What is Kaposi's sarcoma?
Although Kaposi's sarcoma (KS) is a type of cancer, it differs from other types of cancer in the way it develops. Unlike most cancers, which start in one place and may then spread to other parts of the body, KS can appear in several parts of the body at the same time. The most common site for KS is on the skin but it may also affect internal organs, particularly the lymph nodes (part of your immune system), the lungs and parts of the digestive system (the gut).
Causes of Kaposi's sarcoma
Most KS is now believed to be caused by a virus called Human Herpes Virus 8 (HHV8), which is also known as Kaposi’s Sarcoma-associated Herpes Virus (KSHV). It can affect people with a weakened immune system, including people with HIV (Human Immunodeficiency Virus) and Aids.
HHV8 is mainly spread through saliva, but can also be spread in blood and semen, or from a mother to her unborn child. The virus can be passed on through sexual contact, kissing, blood transfusions and organ transplantation.
Types of Kaposi’s Sarcoma
There are four main types of KS They are all more common in men than women.
I. Classic Kaposi’s Sarcoma
The first, called classic KS, develops without any weakened immunity, like many other types of cancer. It is very uncommon and is usually only found in older men of Mediterranean, Middle Eastern, or Jewish descent.
This type of KS is usually only found in the skin, particularly on the lower legs and feet.
As it is a slow-growing cancer, people with early stage classic KS may not need any treatment.
II. Endemic or African Kaposi’s Sarcoma
The second type of KS, endemic or African KS, is found in parts of sub-Saharan Africa. It develops more quickly than classic KS and can affect men, women and children of all ages, although it is more common in men.
III. Aids-related Kaposi’s Sarcoma
The third type of KS, Aids-related KS, is the commonest of the four types, although it has become less common as the treatment of HIV and Aids has improved. As HIV infection develops, the immune system becomes weaker and the risk of developing KS increases.
IV. Transplant-related Kaposi’s Sarcoma
The fourth type of KS usually occurs in people who have a weakened or damaged immune system. People who have had organ transplants, such as a kidney transplant or a bone marrow transplant from a donor, take medicines which suppress their immune system. This is to reduce the risk of their body rejecting the donated organ. Although rare, KS can occur in transplant patients who are taking these immunosuppressant drugs. This type of KS may improve if the immunosuppressant drugs are reduced or stopped.
Signs and Symptoms of Kaposi’s Sarcoma
Kaposi's sarcoma on the skin appears as a small, painless, flat area (lesion) or lump, ranging in colour from brown or brown-red to reddish purple. The lesions or lumps can develop quickly. Although there may be a single area at first, it is not uncommon for more than one to appear.
Any part of the skin, including the inside of the mouth, can be affected. Often the lumps merge to form a larger tumour.
KS can also affect other parts of the body, most commonly the lymph nodes, the lungs and the organs of the digestive system. The signs and symptoms of internal KS depend on the area of the body that is affected. If the lymph nodes are affected, which is common in Aids-related KS, there may be swelling in the limbs. This is known as lymphoedema and is caused by the KS cells blocking the lymph nodes and disrupting the normal circulation of lymph fluid around the body.
Lymphoedema can be a distressing and uncomfortable symptom, and while there is no actual 'cure' there are ways to relieve it.
Our section on lymphoedema gives useful advice about reducing lymphoedema through methods such as exercise and massage.
KS in the lungs commonly causes breathlessness, while a tumour in the digestive system (gut) may cause nausea, vomiting, and bleeding.
How Kaposi’s Sarcoma is diagnosed
You may begin by seeing your GP, who will examine you and check your general health. Your GP will arrange for you to have some tests. You may be referred to a hospital for specialist advice and treatment.
If you already know you have HIV or Aids, you will probably begin by seeing your HIV specialist.
At the hospital you will need to have blood tests and a full examination. Your whole body will be checked, as the lesions can be found on any areas of the skin, including the inside of the mouth, the palms of the hands, the scalp, and the soles of the feet. Although your doctor may suspect that you have KS by simply looking at the lesions, a biopsy is usually done to confirm the diagnosis.
This is generally a quick and simple procedure, which can often be done in an outpatient department. Using a local anaesthetic to numb the area, the doctor removes a small piece of the lesion or lump for examination under a microscope. The area may be sore for a few days afterwards. Further Tests If a diagnosis of KS is confirmed, further tests are usually done to see if there are any signs of KS cells elsewhere in your body.
