LETTERS TO THE EDITOR

 

Colorrectal Kaposi's sarcoma

Sarcoma de Kaposi colorrectal

 

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Key words: GIST. Kaposi's sarcomar. HVV8.

Palabras clave: GIST. Sarcoma de Kaposi. HVV8.

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Dear Editor,

Regarding the case published by Ferreira et al. (1) about Kaposi's sarcoma, we would like to contribute a reflection based on a clinical case.

The diagnosis of Kaposi's sarcoma outside the immunosuppression context is complex and difficult to differentiate especially from GIST.

From the pathological point of view, both diseases can be positive for the markers CD117, c-kit and CD34 (2). The difference lies in the Kaposi's sarcoma positivity for HHV8 (3) (99 % sensitivity, 100 % specificity), apart from infiltration of the lamina propria, the presence of lymphoplasmocytic infiltrates and hemosiderin deposits (4), findings that usually are linked to a young and immunocompromised patient, usually HIV+ (5).

Until the introduction of the highly active antiretroviral therapy (HAART), Kaposi's sarcoma was virtually endemic in these patients (6). Subsequently, there has been a significant decline due to the restoration of the immune system (7), since the HHV8 is inhibited by T lymphocytes. It has also been seen that certain protease inhibitors may reduce the development and progression of typical lesions of Kaposi's sarcoma because of their antiangiogenic effect (8).

 

Case report

We report the case of a 26-year-old male with no history of interest who consulted for diarrhea. The previous week, he had been treated with amoxicillin-clavulamico acid because of a respiratory infection; so initially, it was attributed to previous antibiotic. Due to the persistence of symptoms, with fatigue and weight loss, the study was extended to:

- Colonoscopy: Multiple polypoid formations like mushrooms, red, some ulcerated, with variable sizes from milimeters to 2.5 cm, spread from the rectum to the cecum, suggestive of lymphoma, but that turned out to have a nonspecific biopsy.

- Upper endoscopy: Nodule in stomach, 1 cm approximately, ulcerated, with biopsy of vascular congestion.

- TC thoracoabdominal: Small apical infiltrates right upper lobe. Discrete splenomegaly.

Considering the differential diagnosis between lymphoma and unusual inflammatory disease, we decided to repeat the colonoscopy and biopsy, which this time was compatible with GIST.

The case was discussed in a multidisciplinary committee, and after repeating again a colonoscopy, surgery was decided: total proctocolectomy with ileal J-pouch and loop ileostomy (Fig. 1).

 

 

Final pathological supports multiple Kaposi's sarcoma (42 injuries, some of them reaching the underlying fat), 61 nodes included (13 with metastases).

A new clinical history was made, recognizing the patient risk homosexual practices and physical examination detected telangiectasias on face, a lesion on the palate and one on the fifth toe, consistent with cutaneous Kaposi's sarcoma.

The study was completed and AIDS was diagnosed with stage C3 130 CD4 with Kaposi's sarcoma with oral, cutaneous and digestive affection, correlating as TIS staging system for Kaposi's sarcoma with stage T1 (tumor extended), I1 (< 200 CD4), S1 (presence of B symptoms: diarrhea > 2 weeks and weight loss in this case), indicative of poor prognosis.

Treatment was initiated with HAART and it was proceeded to ileostomy closure 5 months later.

 

Discussion

In conclusion, we emphasize the importance of a complete medical history and a physical examination. The diagnosis accuracy of biopsies is also important and to provide accurate information to pathologists.

 

Rocío Soler-Humanes¹, Luis Alonso Lobato-Bancalero¹, Elena Sanchiz-Cárdenas¹, Eduardo Marques-Merelo¹,
Juan Francisco Espada-Muñoz², Juan José Daza-González¹, Antonio del-Fresno-Asensio¹,
Francisco Javier Fernández-García¹, Carmelo Torres-Moreno¹, Teresa Sánchez-Viguera¹ and Gabriel Carranque-Chaves¹
Departments of ¹Digestive and General Surgery, and ²Internal Medicine. Hospital Universitario Virgen de la Victoria. Málaga, Spain

 

References

1. Ferreira S, Arroja B, Canhoto M, Amado C, Gonçalves C. Sarcoma de Kaposi del recto. Rev Esp Enferm Dig 2011;103:209-10.         [ Links ]

2. Fresno Forcelledo, MF. Determinación inmunohistoquímica de CD117/c-kit en el GIST (tumor estromal gastrointestinal). Oncología 2004;27:242-5.         [ Links ]

3. Pioche M, Boschetti G, Cotte E, Graber I, Moussata D, François Y, et al. Herpesvirus 8-associated colorectal Kaposi's sarcoma occurring in a drug-induced immunecompromised patient with refractory ulcerative colitis: Report of a new case and review of the literature. Inflamm Bowel Dis 2013;19:E12-5.         [ Links ]

4. Parfitt JR, Rodríguez Justo M, Feakins R, Novel MR. Gastrointestinal Kaposi's sarcoma: CD117 expression and the potential for misdiagnosis as gastrointestinal stromal tumour. Histopathology 2008;52:816-23.         [ Links ]

5. Zoufaly A, Schmiedel S, Lohse AW, Van Lunzen J. Intestinal Kaposi's sarcoma may mimic gastrointestinal stromal tumor in HIV infection. World Gastroenterology 2007;13:4514-6.         [ Links ]

6. Rivero Fernández M, García Martos M, Sanz Moya P, Vázquez Romero M, Fernández Amago MT, García Benayas MT, et al. Sarcoma de Kaposi con afectación colorrectal y del canal anal. Gastroenterol Hepatol 2010;33:508-11.         [ Links ]

7. Ferreira S, Arroja B, Canhoto M, Amado C, Gonçalves C. Sarcoma de Kaposi del recto. Rev Esp Enferm Dig 2011;103:209-10.         [ Links ]

8. Sgadari C, Barillari G, Toschi E, Carlei D, Bacigalupo I, Baccarini S. HIV protease inhibitors are potent anti-angiogenic molecules and promote regression of Kaposi sarcoma. Nat Med 2002;8:225-32.         [ Links ]