| Setting | Treatment |
|---|---|
| CLASSIC / ENDEMIC no immunosuppression to reverse | Local therapy for cutaneous disease — RT, intralesional injection, cryotherapy Systemic chemo reserved for extensive / visceral disease |
| AIDS-RELATED, limited cutaneous | Start / optimise antiretroviral therapy (ART)
immune reconstitution alone often regresses KS Local therapy for cosmetically troubling lesions |
| AIDS-RELATED, advanced/visceral or ART-refractory progressive despite ART, extensive cutaneous, or lung/GI involvement | Pegylated liposomal doxorubicin (PLD) — 1st-line systemic
It is an ANTHRACYCLINE — doxorubicin encased in a PEG-coated liposome. The coating evades clearance → long circulation → the drug accumulates preferentially in KS lesions through their leaky vasculature. Dose in KS: 20 mg/m² IV every 2–3 weeks. ⚠ Much LESS cardiotoxic than conventional doxorubicin — but NOT zero: it still counts toward the CUMULATIVE anthracycline dose, so track it and get a baseline LVEF. Also causes less alopecia, nausea and myelosuppression than the conventional drug. ⚠ PLD has its own signature toxicities — not doxorubicin's
PALMAR-PLANTAR ERYTHRODYSAESTHESIA (hand-foot syndrome) is the dose-limiting toxicity — counsel on cooling, emollients, avoiding pressure/friction and heat; it drives dose delay and reduction. INFUSION REACTIONS (flushing, back/chest tightness, dyspnoea) are liposome-related rather than true allergy — run the first dose SLOWLY and they usually settle. Also stomatitis. Paclitaxel — 2nd line Pomalidomide + continued ART
an oral option for relapsed / refractory disease (NCCN-preferred subsequent therapy), including HIV-negative KS · continue ART throughout |
| IATROGENIC / TRANSPLANT-ASSOCIATED | 1st = REDUCE IMMUNOSUPPRESSION Switch to an mTOR inhibitor (sirolimus / everolimus)
antiangiogenic + anti-KS while sparing the graft Add pegylated liposomal doxorubicin if progressive despite this
an anthracycline — same drug, dosing and toxicities as the AIDS-related row above · ⚠ in a transplant recipient, keep the graft team in the loop and get a baseline LVEF before starting |