 30 to 60
Paclitaxel
agent minutes prior to the dose), and
cimetidine, famotidine, or ranitidine (IV
30 to 60 minutes prior to the dose) is
recommended
- Intravenous (IV)
- ~13 to 20 hours over 3-hour infusion
- If protein-binding version then 80% to
98% absorption
- IV*: 50 to 100 mg/m2/day for 5 days
infused over a 30-60-minute period
minimum
*: do not dilute or push, contains alcohol
- Oral:100 to 200 mg/m2/day for 5 days;
administer daily doses >200 mg in 2
Antineoplastic
Etoposide divided doses.
Agent
- Bioavailability (PO): ~50% (range: 25%
to 75%)
- Half-life elimination on IV with normal
renal and hepatic function:
Children: 6 to 8 hours; Adults: 4 to 11
hours
Treatment Options for Classic Kaposi Sarcoma
Seline Tam, Aja Toste, Rita Vitorino, Yupeng Yan 2017
Edema, hypotension,
alopecia, nausea and
vomiting, neutropenia, risk of
infection, myalgia, and
weakness, dyspnea, allergic
reaction with taxane
Alopecia, nausea and
vomiting, abdominal pain,
anorexia, hypotension,
peripheral neuropathy,
hepatotoxicity, severe allergic
reactions, bronchospasm,
chills, dyspnea, fever,
tachycardia,
myelosuppression, may
cause amenorrhea, infertility
or premature menopause
KAPOSI SARCOMA
- Always use either conventional or
protein bound- the types are NOT
interchangeable
- Be mindful of extravasation
- Monitor for GI irritation
- Monitor for cardiovascular
abnormalities
- Be aware of allergic reaction with other
taxanes
-Take caution with handling- use
hazardous drug handling considerations
- Review lab values prior to treatment
- May be confused with teniposide,
etoposide phosphate or Versed
- High alert medication
- Take caution with handling- use
hazardous drug handling considerations
- Keep client warm to promote
circulation and reduce chills
- Monitor vitals
- Administer anti-emetics (prior, during,
and after treatments)
- Assess for lack of sensations in
peripheral limbs
- People with severe leukopenia,
thrombocytopenia, hypoalbiminemia,
hepatic impairment or renal impairment
should not take this medication
- Review lab values prior to treatment
2
 KAPOSI SARCOMA

- 25 mg/m2 days 1 and 8 of a 21-day
treatment cycle (in combination with
gemcitabine) until disease progression or
unacceptable toxicity Fatigue, peripheral - Caution as Vinorelbine may be
- Granulocytes 1500 cells/mm3 on day neuropathy, nausea, confused with vinBLAStine, vinCRIStine
of treatment: Administer 100% of starting constipation, leukopenia, - Administration of this drug needs to be
dose. granulocytopenia, increased adjusted if a patient has hepatic
Can be used if
- Granulocytes 1000-1499 cells/mm3 on serum AST, site reaction, impairment
Vinorelbine patient is not
day of treatment: Administer 50% of includes bruising and vein - If Neurotoxicity grade 2: Discontinue
responsive to
starting dose. discolouration, treatment
(Navelbine) other
treatments - Granulocytes <1000 cells/mm3 on day neuromuscular and skeletal - Monitor for extravasation as medication
of treatment: Do not administer. muscle weakness, localized is a vesicant
* In patients with concurrent hematologic phlebitis, chest pain, skin - Take caution with handling- use
toxicity and hepatic impairment, rash, sepsis, myalgia, jaw hazardous drug handling considerations
administer the lower of the doses pain, ototoxicity - Review lab values prior to treatment
- Intravenously only
- Distribution: Vd: binds extensively to
human platelets and lymphocytes
- If infusion reactions include: back pain,
flushing, and chest tightness then
Edema, angina pectoris, atrial temporary interrupt infusion and
fibrillation, myocardial continue at a slower rate
2 infarction or cardiac arrest, - Take caution with handling- use
- 40 mg/m once every 2 weeks;
pulmonary hypertension, hazardous drug handling considerations
continue until disease progression.
tachycardia, decreased left - Monitor vitals
- If serum creatinine >3 mg/dL:
- Antineoplastic ventricular ejection fraction, - Perform focused cardiac assessments
Administer 50% of normal dose
agent or fatigue, headache, rigors, - Ensure adequate hydration throughout
- If Bilirubin 1.2 to 3 mg/dL: Administer
anthracycline neuropathy, malaise, ataxia, therapy and encourage fluid monitoring
Liposomal 75% of normal dose.
- First Line confusion or drowsiness, hot at home
Daunorubicin - Bilirubin >3 mg/dL: Administer 50% of
Treatment for flashes, dehydration, nausea, - Advocate for echocardiograms
normal dose.
HIV-Associated 3 diarrhea, seizure, alopecia, throughout treatment
- ANC <750/mm : Withhold treatment.
KS abdominal pain, - Perform GI assessments and monitor
- Intravenously (IV) only, injection
gastrointestinal hemorrhage, BM/ stool for blood
contains sucrose 2,125 mg/25 mL
hypersensitivity reactions, - Monitor intake and output
- Half-life elimination: Distribution: 4.4
back pain, tinnitus, polyuria, - Review lab values prior to treatment
hours (stay in the system for 9 hours)
dyspnea, rhinitis, fever, - Be cautious of numerous drug
myelosuppression interactions
- Do not administer to people who are
pregnant

