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LOGO

Pathology of Kaposi Sarcoma

Dr. Amal Abd El Hafez

Ph.D. Pathology;
Faculty of Medicine; Mansoura University, Egypt.
Journal of Cytology& Histology editorial board member.
Pathology of Kaposi Sarcoma
Kaposi´s sarcoma (KS) is an angio-proliferative
spindle cell neoplasm of low grade malignancy,
described by Moritz Kaposi in 1872. It may be solitary
or multifocal. It originates almost from lymphatic
endothelium and it was considered rare until the
discovery of the Acquired Immunodeficiency Syndrome
(AIDS).
 Types of KS

Currently four types are recognized: classic,

endemic, epidemic and iatrogenic.

Despite the fact that each of them has a distinct

progress, they all have in common the participation of
the human herpes virus type 8 (HHV-8) or the Kaposi´s
sarcoma associated herpes virus (KSHV), although other
factors are necessary for the occurrence of the disease.
1. Classic (indolent) KS:

The classic (indolent) KS is seen in white older men of Southern

Mediterranean or Eastern European heritage (over 60 years old in 90%
of the cases) and is not related to HIV infection.

The disease initiates as violaceous or reddish brown maculae and

papules on the feet or hands, progressing to the legs (most common
site) and arms. In 10% of the cases there is involvement of viscera and
mucosa.

It progresses over many years and is not often fatal.

2.Endemic (African) KS :
The endemic KS is divided into two subtypes:
a. African Cutaneous KS b. African Lymphadenopathic KS
It develops in middle age It develops mainly children from
adults (25 to 50 years old) the “Bantu” ethnicity less than 10
from tropical Africa, can years old. It is characterized by
involve bones, causes legs generalized lymphadenopathy and
to swell, and has only local has an aggressive clinical behavior,
aggressiveness. killing within two years after the
diagnosis.
3. Epidemic (AIDS associated) KS:
AIDS was described in 1981, in patients where the KS was the main
element of the syndrome, observed in 30 to 40% of them. This form of KS
develops predominantly in homosexuals and bisexuals, being rare in injectable
drug users and heterosexuals. Due to the changes on the sexual behavior and
the antiretroviral drugs, its frequency went from 40% at the beginning of the
90ties to 15% nowadays. AIDS associated KS starts as small, non-itchy, slightly
painful, violaceous patches first around the head and neck, trunk, limbs and
oral mucosa, with subsequent progression to plaques and nodules. Visceral
lesions are frequent and gastrointestinal and pulmonary involvements are
common. It advances very rapidly, but is not always fatal.
4. Iatrogenic (immunosupression) KS:

The KS associated with immunosuppressive states develops

mainly in solid organs transplant receivers, but also in those
with neoplastic diseases and those with autoimmune conditions
under immunosuppressive treatment. The clinical and
morphological aspects are similar to the classic form. The
suspension of the immunosuppressive treatment usually causes
the regression of the lesions, but increases the risk of losing the
transplant.
 Pathogenesis
Various cofactors have been implicated in the pathogenesis
of KS, including genetic susceptibility, immunologic alterations,
and endocrine factors.

Human herpes virus 8 (HHV-8) also known as Kaposi

sarcoma-associated herpes virus (KSHV) is believed to be a
major causative factor for all clinical variants of KS. The
mechanisms linking infection with this virus to the vascular
lesions are unknown.
 Pathogenesis (cont.)
One hypothesis is that HHV-8 infects lymphatic endothelial or
other cells. The 165 kb HHV-8 genome is notable for molecular
mimicry of several genes homologous to human cellular regulatory
genes that are likely to contribute to the pathogenesis of KS through
complex interactions with human immune and endothelial systems
and promotion of cellular survival and proliferation.

KSHV proteins may disrupt the control of cellular proliferation

and prevent apoptosis of endothelial cells, through the production of
p53 inhibitors and a viral homologue of cyclin D.
 Pathogenesis (cont.)
In AIDS associated KS, the HHV-8 induced effects concert
with cytokines produced by HIV-infected immune cells, to
stimulate proliferation of the vascular cells.