These may include any of the following:
This may be done to check for signs of KS in your lungs and airways (bronchial passages). As lung infections are common in people with Aids, it may be difficult in this situation to tell whether changes on the x-ray are actually caused by KS. A CT scan may be done to confirm the diagnosis.
CT (computerised tomography) Scan
A CT scan takes a series of x-rays which builds up a three-dimensional picture of the inside of the body. The scan is painless but takes from 10–30 minutes. It can help to show whether there are any signs of KS in other parts of the body. It is particularly useful for diagnosing KS in the lymph nodes.
CT scans use a small amount of radiation, which will be very unlikely to harm you and will not harm anyone you come into contact with. You will be asked not to eat or drink for at least four hours before the scan. You may be given a drink or injection of a dye which allows particular areas to be seen more clearly. For a few minutes, this may make you feel hot all over. If you are allergic to iodine or have asthma you could have a more serious reaction to the injection, so it is important to let your doctor know beforehand.
You will probably be able to go home as soon as the scan is over.
This procedure enables the doctor to look inside the body, through a thin flexible tube called an endoscope that is passed down your throat. The endoscope has a tiny camera and a light on the end. If necessary, the doctor can take a small sample of the cells (a biopsy) to be examined under a microscope.
A mild sedative helps you to relax during the test and a local anaesthetic will be sprayed onto your throat to prevent any discomfort as the tube is passed down. The doctor or nurse endoscopist can examine your windpipe, lungs (bronchoscopy), oesophagus and stomach (gastroscopy) in this way, and check for any signs of KS.
Another type of endoscopy is used to examine your large bowel (colon). This test is called a colonoscopy. The bowel must be empty for this test so a careful diet must be followed for a few days beforehand and you may be given laxatives to take. A bowel wash-out is usually done just before the test. This involves a nurse gently passing a tube into your back passage while you are lying on your left side. Water is then passed through the tube. You will be asked to hold the liquid in your bowel for a few minutes before you go to the toilet.
Just before the colonoscopy you may be given a mild sedative to help you to relax. Once you are lying comfortably on your side the doctor or specialist nurse will gently pass a flexible tube (called a colonoscope) into your back passage. The tube can easily pass around the curves of the bowel, and the lining of most of the bowel can be examined. A light and camera on the inside of the tube helps the doctor or nurse to see any abnormal areas or swelling.
Most people are ready to go home a couple of hours after their test. It is a good idea to arrange for someone to collect you from the hospital, as it is best not to drive for several hours after a sedative.
Lung Function test
If tests show that your lungs have been affected you may have lung function tests to check how well your lungs are working. You will be asked to blow into a machine so that a series of measurements can be taken to show how well your lungs are working.
Treatment for Kaposi’s Sarcoma
Types of Treatment
Mild cases of Kaposi's sarcoma may not need to be treated. It may be possible to use skin-camouflage to cover any skin lesions. However, if the lesions or lumps are causing embarrassment and distress, treatment may be recommended.
Your doctor is more likely to suggest that you have treatment if your KS is affecting internal organs, or if there are many skin lesions. If you have HIV that is not very well controlled, your specialist may also recommend that you start anti-HIV treatment. The type of treatment used will depend on a number of different factors, including the size and position of the tumours and your general health.
· Classic KS does not usually require any treatment, although radiotherapy is sometimes used for larger or easily visible lesions.
· Endemic or African KS is often treated with chemotherapy.
· Treatment of Aids-related KS is often affected by the person's general health. As the immune system has already been weakened by the illness, extra care has to be taken to ensure that any side effects of treatment are not going to make your health become worse. For most people with Aids-related KS the treatment will include highly active antiretroviral therapy (HAART) which reduces the level of the HIV virus in the body and improves immunity.
· Transplant-related KS, caused by immunosuppressant drugs, can sometimes be controlled by stopping or reducing these drugs.
If you have any questions about your treatment, don't be afraid to ask your doctor or the nurse looking after you. It often helps to make a list of questions for your doctor and to take a close friend or relative with you to your appointment.
How treatment is planned
In most hospitals a team of specialists will decide the treatment that is best for you. This multidisciplinary team (MDT) will often include:
· virologist – a doctor that specialises in treating people with viruses
· oncologists – doctors who have experience treating KS using chemotherapy and radiotherapy · specialist nurses who give information and support
· radiologists who help to analyse x-rays
· an HIV specialist.
