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Kaposi Sarcoma

Kaposi sarcoma is a multifocal neoplasm of reticuloendothelial cells. It was first described by Moritz Kaposi in 1872.

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Presentation

The skin lesions may be nodular, papular or blotchy and the colour may be red, purple, brown or black. These characteristics may also be seen under or on mucous membranes. The most common sites of the lesions are the throat, nose and mouth and unless they are swollen or inflamed, they are usually painless.

The lesions may equally involve internal organs like lungs (bringing about dyspnoea), the gastrointestinal tract (leading to fatal bleeding) and the lymphatics bringing about lymphedema.

In some cases, there is superimposed bacterial infection. In transplant recipients, the tumor spreads. On rare occasions, lesions occurring in the respiratory tract or the oesophagus may bring about obstruction [7].

Lymphedema
  • Lymphedema could promote the development of certain tumors by altering immunocompetence.[ncbi.nlm.nih.gov]
  • Quality-of-Life measure (LYMQOL) for Kaposi Sarcoma [ Time Frame: 3 years ] The Lymphedema Quality-of-Life measure (LYMQOL) has separate tools for assessing arm lymphedema and leg lymphedema.[clinicaltrials.gov]
  • The treatment options include surgical excision, cryotherapy, radiotherapy, intralesional chemotherapy, laser, and elastic stockings for the prevention of lymphedema.[ncbi.nlm.nih.gov]
  • KS-IRIS was defined as 2 of the following: abrupt increase in number of KS lesions, appearance or exacerbation of lung-opacities or lymphedema, concomitantly with an increase in CD4 cell-count 50 cells/mm 3 and a decrease of 1 log in viral-load once started[ncbi.nlm.nih.gov]
  • KS is also intimately associated with lymphedema. Chronic lymphedema may even precede KS lesions.[diagnosticpathology.biomedcentral.com]
Lymphadenopathy
  • CONCLUSIONS In conclusion, posttransplant KS may present as general lymphadenopathy without mucocutaneous manifestations, thus mimicking posttransplant lymphoproliferative disorder, which is often the first clinical suspicion.[ncbi.nlm.nih.gov]
  • Kaposi sarcoma herpesvirus (KSHV)-associated multicentric Castleman disease (MCD) is a rare, polyclonal lymphoproliferative disorder characterized by flares of inflammatory symptoms, edema, cytopenias, lymphadenopathy, and splenomegaly.[ncbi.nlm.nih.gov]
  • A CT scan showed diffuse pulmonary infiltrates with a 'tree-in-bud' appearance, striking splenomegaly and abdominal lymphadenopathy. A bronchoscopy was performed, revealing typical Kaposi's lesions in the upper respiratory tract.[ncbi.nlm.nih.gov]
  • A new TAP CT, performed at 5 months from the diagnosis, showed stable disease (SD), with a minor reduction in size of mediastinal lymphadenopathies.[ncbi.nlm.nih.gov]
  • Computed tomography showed lung lesions and hilar lymphadenopathy, while magnetic resonance imaging showed an increased signal in the cervical cord.[ncbi.nlm.nih.gov]
Generalized Lymphadenopathy
  • CONCLUSIONS In conclusion, posttransplant KS may present as general lymphadenopathy without mucocutaneous manifestations, thus mimicking posttransplant lymphoproliferative disorder, which is often the first clinical suspicion.[ncbi.nlm.nih.gov]
  • lymphadenopathy – particularly cervical region Highly aggressive – death within 2 years Epidemic form Males 30 years with HIV More common in men having sex with men Aggressive tumor with systemic involvement Transplant form Tends to develop within months[arupconsult.com]
  • lymphadenopathy Generalized swelling of lymph nodes Swollen lymph nodes affecting all regions of the body [ more ] 0008940 Hemangioma Strawberry mark 0001028 Immunodeficiency Decreased immune function 0002721 Lymphoproliferative disorder 0005523 Papule[rarediseases.info.nih.gov]
  • It is characterized by generalized lymphadenopathy and has an aggressive clinical behavior, killing within two years after the diagnosis. 6 The KS associated with immunosuppressive states develops mainly in solid organs transplant receivers, but also[scielo.br]
Lymphocyte Disorder
