Original Research

Intralesional Vinblastine Injections for Treatment of Classic Kaposi Sarcoma in Diabetic Patients

Cutis. 2015 May;95(5):E28-E34

References

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All participants reported pain on the second and third days posttreatment, but analgesics were only prescribed to participants 2 and 4. Hyperpigmentation developed after 3 to 6 months in 3 participants. Two participants developed small ulcers within 2 weeks following treatment that healed within 3 months.

Comment

Classic KS is characterized by a localized onset with slow progression of systemic involvement. Cutaneous lesions progress from mild to severe.⁹ Systemic therapeutic strategies currently employed for the management of KS include single-agent and multiagent cytotoxic chemotherapy.¹⁰ Because these drugs have been associated with remarkable systemic side effects and patients often are elderly individuals, systemic therapy may be unsuitable for long-term use. In an epidemiologic study of 37 patients with KS, 12 patients (32%) were found to have concurrent diabetes mellitus.¹¹ Some authors suggest that KS in diabetic patients is a subtype of KS because of the immunosuppressive state caused by diabetes.^12-15

Some of the reported therapies for lesions of classic KS include cryotherapy, surgical excision, radiation therapy, alitretinoin gel 0.1%, and infrared photocoagulation.^3-16 Cryotherapy of a small papular lesion requires a 30- to 60-second freeze time that usually needs to be followed by further cryotherapy applications and is not known to be effective in lesions larger than 1 cm.¹⁷ Surgical procedures in the management of cutaneous KS may cause discomfort and bleeding and also are expensive.¹⁸ Radiotherapy is an alternative therapy, especially in plaque lesions.¹⁹ Alitretinoin gel 0.1% has been shown to be effective and well tolerated for the treatment of cutaneous lesions in patients with AIDS-related KS. Although Morganroth²⁰ reported alitretinoin gel 0.1% as a promising therapy for control of classic KS cutaneous lesions, Rongioletti et al²¹ described failure of this topical treatment for classic KS. The efficacy of topical alitretinoin in classic KS needs to be confirmed by further studies. Short pulses of the infrared coagulator have been reported for the treatment of 10 cutaneous AIDS-related KS lesions in 7 patients. The infrared coagulator may be a useful addition in the palliative cosmetic treatment of KS, producing acceptable results in small (ie, <2 cm in diameter) lesions of the arms and trunk but not in those situated on the legs, as in our patients.¹⁶

The use of VNB in classic KS was pioneered in 1980 by Klein et al²² who described 14 patients with KS who were systemically treated with VNB sulfate at a low dose with excellent therapeutic results leading to regression of cutaneous lesions. In this study, intravenous VNB therapy was supplemented with intralesional VNB.²² In other reports, intralesional VNB injections have proved to be effective in reducing lesion size and symptoms in oral KS with mild adverse effects.^19-29 For this reason, we decided to employ intralesional VNB injections in nodules and plaques of KS patients with diabetes. After treatment, lesion size was reduced in all 6 participants, with 4 participants achieving more than 50% reduction of the lesion size. In other studies reporting oral lesions,³ the highest proportion of complete responses was achieved with injections done periodically until evidence of clinical resolution was obtained, with a mean number of 2.4 injections per patient. In contrast, another study reported complete response of 48% in patients who received a single dose of VNB,⁷ as in our study.

Minimal complications following intralesional VNB injections have been reported. In our study, moderate pain following VNB injection was common during the first week posttreatment but typically resolved partially or completely during the following weeks. Additionally, pain described as needlelike during the procedure was minimal except for 1 participant who reported severe pain a day after the treatment. Unlike the study by Smith et al,³⁰ lidocaine with epinephrine was not used in our study as a pretreatment.

At 1-month follow-up, clinical evaluation of the injection site revealed ulceration in 2 participants, but no ulcers were noted at 3-month follow-up. To avoid this potentially dangerous complication, which can involve the foot in diabetic patients, further studies of a larger sample of patients using a lower dose of VNB are needed.

In our small group of diabetic patients, intralesional injections of VNB proved to be effective in the management of cutaneous lesions of classic KS with minimal adverse side effects. Even in cases where only one intralesional injection was administered, improvement was observed in all treated lesions. Imiquimod also has been proposed for the treatment of KS. Célestin Schartz et al³¹ conducted a study of 17 patients who were treated with imiquimod cream applied under occlusion 3 times weekly for 24 weeks. Eight patients had an objective clinical response (2 complete and 6 partial responses), and tumor progression was noted in 6 patients.³¹ This treatment appears to be suitable for new small skin lesions in immunocompetent patients; however, no known comparative studies have been conducted, possibly because of the relatively high cost of treatment due to the chronic nature of the disease. Intralesional bleomycin also has been reported as useful in the treatment of cutaneous KS. The best results were obtained with macular lesions.³² However, the risk for necrosis is high. Therefore, bleomycin is not the first choice for diabetics, particularly those who have lesions localized on legs.