However, classic KS may arise subsequent to other

malignancy (often of the reticuloendothelial system). This
primary malignancy may precede, coincide with or follow the
occurrence of classic KS, offering the suggestion of a common
etiology.
 Gross pathology and disease distribution

Cutaneous lesions of KS usually arise as multicentric neoplasm

evidencing as slow progressing multiple vascular cutaneous raised red
or purple macules or patches. The lesions could acquire nodular
characteristics when the disease progresses. Lesions may be limited to
skin or sometimes arises to oral cavity or other mucosal surfaces as
mucosal nodules. Lymph nodes or viscera may be involved. The
gastrointestinal tract is the most common extracutaneous site of
involvement. Other visceral organs that may be affected include liver,
heart and lungs.
Gross appearance of different Kaposi Sarcoma
lesions including multicentric patch and
nodular cutaneous and oral mucosal lesions.
 Microscopic features
The tumor reveals proliferation of spindle cells (that are mostly
latently infected with KSHV) arranged in fascicles with interspersed
vascular channels filled with red blood cells. Tumors are distinguished
by inflammatory infiltrates, extravasated red blood cells, hemosiderin-
laden macrophages and leaky vasculature. Occasional PAS-positive
diastase-resistant hyaline globules may be seen. Pleomorphism is
usually minimal and mitosis is occasional. The hyaline globules and
spindle cells are positive for CD34. Early lesions are difficult to
distinguish from granulation tissue.
 Microscopic features (cont.)

The microscopic pictures provided here are for a Kaposi’s

sarcoma lesion from a middle age male patient who was receiving
chemotherapy for a malignant lymphoma then developed a cutaneous
patch lesions in the arm which was biopsied and sent to our laboratory
for histopathologic examination.

Moreover, the serologic assessment for the patient confirmed

his HHV-8 positive serostatus.
Histopathology shows ill-defined vascular proliferation in the
dermis (H&E, x100).
 The tumor is composed of proliferating spindle cells with
interspersed vascular channels filled with red blood cells. Note the
inflammatory infiltrate, extravasated red blood cells and the hyaline
globules (H&E,x200).
 How do diagnose KS?
1. Histopathologic examination of tissue biopsy is mandatory for diagnosis.

2. HHV-8 serostatus determined by detection of antibodies to viral lytic

antigens by indirect immunofluorescence, combined with the detection of
specific antibodies to the K8.1 HHV-8 protein by ELISA.

3. Serum testing for antibodies to HIV, using ELISA and Western Blot.

4. Chest radiography.

5. When clinically indicated, gastrointestinal endoscopy and abdominal

ultrasound or computerized tomography (CT).
 Staging Systems for KS
There is no officially accepted system for staging Kaposi
sarcoma. However Mitsuyasu classification system is the most simple
and clinicaly acceptable system which comprises 4 stages:

Stage I: Localized nodular Kaposi sarcoma in elderly men

Stage II: Localized, invasive, and aggressive Kaposi sarcoma (mostly

seen in Africa)

Stage III: Disseminated mucocutaneous Kaposi sarcoma in African

children and patients who are homosexual

Stage IV: Stage III with visceral involvement

 Prognosis of KS?
Prognosis appears to correlate with the degree of immunosuppression
and older age among classic KS patients. Clinical classification of KS may be the
best prognosticator, comparing localized nodular disease, locally aggressive
disease, and generalized KS. Because indolent KS appears in the elderly and
takes many years to develop, many patients die of another condition before
their KS becomes serious enough to be fatal.

African KS appearing in young children are the most serious. Left untreated,
these forms can result in death in a few short years.

Despite the fact that it is associated with AIDS, AIDS-related KS is most

commonly treatable and not fatal.
 How to treat KS?
Even though it often progresses slowly, KS can ultimately be fatal, so
it should always be treated.

There are several ways of treating KS, including:

1.Surgical excision for small single or few localized tumors,

2.Cryotherapy,

3.Electrodessication,

4.Chemotherapy (doxorubicin lipid complex),

5.Interferon (an anti-viral agent), and

6.Radiation (in treating KS when the lesions are not spread over a large part of
the body).
 Suggested References
1. Antonio Angeloni, Maria Vittoria Masala, Maria Antonietta Montesu, Roberta
Santarelli, Rosanna Satta et al. (2006) Clinical Infectious Diseases ; 42:e66–68.

2. Hassan Errihani, Narjisse Berrada, Soundouss Raissouni, Fadoi Rais, Hind Mrabti
et al. (2011) Classic Kaposi’s sarcoma in Morocco: Clinico - epidemiological study
at the National Institute Of Oncology. BMC Dermatology; 11:15.

3. Ricardo Montibeler Tiussi, Antonio Luiz de Oliveira Caus, Lucia Martins Diniz,
Elton Almeida Lucas (2012) Kaposi's Sarcoma: clinical and pathological aspects in
patients seen at the Hospital Universitário Cassiano Antônio Moraes - Vitória -
Espírito Santo – Brazil. An Bras Dermatol;87(2):220-227.
4. Thomas S. Uldrick, Denise Whitby (2011) Update on KSHV-
Epidemiology, Kaposi Sarcoma Pathogenesis, and Treatment of Kaposi
Sarcoma. Cancer Lett ; 305(2): 150–162.

5. Pramod Kumar (2011) Classic Kaposi's sarcoma in Arabs - Widening

ethnic involvement. J Can Res Ther;7:92-94.
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