  • Abstract Kaposi sarcoma-associated herpesvirus (KSHV) is linked with the development of Kaposi sarcoma and the B lymphocyte disorders primary effusion lymphoma (PEL) and multi-centric Castleman disease.[ncbi.nlm.nih.gov]
Cough
  • The patient in our case presented with progressive dyspnoea and cough. Chest radiograph reveals complete opacification of the hemithorax. Complete lung consolidation was not seen on chest CT.[ncbi.nlm.nih.gov]
  • CASE REPORT A 34-year-old heterosexual male presented with a one month history of cough and 15-20 pound weight loss within six months. Examination revealed oral thrush, decreased breath sounds and crackles on the right lower lung base.[ncbi.nlm.nih.gov]
  • Case Presentation A 40 year-old HIV positive homosexual male not on HAART Therapy presents with a 1month history of intractable cough, hemoptysis and shortness of breath.[austinpublishinggroup.com]
  • Complications can include: Cough (possibly bloody) and shortness of breath if the disease is in the lungs Leg swelling that may be painful or cause infections if the disease is in the lymph nodes of the legs The tumors can return even after treatment.[nlm.nih.gov]
  • […] reticulonodular pulmonary infiltrates, solitary lung nodules, or pleural effusions Tumor follows lymphatic channels Detection of HHV8 DNA is highly specific and sensitive for diagnosis of pulmonary Kaposi sarcoma Case reports 42 year old HIV man with chronic coughing[pathologyoutlines.com]
Pleural Effusion
  • A 50-year-old man who had received kidney transplantation from a living unrelated donor presented with a massive left-side pleural effusion, ascites, and a skin lesion. The pleural effusion and ascites were bloody.[ncbi.nlm.nih.gov]
  • We report a 52-year-old Caucasian man with HIV/AIDS and Kaposi sarcoma who presented with dyspnea and pleural effusion. He reported numerous tender subcutaneous nodules developing over the past few months on his chest, back and abdomen.[ncbi.nlm.nih.gov]
  • Definition / general Usually associated with AIDS, HHV8 infection; also immunocompromise, organ transplant Diffuse reticulonodular pulmonary infiltrates, solitary lung nodules, or pleural effusions Tumor follows lymphatic channels Detection of HHV8 DNA[pathologyoutlines.com]
  • Chest examination was consistent with bilateral pleural effusion. Other physical examinations were unremarkable.[academic.oup.com]
  • effusion(s) mediastinal and/or hilar lymphadenopathy CT On HRCT of the chest: ill-defined (flame-shaped) nodular opacities with usually bilateral and roughly symmetrical perilymphatic and peribronchovascular distribution (1-2 mm) 1 may have surrounding[radiopaedia.org]
Hemoptysis
  • It's a 46-year-old Chinese man presented with sore throat, hemoptysis, fever, dyspnea and multiple lung nodules. The lung lesions grew over a 5-month period so as the symptoms worsened.[ncbi.nlm.nih.gov]
  • Case Presentation A 40 year-old HIV positive homosexual male not on HAART Therapy presents with a 1month history of intractable cough, hemoptysis and shortness of breath.[austinpublishinggroup.com]
  • Dyspnea, cough, hemoptysis, stridor, nodular infiltrates, pleural effusion, low diffusion capacity, and absence of arterial desaturations are more likely to be due to pulmonary KS than to opportunistic infections. 7 However, among persons at high risk[contagionlive.com]
  • Complications include: ulceration of skin lesions bleeding of the skin, mucous membranes, GI tract hemoptysis anemia lymphedema shortness of breath respiratory failure Risk factors for poor outcome include: visceral involvement diffuse mucocutaneous disease[infectiousdiseaseadvisor.com]
Dyspnea
  • We report a 52-year-old Caucasian man with HIV/AIDS and Kaposi sarcoma who presented with dyspnea and pleural effusion. He reported numerous tender subcutaneous nodules developing over the past few months on his chest, back and abdomen.[ncbi.nlm.nih.gov]
  • It's a 46-year-old Chinese man presented with sore throat, hemoptysis, fever, dyspnea and multiple lung nodules. The lung lesions grew over a 5-month period so as the symptoms worsened.[ncbi.nlm.nih.gov]