The MDT may also include a number of other healthcare professionals, such as a:
· occupational therapist
· psychologist or counsellor.
Together they will be able to advise you on the best course of action and plan your treatment taking into account a number of factors. These include your age, general health, and the size and position of the tumours. Remember to ask questions about any aspects that you do not understand or feel worried about. You may find it helpful to discuss the benefits and disadvantages of each option with your doctor, specialist nurse, or with the nurses on our cancer information and support service. Giving your consent .
Before you have any treatment, your doctor will explain the aims of the treatment to you. They will usually ask you to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment.
No medical treatment can be given without your consent, and before you are asked to sign the form you should have been given full information about:
· the type and extent of the treatment you are advised to have
· the advantages and disadvantages of the treatment
· any possible other treatments that may be available
· any significant risks or side effects of the treatment.
If you do not understand what you have been told, let the staff know straight away so that they can explain again. Some cancer treatments are complex, so it is not unusual for people to need repeated explanations. It is often a good idea to have a friend or relative with you when the treatment is explained, to help you remember the discussion more fully. You may also find it useful to write down a list of questions before you go to your appointment.
People often feel that the hospital staff are too busy to answer their questions, but it is important for you to be aware of how the treatment is likely to affect you. The staff should be willing to make time for you to ask questions.
You can always ask for more time to decide about the treatment if you feel that you can’t make a decision when it is first explained to you.
You are also free to choose not to have the treatment. The staff can explain what may happen if you do not have it. It is important to tell a doctor, or the nurse in charge, so that they can record your decision in your medical notes. You do not have to give a reason for not wanting to have treatment, but it can be helpful to let the staff know your concerns so that they can give you the best advice.
Usually a number of cancer specialists work together as a team and they use national treatment guidelines to decide on the most suitable treatment for a patient. Even so, you may want to have another medical opinion. Either your specialist, or your GP, will be willing to refer you to another specialist for a second opinion, if you feel it will be helpful. The second opinion may cause a delay in the start of your treatment, so you and your doctor need to be confident that it will give you useful information.
If you decide to have a second opinion, it may be a good idea to take a friend or relative with you, and have a list of questions ready, so that you can make sure your concerns are covered during the discussion.
Most people with Aids-related Kaposi's sarcoma will be offered treatment with anti-HIV drugs (antiretroviral therapy). A combination of some of the antiretroviral drugs (usually three or more) will usually be used. To be effective, antiretroviral drugs need to be taken every day, often for the rest of your life. Your doctor will discuss the benefits and possible side effects with you if they are appropriate in your situation.
These drugs can stop the HIV virus from multiplying inside the cells that it has affected, and can stop the virus from infecting other cells. This reduces the amount of HIV in the body and limits the damage that the virus can do to the immune system. In many cases, antiretroviral therapy alone can control KS, although this may take many months.
There are different types of anti-HIV drugs. Commonly used types are
· Nucleoside reverse transcriptase inhibitors (NRTIs) such as abacavir (ABC), didanosine (ddI), emtricitabine lamiduvine (3TC), stavudine (d4T), and zidovuvine (AZT)
· Nucleotide reverse transcriptase inhibitors (NtRTIs) such as tenofovir (TFV)
· Protease inhibitors (PIs) such as amprenavir, atazanavir, indinavir, lopinavir, nelfinavir, ritonavir, and saquinavir
· Non-nucleoside reverse transcriptase inhibitors (NNRTIs) such as efavirenz and nevirapine
· Other antiretrovirals such as enfuvirtide.
You can get more information about anti-HIV treatment from some of the specialist HIV and Aids organisations.
Treating Kaposi’s Sarcoma with surgery
Surgery may be used to remove Kaposi's sarcoma from the skin, particularly when the lesions are small. This is a simple procedure and may be done in the outpatient clinic or day ward. The doctor injects local anaesthetic into the skin around the lesions to numb the area. The lesions are removed and the wound stitched. This will leave a small scar which gradually fades.
Some KS lesions can be removed using cryotherapy, which freezes the area to destroy the cancer cells. Sometimes, a laser may be used to burn away the lesion.
Your doctor or specialist nurse can give you more information
Treating Kaposi Sarcoma with Chemo therapy
This is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. They work by disrupting the growth of cancer cells. Commonly used chemotherapy drugs to treat Kaposi's sarcoma are doxorubicin, vincristine (Oncovin®), bleomycin, etoposide (Etopophos®, Vepesid®) and paclitaxel (Taxol). Chemotherapy for internal KS The chemotherapy drugs are usually given by drip (infusion) into a vein in your arm (intravenously), but some chemotherapy drugs can be taken as tablets (orally). They are then carried around the body by the bloodstream. Chemotherapy for KS is usually given every three weeks but may be given more frequently, depending on the drugs used. Treatment is often given as an outpatient.
