Kaposi Sarcoma (KS)

Look in the mouth before you instrument it - The oral cavity is a common presenting site. Do a deliberate oral and oropharyngeal inspection for violaceous patches, plaques, and nodules on the palate, gingiva, and tongue before laryngoscopy. These are vascular lesions that ulcerate and invade adjacent tissue, so laryngoscopy, rigid suction, and NG placement can all provoke bleeding from a lesion you did not see.

Video laryngoscopy - When mucocutaneous lesions are present, a video laryngoscope gives you the view without the blind pressure of a direct blade against friable tumor. Have suction and a smaller tube ready.

Pulmonary involvement - Get a room-air saturation and review the most recent chest imaging. KS has a predilection for the lungs, pulmonary involvement causes respiratory distress and can be fatal, and visceral pulmonary disease is the finding that carries the worst prognosis in this disease.

GI involvement and anemia - KS involves the GI tract, and radiation is used palliatively for bleeding lesions. Check the hemoglobin and the transfusion history, and type and screen before anything that will disturb the gut.

Immunocompromise - Prognosis in the AIDS-related form tracks CD4 count and opportunistic infection. Review the CD4 count, viral load, and the current antiretroviral regimen, and hold a strict aseptic line for every line, block, and airway. See the Human Immunodeficiency Virus Infection (HIV) entry for the systemic picture and drug considerations.

Transplant recipients - Iatrogenic KS is treated by reducing immunosuppression or withdrawing steroids, which is a direct trade against graft rejection. Find out which immunosuppressants are still running, whether steroids were recently reduced, and how the graft is functioning on creatinine and LFTs.

Bleomycin and inspired oxygen - Bleomycin is part of standard KS chemotherapy, and pulmonary toxicity is its dose-limiting effect with a mortality of 20% to 25% among those affected. Supplemental oxygen is a recognized risk factor for serious bleomycin adverse effects, so titrate FiO2 to the lowest that maintains an acceptable saturation rather than running high oxygen by habit.

Anthracycline exposure - Liposomal anthracyclines and doxorubicin combinations are standard, and cardiac toxicity is a named chemotherapy complication. Get a baseline ECG and, in a patient with meaningful cumulative exposure or any exertional decline, an echo for ventricular function before an elective case.

Where the cuff and the IV go - Lesions carry associated lymphedema and secondary infection, and radiation leaves skin dry, avascular, and slow to heal. Site the BP cuff, IV, and any A-line away from lesional, lymphedematous, and irradiated skin; that tissue bleeds, breaks down, and does not close.

Positioning and pain - Larger lesions are painful and disfiguring with associated edema. Pad generously, ask the patient which positions they can tolerate awake, and factor lesional pain into the postoperative plan rather than attributing it all to the incision.

Kaposi sarcoma (KS) is a vascular tumor of endothelial origin driven by human herpesvirus-8 (HHV-8). The virus reprograms infected endothelial cells toward lymphatic differentiation, upregulates VEGF and bFGF, blocks apoptosis through latency-associated nuclear antigen, and produces aberrant angiogenesis. HHV-8 alone is not enough; immunosuppression is the required cofactor, which is why KS clusters where immunity is impaired.

Four forms exist: classic, in older men of Mediterranean and Eastern European descent; endemic, in sub-Saharan Africa including children; iatrogenic, in transplant recipients, who carry a 400- to 500-fold increased risk; and AIDS-related, an AIDS-defining illness in patients with CD4 counts below 200 cells/mm3.

Lesions progress through patch, plaque, and nodular stages as violaceous plaques on skin and mucocutaneous surfaces, and have a predilection for the lungs and GI tract. Perioperatively this is a friable vascular tumor in an immunosuppressed patient, and visceral involvement, especially pulmonary, carries the worst prognosis.