  • A 40 year old HIV positive homosexual male presented with fever, intractable cough and dyspnea. He was noted with non blanching purple skin lesions all over his body. CD4 count was 63 cells/mm3and viral load of 50,000.[austinpublishinggroup.com]
  • Dyspnea, cough, hemoptysis, stridor, nodular infiltrates, pleural effusion, low diffusion capacity, and absence of arterial desaturations are more likely to be due to pulmonary KS than to opportunistic infections. 7 However, among persons at high risk[contagionlive.com]
  • Internal involvement: in advanced disease, patients may develop pulmonary and/or gastrointestinal (GI) involvement, and associated symptoms may include nausea, vomiting, GI bleeding, perforation, ileus, cough, bronchospasm, and/or dyspnea. Figure 1.[infectiousdiseaseadvisor.com]
Nausea
  • Side effects include fever, chills, loss of appetite, headaches, nausea, fatigue and body aches. Preventive measures Preventive measures include practicing safe sex to reduce the risk of acquiring HIV.[news-medical.net]
  • Lesions in the gastrointestinal tract may lead to nausea, diarrhea, bleeding with stools and vomiting in some individuals. Over a long term bleeding may lead to anemia. This is caused due to lowering in the number of red blood cells.[news-medical.net]
  • Dear Editor, A male, 29-year-old, homosexual patient presenting with history of 20 kg-weight loss, asthenia, nausea and stomach pain for three months in association with appearance of skin lesions in upper limbs and scrotal sac.[scielo.br]
  • When the tumours grow in the digestive tract, they can cause nausea and sickness as well as possible bleeding. In the lungs, Kaposi sarcoma can cause breathlessness and a cough. If the lymph nodes are affected they can become swollen.[cancervic.org.au]
Vomiting
  • Chemotherapy drugs for Kaposi's sarcoma include: Doxorubicin ( Adriamycin, Doxil ) Paclitaxel ( Taxol ) Vinblastine ( Velban ) Chemotherapy can have side effects, including hair loss, vomiting, and fatigue.[webmd.com]
  • Lesions in the gastrointestinal tract may lead to nausea, diarrhea, bleeding with stools and vomiting in some individuals. Over a long term bleeding may lead to anemia. This is caused due to lowering in the number of red blood cells.[news-medical.net]
  • If you still feel sick or are vomiting, contact the hospital as soon as possible. They can give you advice and change the anti-sickness drug to one that works better for you.[macmillan.org.uk]
  • This can cause: uncomfortable swelling in the arms or legs (lymphoedema) breathlessness, coughing up blood, and chest pain nausea, vomiting, stomach pain, and diarrhoea How quickly the symptoms progress depends on the type of Kaposi's sarcoma.[nhs.uk]
Abdominal Pain
  • We report the case of a 45-year-old young woman with abdominal pain, episodic diarrhea and a mild weight loss.[ncbi.nlm.nih.gov]
  • Lesions that develop in the stomach and intestines can cause abdominal pain and diarrhea. Sometimes KS lesions bleed. If the lesions are in the lung, it can cause you to cough up blood and lead to shortness of breath.[cancer.org]
  • pain Treatment Chemotherapy and radiation preferred over surgery Clinical images Images hosted on other servers : Kaposi sarcoma Cherry red polyps on endoscopy Gross description Reddish brown to purple macules or polyps, typically 0.5 - 1.5 cm Microscopic[pathologyoutlines.com]
  • Upper Endoscopy Doctors may recommend an upper endoscopy for people with Kaposi sarcoma skin lesions who also have abdominal pain or blood in the stool.[nyulangone.org]
  • Lesions in the digestive tract may lead to abdominal pain, diarrhea, or bleeding from the rectum.[mskcc.org]
Melena
  • Lesions are often asymptomatic and clinically indolent, but signs and symptoms can include the following: Odynophagia, dysphagia Nausea, vomiting, abdominal pain Hematemesis, hematochezia, melena Bowel obstruction Pulmonary lesions may be an asymptomatic[emedicine.com]
  • […] and fluorine-18-fluorodeoxyglucose (F-FDG) positron emission tomography (PET)/CT findings in an adult patient with KH associated with lymphangiomatosis involving mesentery and ileum.A 22-year-old female complained of a 9-month history of intermittent melena[cancerindex.org]
