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Thalidomide in Kaposi Sarcoma: Promising or Disappointing?

retrospective studies [9, 10] . In the first study, Rubegni et al. [9] treated 3 patients with 100 mg/day of thalidomide for 1 year and observed a complete response in 2 patients (including an immunosuppressed patient with systemic KS) and a partial response in the third. In the two responding cases, they observed a negativation of the HHV8 viral load in the skin and the blood. In the second study [10] , 11 patients were treated with a median dose of 100 mg/day for a median time of 3 months. The results are less impressive, with only 3 patients (27%) achieving a partial response. Out of these 14 patients, 4 (28%) discontinued thalidomide for side-effects. The overall response rate appears thus to be quite similar in KS, whether HIV associated or not, and lower than the response rates obtained with other systemic therapies such as interferon, pegylated liposomal doxorubicin [10] or even radiotherapy in localized cases [11] . Taken together, these results suggest that thalidomide is not a major therapy for KS, with a disappointing response rate and limitations due to side-effects, although it could be useful in some specific cases as shown by Rubegni et al. [9] . However, an anti-angiogenic approach may still be interesting in KS, as suggested by Ben M’barek et al. [10] . With the ‘rediscovery’ of thalidomide, several structural analogues have been developed in an attempt to find compounds with thalidomide’s properties without the associated side-effects. In particular, lenalidoThalidomide, well known by dermatologists for its anti-tumor necrosis factor activity, is used for several inflammatory cutaneous disorders. Anti-angiogenic properties of thalidomide, mediated by inhibition of angiogenic factors such as vascular endothelial growth factor and basic fibroblast growth factor, were first shown in 1994 on a rabbit cornea model [1] . Since the mid 1990’s, the discovery of this anti-angiogenic effect has led to renewed interest for this drug, especially in oncology [2] . Thalidomide has been shown to be an active and promising anti-carcinogenic drug, as a single agent or in combination with dexamethasone in hematological malignancy, such as relapsing or refractory multiple myeloma, myelodysplasia or acute myeloid leukemia [3] . Since Kaposi sarcoma (KS) is an angiogenic neoplasm, it has been logically hypothesized that thalidomide might be of interest in KS. Thalidomide was first studied in HIV-associated KS. In four publications that involved a total of 50 patients [4–7] , well reviewed and analyzed by Krown [8] , 17 patients (34%) showed objective KS regression. Dosages ranged from 100 to 1,000 mg/day during 8 weeks to 12 months; no complete response was observed, and HHV-8 viral load was reduced only in 3 responding cases. Eleven patients (22%) withdrew because of toxicity. In this issue of Dermatology, the effect of thalidomide is assessed for non-HIV KS (iatrogenic or classic) in two