Evaluation of Kaposi’s Sarcoma (KS) patients in Lilongwe Malawi: Clinical characteristics,
2011 Conference on
KSHV virology and gene expression (AMC-S001)
1,2,3MinaHosseinipour, 4Kristen Tamburro, 5Dan Namarika, 6Michael Nyirenda, 3Loreen Chiwoko, 3Deborah Kamwendo, 1,2Irving Hoffman, 6Sam Phiri, 1,4,7Dirk P. Dittmer
Opportunistic Infections, 1Center for Infectious Diseases, 2Department of Medicine, 3UNC Project, Lilongwe Malawi 4Department of Microbiology and Immunology, Lineberger Comprehensive Cancer Center, and Center for AIDS Research (CfAR) at the
Boston, MA University of North Carolina at Chapel Hill, 5Kamuzu Central Hospital, 6Lighthouse Trust, 7AIDS malignancy consortium
Contact: Mina Hosseinipour, email@example.com or Dirk Dittmer, firstname.lastname@example.org
Figure 1: Selection of Patients Population: Among enrolled clients, 71% KSHV Virology and Gene Expression
KS, a virally associated malignancy, is a common presenting condition were male and median (Interquartile range)
among HIV infected patients in Malawi. We sought to correlate KS clinical age, BMI, CD4 and HIVRNA were 32 years KSHV RNA was detectable in nearly all specimens with a range of 0 to nearly 7 Figure 2. Plasma KSHV RNA values expressed aslog10
217 Patients with Kaposi’s Sarcoma 38 on ART copies/ml for all 70 patients. NTC refers to non-Template
presentation with KSHV viral load and KSHV gene expression and (IQR29-38), 22.4kg/m2 (20.4-24.3), 181 log10copies/ml (Figure 2).
14 on Chemotherapy control
conducted an observational clinical trial (AIDS malignancy consortium 53 on both ART and
cells/mm3 (84-267) and 140,695 copies/ml
Chemotherapy (54,262-267921), respectively, There were no
AMC-S001). 12 Oral KS only statistically significant differences between T1
We present the interim results of the first 21 specimens . Percent lytic activity
28 Other and T0 stage patients although there was a was based on the cluster analysis of all 80 KSHV viral mRNAs. Two genes of
We hypothesized that if a significant fraction of KS patients present with 70 Patients enrolled clinical importance, the viral thymidine kinase and the viral kinase (orf36), which
trend for fewer skin lesions among T0 patients
tumors that express the viral thymidine kinase, this could justify testing anti- (Table 1). can phosphorylate ganciclovir , are shown graphically (Figure 3).
herpesvirus drugs as an adjunct to antiretroviral therapy. Table 1. Baseline demographic and clinical characteristics of Kaposi’s Sarcoma Patients
Methods Characteristic Total ACTG T0 ACTG T1 p-value Figure 3. Viral Messenger RNA levels in n= 21 evaluable specimens. The mRNA
levels were determined by real-time qPCR. Relative levels are expressed as dCT
Study Setting: The Lighthouse clinic at Kamuzu Central Hospital ART clinic serves N=70 N=12 N=58 (expression level/ gapdh mRNA level) on a log2 scale. A level of 0 corresponds to
as the Centre of Excellence for the Central Region of Malawi. In addition to providing equivalency between viral mRNA and gapdh mRNA.
primary care and general ART services for 14,000 ART clients according to Malawi Age < 30 years 30% 25% 31% 0.597
ART guidelines, the Lighthouse provides specialized services for referred cases Shown is the density distribution of mRNA levels across the biopsies. LANA and vCYC,
including combination chemotherapy for Kaposi’s Sarcoma, evaluation of severe latent mRNA , was expressed in all tumor specimens, confirming the KS diagnosis.
toxicities and ART treatment failure, and modification of ART for second line and non- Age 30-39 years 54% 67% 52%
standard regimens. All services at Lighthouse are provided for free. Thymidine Kinase (TK) expression, evidence of lytic activity, segregated into 2 classes
Age >=40 years 16% 8% 17% (positive and negative) with 8/21 (39%) samples expressing, significant, but low levels
Design: Cross-Sectional Study of TK. KIN (orf 36) expression had broad distribution with high and low expression
% Male 71% 58% 74% 0.27 densities. As expected the median levels for these two lytic genes were lower than
Participants: All adult (age>= 18 years) KS patients presenting to the LH clinic those of the latent genes, as only a fraction of tumor cells express KSHV lytic genes.
between Nov 2008 through Aug 2010 were evaluated for potential enrollment.
Patients with prior chemotherapy or antiretroviral therapy use were excluded as were % Female 29% 42% 26% Not shown are the expression levels for all other approximately 80 genes. On the basis
individuals with disease limited to the oral cavity (due to inability to safely biopsy in the of the complete viral genome profile KS lesions could be stratified into those with
clinical setting). BMI < 18.5 6% 8% 5% 0.67 significant lytic gene expression and those with restricted, predominantly latent viral
gene expression profile.
Clinical Procedures: KS clinical staging was performed according to ACTG criteria
(T1 advanced stage vs. T0 limited disease), blood was obtained for CD4 cell count BMI >=18.5 94% 92% 95%
and KSHV quantification and punch biopsy was performed for evaluation of KSHV Conclusions
gene expression. Karnovsky score > =70 84% 91% 83% 0.44
• KS patients in Lilongwe Malawi present with advanced stage (T1) disease and low CD4 count .
Laboratory Procedures: CD4 counts and HIVRNA was performed in real time at the
UNC Project laboraotry using FACSCOUNT and Roche amplicor assay 1.5.
Karnovsky score < 70 16% 9% 17% All KS tumors expressed latent genes.
KSHV RNA and gene expression analysis was performed in batch at the UNC-Chapel Approximatly 39% of ART naive KS patients had evidence of lytic KSHV gene expression. By contrast, only 13%
Hill Vironomics core as per our published procedures (Dittmer DP. Cancer Res. 2003 1-10 lesions 22% 42% 18%
of KS lesions that were studied in HIV-suppressed patients in the US showed evidence of lytic KSHV gene
May 1;63(9):2010-5.). In short, RNA was isolated by RNAzol™ and subjected to real-
time qPCR using primers specific for the indicated genes of KSHV.
> 10- <=50 lesions 61% 50% 63% 0.16
ART naive KS patients may potentially benefit from anti-herpesviral therapy in addition to ART and/or anti-cancer
Statistical Analysis: We performed basic descriptive statistics with bivariate therapy.
comparisons according to ACTG Tumor status using Chi2 methodology and student’s > 50 lesions 17% 8% 19%
t-test as appropriate. Acknowledgements
CD4 < 200 56% 67% 53% 0.40 This study was supported by the AIDS malignancies clinical trials consortium (CA121947), and NIH grants (DE018304, CA109232) to
Ethics: The study was IRB approved in Malawi and at UNC (IRB# 08-0567) as
DD. K.T. is supported by T32 GM07092-34 and by a grant to the University of North Carolina at Chapel Hill from Howard Hughes
> "AMC-S001: CID 0802 - A Pilot Study of Kaposi Sarcoma-Associated Herpesvirus
Medical Institute (HHMI) through the Med into Grad Initiative.
(KSHV) Gene Expression in Patients with Newly Diagnosed Kaposi Sarcoma (KS) in CD4 >=200 44% 33% 47%