Dysphagia
  • A 57-year-old African woman was admitted to our clinic with a 1-week history of dysphagia and hematemesis. Her medical history was relevant for recently diagnosed human immunodeficiency virus (HIV). On admission she was hypotensive and tachycardic.[scielo.mec.pt]
  • Lesions are often asymptomatic and clinically indolent, but signs and symptoms can include the following: Odynophagia, dysphagia Nausea, vomiting, abdominal pain Hematemesis, hematochezia, melena Bowel obstruction Pulmonary lesions may be an asymptomatic[emedicine.com]
Chest Pain
  • This can cause: uncomfortable swelling in the arms or legs (lymphoedema) breathlessness, coughing up blood, and chest pain nausea, vomiting, stomach pain, and diarrhoea How quickly the symptoms progress depends on the type of Kaposi's sarcoma.[nhs.uk]
  • Internal organs can also be affected, including the lymph nodes, lungs and the digestive system, which can cause symptoms such as: uncomfortable swelling in the arms or legs (lymphoedema) breathlessness, coughing up blood and chest pain nausea, vomiting[nhsinform.scot]
Vascular Disease
  • Cardiovascular late side effects have been termed radiation-induced heart disease (RIHD) and radiation-induced vascular disease (RIVD). [24] Symptoms are dose dependent and include cardiomyopathy, myocardial fibrosis, valvular heart disease, coronary[en.wikipedia.org]
Skin Lesion
  • CONCLUSIONS: The CXCL12/CXCR4-CXCR7 trio is upregulated in KS and correlates with KS pathophysiological markers and the severity of skin lesions.[ncbi.nlm.nih.gov]
  • Skin lesions associated with CLL mostly develop on the bases of infectious or a hemorrhagic origin with an estimated incidence of 25% of all the cases.[ncbi.nlm.nih.gov]
  • Acroangiodermatitis (AAD) (synonym, pseudo-Kaposi sarcoma) is a term that encompasses 2 different conditions: (1) AAD of Mali, which refers to skin lesions that mainly develop bilaterally on the lower extremities of patients with chronic venous insufficiency[ncbi.nlm.nih.gov]
  • Typically, it can be identified because of the classical skin lesion. We herein report an unusual case of rapid progressive KS without skin lesions in a 52-year-old patient leading to death within 8 months after kidney transplantation.[ncbi.nlm.nih.gov]
  • Dermatologists reviewed the skin lesions and diagnosed KS, which was confirmed with biopsies. The patient's neurological deficit remains.[ncbi.nlm.nih.gov]
Skin Plaque
  • There are four recognized variants 1 : classic (chronic): multiple distal lower extremity predominant purple skin plaques and rarely involve visceral organs endemic (lymphadenopathic): common in equatorial Africa iatrogenic (organ transplant-related)[radiopaedia.org]
  • […] shape [ more ] 0002088 Abnormality of the liver Abnormal liver Liver abnormality [ more ] 0001392 Diarrhea Watery stool 0002014 Fatigue Tired Tiredness [ more ] 0012378 Fever 0001945 Lymphedema Swelling caused by excess lymph fluid under skin 0001004 Skin[rarediseases.info.nih.gov]
Skin Papule
  • Stage II, rosacea papulopustulosa (vascular rosacea), is characterized by persistent facial erythema, telangiectasia, thickened skin, papules and pustules (Fig 9 ).[doi.org]
Eczema
  • Because Paget’s disease often originates from breast duct cancer, the eczema-like cancer usually appears around the nipple. Paget’s disease also is considered a rare form of breast cancer.[massey.vcu.edu]
  • Eczemas were the leading disease group (43.7%), with unclassified eczemas (33.9%) predominating. Papulosquamous disorders (15.4%) were second with psoriasis (50%) being the leading disease.[cancerindex.org]
Skin Discoloration
  • The use of intralesional interferon (IFN)-alfa (3-5 MU three times per week for 3-4 weeks) achieves similar results.(21) As with other local therapies, skin discoloration is the rule posttherapy.[hivinsite.ucsf.edu]
Limb Weakness
  • The patient then developed unilateral limb weakness. Computed tomography showed lung lesions and hilar lymphadenopathy, while magnetic resonance imaging showed an increased signal in the cervical cord.[ncbi.nlm.nih.gov]