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- 10 units/m2 days 1 and 15 of a 28-day
treatment cycle (in combination with
doxorubicin, vinblastine, and
dacarbazine)
- Solution reconstitution is 15 units (1
each); 30 units (1 each)
Bleomycin - Antineoplastic
- Administer slowly over 10 minutes
agent
- Intravenously (IV) preferred
(Blenoxane) - Antibiotic
- Absorption: IM, SC, and intrapleural
administration: 100%, 70%, and 45%,
respectively, of IV serum concentrations
- Half-Life of IV is 2 hours (this means
the drug will stay in your system for at
least 4 hours)
2
- 1.4 mg/m /dose
- Frequency dependent on your
oncologists expertise
Vincristine - Serum bilirubin >3 mg/dL: Administer
Antineoplastic 50% of normal dose
(Vincristine agent - Intravenously (IV)
Sulfate) - Half-life ranges from 19-155 hours with
an average of 85 hours (meaning this
treatment could remain in your system
for more than 7 days)
Treatment Options for Classic Kaposi Sarcoma
Seline Tam, Aja Toste, Rita Vitorino, Yupeng Yan 2017
Phlebitis, tumour pain,
hyperpigmentation, erythema
(bruising or redness), weight
loss, nail changes, stomatitis,
mucositis, anorexia, febrile
reaction
Edema, hyper- or
hypotension, myocardial
infarction, phlebitis, abnormal
gait, ataxia, cranial nerve
dysfunction, dizziness,
headache, neuropathic pain
and/or peripheral neuropathy,
paraesthesia, skin rash,
alopecia, constipation,
anemia, foot drop, back pain,
limb pain, transient cortical
blindness, polyuria, dyspnea
and bronchospasm,
hypersensitivity reaction
KAPOSI SARCOMA
- Nay be confused with Cleocin
- High alert medication
- Risk for pulmonary toxicity increases
with age >70 years and cumulative
lifetime dose of >400 units need to
adjustment once pulmonary diffusion for
DLCO <30% of baseline
- Take caution with handling- use
hazardous drug handling considerations
- Review lab values prior to treatment
- Monitor for pain at injection site
- Advocate for pulmonary function tests
- Do not administer in people who are
pregnant
- Practices (ISMP) strongly recommend
dispensing vincristine in a minibag
(NOT a syringe)
- Considered a high alert medication
- Take caution with handling- use
hazardous drug handling considerations
- Review lab values prior to treatment
- Monitor for signs of extravasation
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 KAPOSI SARCOMA

Reference:
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Retrieved from https://www.cancer.gov/types/soft-tissue-sarcoma/patient/kaposi-treatment-
pdq#section/_50
2. Krown, S.E., and Singh, J.C. (March 30th, 2017). Classic Kaposi Sarcoma: Clinical features, staging,
diagnosis, and treatment. Retrieved from UptoDate [Accessed March 3rd, 2017]
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sarcoma patients from diagnosis to treatments: predictors and longitudinal trajectories. European
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http://online.lexi.com.myaccess.library.utoronto.ca/lco/action/index/dataset/pdh_f.
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therapy
6. Cancer Treatment Centers of America. (2017). EBRT for soft tissue sarcoma. Retrieved from
http://www.cancercenter.com/soft-tissue-sarcoma/ebrt/
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from http://www.cancercenter.com/soft-tissue-sarcoma/pain-management/
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Mosby.
10. Groopman J.E, Dezube B.J., and Ross M.E. (Dec 17, 2014). AIDS-related Kaposi sarcoma: Staging
and treatment. UpToDate [Accessed on March 3rd, 2017]
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Retrieved from http://emedicine.medscape.com/article/279734-treatment#d8
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https://www.cancer.gov/about-cancer/treatment/cam
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http://sarcomaalliance.org/what-you-need-to-know/complimentary-therapies/
14. Andritsch, E., Beishon, M., Bielack, S., Bonvalot, S., Casali, P. Crul, M., Delgado-Bolton, R., Donati,
D.M., Douis, H., Haas, R., Hogendoorn, P., Kozhaeva, O., Lavender, V., Lovey, J., Negrouk, A.,
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