Consensus of the Brazilian Society of Infectious Diseases and Brazilian Society of Clinical Oncology on the management and treatment of Kaposi's sarcoma

Arruda, Érico; Jacome, Alexandre Andrade dos Anjos; Toscano, Ana Luiza de Castro Conde; Silvestrini, Anderson Arantes; Rêgo, André Santa Bárbara; Wiermann, Evanius Garcia; Cunha Jr., Geraldo Felicio da; Melo, Heloisa Ramos Lacerda de; Morejón, Mirna Loro; Goldani, Luciano Zubaran; Pereira Jr., Luiz Carlos; Silva, Mariliza Henrique; Treistman, Mauro Sergio; Pereira, Mônica Cristina Toledo; Romero, Patricia Maria Bezerra Xavier; Schmerling, Rafael Aron; Guedes, Rodrigo Antonio Vieira; Camargo, Veridiana Pires de

doi:10.1016/j.bjid.2014.01.002

person Érico Arruda

schoolSociedade Brasileira de Infectologia, Vila Mariana, SP, Brazil

person Alexandre Andrade dos Anjos Jacome

schoolHospital Mater Dei, Belo Horizonte, MG, Brazil

person Ana Luiza de Castro Conde Toscano *

schoolInstituto de Infectologia Emílio Ribas e Centro de Referência e Treinamento em DST/AIDS, São Paulo, SP, Brazil

person Anderson Arantes Silvestrini

schoolSociedade Brasileira de Oncologia Clínica e Grupo Acreditar, Brasília, DF, Brazil

person André Santa Bárbara Rêgo

schoolHospital Santa Lúcia, Brasília, DF, Brazil

person Evanius Garcia Wiermann

schoolSociedade Brasileira de Oncologia Clínica, Brasília, DF, Brazil

person Geraldo Felicio da Cunha Jr.

schoolHospital da Baleia, Belo Horizonte, MG, Brazil

person Heloisa Ramos Lacerda de Melo

schoolHospital das Clínicas, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil

person Mirna Loro Morejón

schoolHospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brazil

person Luciano Zubaran Goldani

schoolHospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil

person Luiz Carlos Pereira Jr.

schoolHospital Dia, Instituto de Infectologia Emilio Ribas, São Paulo, SP, Brazil

person Mariliza Henrique Silva

schoolCentro de Referência e Treinamento-DST-AIDS, São Paulo, SP, Brazil

person Mauro Sergio Treistman

schoolServiço de Infectologia de Rede Hospitalar Privada e Câmara Técnica de Doenças Infecciosas do CREMERJ

person Mônica Cristina Toledo Pereira

schoolFundação Hospitalar do Estado de Minas Gerais, Belo Horizonte, MG, Brazil

person Patricia Maria Bezerra Xavier Romero

schoolHospital São Camilo, São Paulo, SP, Brazil

person Rafael Aron Schmerling

schoolCentro de Oncologia Antonio Ermirio de Moraes, São Paulo, SP, Brazil

person Rodrigo Antonio Vieira Guedes

schoolCentro de Oncologia do Hospital Sírio-Libanês, São Paulo, SP, Brazil

person Veridiana Pires de Camargo

schoolInstituto do Câncer do Estado de São Paulo e do Hospital Sírio Libanês, São Paulo, SP, Brazil

*
Corresponding author at: Av. Doutor Arnaldo, 165, Sao Paulo, SP, 01246-900, Brasil.E-mail address:
analuizaconde@ig.com.br (A.L.C.C. Toscano).

Conflicts of interestThe authors declare no conflicts of interest.

Sociedade Brasileira de Infectologia, Vila Mariana, SP, Brazil

Hospital Mater Dei, Belo Horizonte, MG, Brazil

Instituto de Infectologia Emílio Ribas e Centro de Referência e Treinamento em DST/AIDS, São Paulo, SP, Brazil

Sociedade Brasileira de Oncologia Clínica e Grupo Acreditar, Brasília, DF, Brazil

Hospital Santa Lúcia, Brasília, DF, Brazil

Sociedade Brasileira de Oncologia Clínica, Brasília, DF, Brazil

Hospital da Baleia, Belo Horizonte, MG, Brazil

Hospital das Clínicas, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil

Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brazil

Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil

Hospital Dia, Instituto de Infectologia Emilio Ribas, São Paulo, SP, Brazil

Centro de Referência e Treinamento-DST-AIDS, São Paulo, SP, Brazil

Serviço de Infectologia de Rede Hospitalar Privada e Câmara Técnica de Doenças Infecciosas do CREMERJ

Fundação Hospitalar do Estado de Minas Gerais, Belo Horizonte, MG, Brazil

Hospital São Camilo, São Paulo, SP, Brazil

Centro de Oncologia Antonio Ermirio de Moraes, São Paulo, SP, Brazil

Centro de Oncologia do Hospital Sírio-Libanês, São Paulo, SP, Brazil

Instituto do Câncer do Estado de São Paulo e do Hospital Sírio Libanês, São Paulo, SP, Brazil