Workup

Even though KS can be detected from the appearance of lesions and the risk factor of the patient, definitive diagnosis can only be made by biopsy and microscopic examination. When KSHV protein LANA is detected in the tumor cells, the diagnosis is confirmed [8].

Again patients with HIV infection will need to undergo CD4 lymphocyte counts and plasma HIV viral-load studies.

Chest X-Ray Abnormal
  • However, the isolation of this agent is difficult to obtain, which justifies the sub-notification of the entity and the empirical treatment of patients with cough and chest X ray abnormalities. 16 Data on viral load and CD4 from the patients with the[scielo.br]
Liver Biopsy
  • We describe a case of rapid obstructive jaundice after initiation of antiretroviral therapy, in which the liver biopsy confirmed hepatic Kaposi sarcoma, and the clinical course was altered by the addition of montelukast.[ncbi.nlm.nih.gov]
Pleural Effusion
  • A 50-year-old man who had received kidney transplantation from a living unrelated donor presented with a massive left-side pleural effusion, ascites, and a skin lesion. The pleural effusion and ascites were bloody.[ncbi.nlm.nih.gov]
  • We report a 52-year-old Caucasian man with HIV/AIDS and Kaposi sarcoma who presented with dyspnea and pleural effusion. He reported numerous tender subcutaneous nodules developing over the past few months on his chest, back and abdomen.[ncbi.nlm.nih.gov]
  • Definition / general Usually associated with AIDS, HHV8 infection; also immunocompromise, organ transplant Diffuse reticulonodular pulmonary infiltrates, solitary lung nodules, or pleural effusions Tumor follows lymphatic channels Detection of HHV8 DNA[pathologyoutlines.com]
  • Chest examination was consistent with bilateral pleural effusion. Other physical examinations were unremarkable.[academic.oup.com]
  • effusion(s) mediastinal and/or hilar lymphadenopathy CT On HRCT of the chest: ill-defined (flame-shaped) nodular opacities with usually bilateral and roughly symmetrical perilymphatic and peribronchovascular distribution (1-2 mm) 1 may have surrounding[radiopaedia.org]

Treatment

Kaposi Sarcoma is generally incurable and can only be controlled using palliative treatments. All underlying causes will however be treated where possible such as immunosuppression and immunodeficiency. For AIDS related KS or epidemic KS, beginning HAART will often lead to a reduction of lesions in more than 40% of cases [9]. However, the KS will continue to grow in some instances even with the use of antiretrovirals.

When there are only a few lesions, the treatments that can be considered include: Radiotherapy, cryothrapy or cryosurgery.

Surgery has the risk of KS occurring on the edges of the wound and is often only appropriate for small lesions on the surface. To prevent KS occurring on edges, electrodessication with curettage can equally be used.

For a more widespread KS or organ involvement, systemic therapy is required. Examples of such therapy include interferon alfa, liposomal anthracyclines and paclitaxel.

Prognosis

Prognosis is dependent on the variation of KS, how deeply the immune system is affected, presence of dissemination and whether or not the KS is recurrent [6]. Since the AIDS death rate declined in the 1990s however, there has been a reduction in the severity of KS conditions and the general occurrence.

Etiology

As stated above, the KS disease is caused by infection with a virus known as the Kaposi sarcoma herpes virus, KSHV or the human herpesvirus 8 (HHV8). The KSHV virus is similar to the Epstein-Barr virus known to cause mononucleosis and other varieties of cancer.

With KS, the endothelial cells become infected with KSHV. The presence of the virus brings in genes that cause excessive cell divisions and make the cells live longer than normal. A combination of these changes, end up turning them into cancerous cells.

Infection with the KSHV virus is more common than the KS disease condition and many people who get infected with this virus do no go on to develop KS. In fact a greater percentage of people with KSHV do not show any symptoms [2]. For KS to occur KSHV must be present but in many cases the virus on its own does not bring about KS. People who develop KS have a weak immune system that may be caused by HIV infection, organ transplant, older age etc.

Epidemiology

Kaposi Sarcoma was rare in the United States before the AIDS epidemic. In recent times, the figures have gone back to pre-epidemic figures.

In Africa however, the incidence of KS is quite high with 37.7 cases per 100,000 men and 20.5 cases per 100,000 women. The highest incidence of Kaposi sarcoma in Europe is seen in Sicily with 30 cases per million for men and 5.4 cases per million in women [3].

Sex distribution
Age distribution

Pathophysiology

Regardless of the name, KS is not truly considered to be a sarcoma as sarcomas often arise from a mesenchymal tissue. On the other hand, KS is a cancer of the lymphatic endothelium forming vascular channels that are filled with blood cells. The filled vascular channels are what give the resultant KS tumor its bruise like appearance. In KS cancer cells, KSHV proteins are uniformly detected [4].