Chemotherapy for Skin KS
If the KS is only affecting the skin, it may be possible to use chemotherapy injected directly into the skin lesion. This is known as intralesional chemotherapy and tends to be used for smaller lesions (less than 0.5cm (¼ inch) wide). It can be a useful alternative to radiotherapy for areas or skin types where radiotherapy might cause some darkening of the skin, particularly on the face. Intralesional chemotherapy can also be used for tumours inside the mouth.
For more extensive skin KS, chemotherapy is usually given as a drip into a vein.
Chemotherapy treatment can shrink the areas of Kaposi's sarcoma in the skin and make them lighter in colour. In some people the lesions may almost disappear completely.
A different form of chemotherapy, called liposomal chemotherapy, is now often used to treat KS. The molecules of the chemotherapy drugs are enclosed (encapsulated) in a fat-based coating known as a liposome. Liposomes are able to travel to the tumour site, where they release the drug. The advantage of this type of chemotherapy is that there are fewer side effects, which means that treatment can be given over a longer period.
The liposomal chemotherapy drugs that are commonly used to treat KS are liposomal daunoroubicin (Daunoxome®) and liposomal doxorubicin (Caelyx®, Myocet®). These drugs are usually given as drips (infusions) every 2–3 weeks.
Our section on chemotherapy discusses the treatment and its side effects in more detail. Information about individual drugs and their particular side effects are also available.
Chemotherapy can cause unpleasant side effects. However, many people have few side effects, and those that occur can often be well controlled with medicine. The main side effects are described here, along with some of the ways they can be reduced.
Lowered resistance to infection The chemotherapy can reduce the production of white blood cells by the bone marrow, making you more prone to infection. This is a common side effect of chemotherapy and usually begins seven days after treatment has been given. The number of white blood cells in your blood usually reaches its lowest point at 10–14 days after chemotherapy. Your blood cells will then increase steadily and will usually have returned to normal before your next course of chemotherapy is due.
Contact your doctor or the hospital straightaway if:
· Your temperature goes above 38ºC (100.5ºF)
· You suddenly feel unwell (even with a normal temperature).
You will have a blood test before having more chemotherapy, to make sure that your cells have recovered. Occasionally it may be necessary to delay your treatment if your blood count is still low.
Anaemia (low number of red blood cells) While having chemotherapy you may become anaemic. This may make you feel tired and breathless.
Bruising or bleeding
The chemotherapy can also reduce the production of platelets, which help the blood to clot. Let your doctor know if you have any unexplained bruising or bleeding.
Nausea and vomiting
Some of the drugs used to treat KS may cause nausea (feeling sick) and vomiting. There are now very effective anti-sickness drugs (anti-emetics) to prevent or reduce nausea and vomiting. Your doctor will prescribe these for you.
Unfortunately, some chemotherapy drugs can make your hair fall out. You can ask your doctor if the drugs you are taking are likely to cause hair loss or other specific side effects.
People who lose their hair often wear wigs, hats or bandannas. Some people are entitled to a free wig from the NHS and your doctor or nurse will be able to give you more details. If your hair falls out, it will grow back within 3–6 months, once your treatment is over.
Sore mouth Some chemotherapy drugs can make your mouth sore and cause mouth ulcers. Regular mouthwashes can help to keep your mouth clean and relieve any soreness. Your nurse will show you how to use these properly. If you don’t feel like eating during treatment, you could try a diet of soft food or replacing some meals with nutritious drinks.
Intralessional chemotherapy may cause temporary inflammation of the skin.
Tiredness You may feel tired and have a general feeling of weakness. It is important to allow yourself plenty of time to rest.
Although they may be hard to bear at the time, these side effects will gradually disappear once your treatment is over.
Chemotherapy affects people in different ways. Some people find they are able to lead a fairly normal life during their treatment, but many find they become very tired and have to take things much more slowly. Just do as much as you feel like and try not to overdo it. Treating Kaposi’s Sarcoma with
Radiotherapy is a treatment which uses high-energy rays to destroy the Kaposi's sarcoma cells while doing as little harm as possible to normal cells. The radiotherapy is aimed at the skin lesions or internal tumours and is painless. Usually between one and five doses are given. After radiotherapy to the skin, small lesions may fade completely but larger and deeper lumps may become smaller and flatter, similar to a mole. Radiotherapy can be very effective in reducing symptoms of internal KS, particularly swelling, pain and bleeding.