	Low risk (0) Any of the following findings	High risk (1) Any of the following findings
Tumor	Confined to the skin and/or lymph node and/or minimum oral disease^a	• Edema or ulceration associated with tumor • Extensive oral disease • Gastrointestinal disease • Visceral disease other than lymph node

Immune system	CD4 cells =200 µL^-1	CD4 cells <200 µL^-1

Systemic disease	• Absence of history of opportunistic infections or canker sores • Absence of symptoms B • Performance status (PS) =70	• History of opportunistic infections or canker sores • Presence of symptoms B • Performance status <70 • Another HIV related disease (neurological, lymphoma)

Local treatment
Retinoids	Radiotherapy Intralesional chemotherapy
Systemic treatment
Chemotherapy • Liposomal doxorubicin • Liposomal daunorubicin • Bleomycin • Vincristine, vinblastine • Paclitaxel

	Pegylated liposomal doxorubicin	Daunorubicin citrate liposome	Doxorubicin hydrochloride	Bleomycin sulfate	Vincristine sulfate	Vinblastine sulfate	Paclitaxel
Dose schedule	20 mg/m²every two or three weeks For doses <90 mg: dilute in 250 ml of glucose solution at 5% (50 mg/ml). For doses >90 mg: dilute in 500 ml of glucose solution at 5% (50 mg/ml)	40 mg/m²15/15 days Should be diluted in glucose solution at 5–100 ml for 1 mg/ml concentration and infused within 60 min	10–20 mg/m²It should be dissolved in 0.9% sodium chloride or sterile water for injections Recommended concentration is 2 mg/ml	10 U/m²(1 U = 1 mg) 15/15 days Dilute in 20 ml saline solution Apply in 10 min	0.01–0.03 mg per kg of bodyweight, as single dose every 7 days; or 0.4 to 1.4 mg/m²of body surface, as single dose every 7 days Reconstitute in diluent provided with the product (benzyl alcohol) and only administer intravenously Weekly dose when isolated and 15/15 days in combination with other chemotherapeutic agents	Initial dose of 3.7 mg/m² of body surface per week Sequential increases should follow from 1.8 to 1.9 mg/m² of body surface at weekly intervals Dilute with saline solution at the concentration of 1 mg/ml Administer bolus in 10–15 min in “Y”	135 mg/m²every 3 weeks OR 100 mg/m²every 2 weeks Premedicate with diphenhydramine, 50 mg EV, dexamethasone 20 mg EV and cimetidine, 300 mg (or ranitidine, 50 mg EV) before paclitaxel

Guidelines and precautions	The initial dose is administered at a rate not exceeding 1 mg/min. If no infusion reaction is observed, subsequent infusions can be administered over a period of 60 min In cases of palmar-plantar erythrodysesthesia, hematologic toxicity and stomatitis, the dose can be reduced or delayed	Should not be administered with other chemotherapeutic drugs (no studies on interactions) Heart failure can occur with cumulative dose above 300 mg/m²May cause myelosuppression (especially of granulocytic series)	Leucopenia reaches its lowest point in 10–14 days, with Retrieval approximately on day 21 Cumulative dose above 550 mg/m²: risk of heart failure. Significant finding on ECG: QRS voltage reduction Can be used with other chemotherapeutic c agents	When in combination with vincristine, administer it previously as it increases sensitivity to bleomycin. Risk of pulmonary fibrosis increases with cumulative doses above 400 U Low myelotoxicity. Can be associated with other chemotherapeutic agents	Common occurrence of neuropathy Little Myelosuppressi ve effect Can be used with other chemotherapeutic agents	Do not administer with doxorubicin When administered with bleomycin, apply vinblastine beforehand Alopecia Dose-dependent leukopenia	Some antiretroviral drugs are enzyme inducers and can interfere with the activity of paclitaxel by increasing metabolism Use G-CSF or peg-GCSF as primary prophylaxis when there is risk of neutropenic fever >20% or secondary to filgrastim 5 mcg/kg/day or pegfilgrastim a 6 mg subcutaneousl y per dose (only if the interval between cycles >2 weeks). Note: Always start 24 h after the end of chemotherapy

[TFN01t01] ^a
Non-nodular disease confined to the palate; symptoms B = unexplained fever, night sweats, >10% weight loss or persistent diarrhea lasting more than 2 weeks

[TFN02t01] ^PS
= Karnofsky scale; adapted from ACTG-AIDS Clinical Trials Group Oncology Committee.

Consensus of the Brazilian Society of Infectious Diseases and Brazilian Society of Clinical Oncology on the management and treatment of Kaposi's sarcoma

Abstract