KS lesions have tumor cells with a characteristically abnormal elongated shape known as spindle cells. The most typical feature of Kaposi sarcoma is the presence of spindle cells that form slits containing red blood cells. Pleomorphism is often absent and Mitotic activity is only moderate. The tumor is very vascular and contains irregular blood vessels that are abnormally dense. This is what gives the tumor its dark colour. Inflammation around this tumor may produce swelling and pain.

HHV8 is found in all lesions of KS regardless of whether it is HIV related, classic, endemic or iatrogenic [5].

Prevention

There are still doubts till date as to how Kaposi sarcoma herpes virus is acquired but it is commonly believed to be transmitted through the saliva of an infected person. Therefore the first step is to avoid body fluids from individuals diagnosed with the KSHV. However, keep in mind that the KS condition will only develop if there are other enabling factors [10].

Summary

Kaposi sarcoma (KS) is a cancer of the connective tissue caused by the human herpes virus 8. This virus is now known as the Kaposi sarcoma associated virus (KSHV) [1]. The condition is basically a malignant lesion that is characterised by neoplastic cells and abnormally growing blood vessels. Named by the Hungarian dermatologist Moritz Kaposi who discovered it in 1872, its viral gene sequence was only determined recently in 1995-1996. The lesions from KS may begin in more than one place at the same time making it different to other neoplasms.

The different types of KS include:

  • Classic KS
  • Endemic or African KS
  • Transplant-related or acquired KS
  • Epidemic KS
  • Non-epidemic KS
  • Recurrent KS

Patient Information

Kaposi sarcoma (KS) is a cancer of the skin that can also affect other parts of the body. The condition is caused by a virus and it is mostly seen in individuals that have an immune system that is not as strong as should be. The condition is relatively common with individuals living with AIDS and is seen around the world.

On its own, KS isn't life threatening but a lot depends on how deeply the immune system has been affected. There is no conclusive treatment for it but when there are a few lesions, radiotherapy may be used. One important part of management of this condition is regular support by health professionals. To prevent Kaposi sarcoma, patients with a disease that affects the immune system should stay away from body fluids from patients of the KS condition.

References

Article

  1. Maurer TA. Dermatologic manifestations of HIV infection. Top HIV Med. 2005 Dec-2006 Jan;13(5):149-54.
  2. Arav-Boger R. Treatment for Kaposi sarcoma herpesvirus: great challenges with promising accomplishments. Virus Genes. 2009 Apr;38(2):195-203. Epub 2009 Jan 13.
  3. Coogan MM, Greenspan J, Challacombe SJ. Oral lesions in infection with human immunodeficiency virus. Bull World Health Organ. 2005 Sep;83(9):700-6. Epub 2005 Sep 30.
  4. Guttman-Yassky E, Kra-Oz Z, Dubnov J, et al. Infection with Kaposi's sarcoma-associated herpesvirus among families of patients with classic Kaposi's sarcoma. Arch Dermatol. 2005 Nov;141(11):1429-34.
  5. Dupuy A, Schulz T, Chevret S, et al. Asymmetrical transmission of human herpesvirus 8 among spouses of patients with Kaposi sarcoma. Br J Dermatol. 2009 Mar;160(3):540-5. Epub 2008 Dec 10.
  6. Gao SJ, Kingsley L, Hoover DR, et al. Seroconversion to antibodies against Kaposi's sarcoma-associated herpesvirus-related latent nuclear antigens before the development of Kaposi's sarcoma. N Engl J Med 1996; 335:233.
  7. Gao SJ, Kingsley L, Li M, et al. KSHV antibodies among Americans, Italians and Ugandans with and without Kaposi's sarcoma. Nat Med 1996; 2:925.
  8. Martin JN, Ganem DE, Osmond DH, et al. Sexual transmission and the natural history of human herpesvirus 8 infection. N Engl J Med 1998; 338:948.
  9. Schwartz RA. Kaposi's sarcoma: an update. J Surg Oncol 2004; 87:146.
  10. Mohanna S, Sanchez J, Ferrufino JC, et al. Lymphangioma-like Kaposi's sarcoma: report of four cases and review. J Eur Acad Dermatol Venereol 2006; 20:1010.

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Last updated: 2019-07-11 22:01