Skin care Side effects of radiotherapy depend on the area of the body which is being treated. Radiotherapy to the skin alone usually causes few side effects. Pale skin around the treated area may become red, sore and itchy. People with darker skins may develop a blue or black tinge in the treated area. Advice about skin care varies from one hospital to another. Some will advise you not to wash the skin at all while you are having radiotherapy. Others will advise you to use only tepid water on the area and to pat it dry with a soft towel. Perfumed creams and lotions should be avoided and you should check with the radiotherapy staff before applying anything to your skin.
If necessary, your doctor will prescribe a special cream to soothe the sore area. Avoid exposing the treated area to the sun or extremes of hot or cold.
Radiotherapy may make your hair fall out in the treated area. Hair in other areas of the body is not affected. Your hair may grow back once your treatment is over, but in some cases the hair loss may be permanent.
Feeling sick Radiotherapy to tumours in or near the digestive system can lead to nausea and vomiting. Anti-sickness (anti-emetic) drugs can often help to overcome this problem. It can also help if you avoid large meals and eat small amounts more often, or supplement your diet with nutritious drinks, which you can buy at most chemists.
Hoarse voice Radiotherapy near the voice box (larynx) may cause hoarseness of the voice. This is usually temporary and should begin to reduce once the treatment has finished.
Tiredness You may feel very tired. It is important to get as much rest as possible, especially if you are travelling a long way for treatment every day.
Most side effects of radiotherapy disappear gradually once your course of treatment is over, although some may continue for several months afterwards. If you have any problems during your treatment, talk to the radiotherapy staff at the hospital, as they have experience of looking after other people in the same situation as yourself.
Radiotherapy does not make you radioactive and it is perfectly safe for you to be with other people, including children, throughout your treatment.
Treating Kaposi's sarcoma with immunotherapy
This type of treatment is occasionally used to treat Kaposi's sarcoma. It is often used alongside other treatments such as anti-HIV therapies. Immunotherapy involves the use of proteins normally produced by the body during viral infections such as flu. These anti-viral proteins can also be produced in a laboratory.
Interferon is the most common type of immunotherapy used to treat KS and is usually given three times a week by injection under the skin. Alternatively, it may be injected into the lesion. The needle is very small and fine so the injections are only slightly uncomfortable. You will be taught how to give yourself these injections so you can do them at home.
In the first week or two of treatment, interferon can cause side effects similar to those of flu: especially chills, fever, headaches, tiredness and aching in the back, joints and muscles. However, these soon disappear. Your doctor may recommend that you take paracetamol about half an hour before your injection to prevent these side effects.
Living with Kaposi's sarcoma
Many people with slow-growing or early KS often find that physically they feel quite well, but emotionally may find it difficult to cope. For some people the appearance of KS is the first sign that they have Aids. In this situation, coming to terms with the diagnosis, whether they knew about it beforehand or not, together with the constant physical reminder of their illness, can be devastating.
It often helps to talk to someone who understands the special needs and problems of people with Aids, their partners and families. A large number of organisations offer help and support to people with Aids. Some of the main Aids organisations in the UK are listed in this section (see organisations). Local support groups can also provide support and you can get details of these from The Terrence Higgins Trust.
People affected by Kaposi's sarcoma in the skin may find this distressing. However, there is a way to reduce the differences in skin colour and make the areas of KS less noticeable. Camouflage make-up consists of specially designed creams, and the ranges available are suitable for all skin types and colours, in both men and women. Some clinical nurse specialists, the British Association of Skin Camouflage and the British Red Cross offer a camouflage make-up service with individual teaching sessions on how to apply it for the best effect.
If KS has caused swelling of the limbs and lymph nodes (lymphoedema), you may have hot, overstretched and painful skin in those areas. We have a section on lymphoedema, and our cancer information and support service can give you details of your nearest lymphoedema clinics.
If you are finding it difficult to eat and are losing weight, it may be advisable to take small, frequent, high-calorie, high-protein drinks which are available from chemists and hospital dietitians. If cleaning your teeth is painful because of mouth lesions, try using a soft toothbrush or foam stick.