Kaposi Sarcoma and Lymphoproliferative Disorders W e read with great interest the article by Fossati et al. 1 on human immunodeficiency virus (HIV) negative Kaposi sarcoma (KS) and lymphoproliferative disorders (LD). In this article, of the six patients with KS, five developed KS after the diagnosis of LD, whereas only one patient developed KS before the LD diagnosis. In this patient the chemotherapeutic agent (etoposide) used for the treatment of KS most likely led to the development of acute promyelocytic leukemia. 2 The authors stated that previous studies of a possible association betweeen HIV negative KS and LD produced discordant results. However, we believe that such an association must be interpreted according to the sequence of occurrence of KS and LD. It has been postulated that the development of secondary malignancies, including LD, after the diagnosis of KS in HIV negative and positive patients is not increased. 3,4 Conversely, the risk of developing KS after LD is high due to immunosuppression secondary to chemotherapeutics, infectious agents, and radiotherapy, and even in those patients with benign lesions treated with corticosteroids and/or azathioprine. 5-7 However, we believe that a third distinctive category exists that must be evaluated seperately: the synchronous or metachronous occurrence of KS and LD. In our experience a male patient age 55 years presented with an HIV negative KS on the lower extremities and with synchronous Ann Arbor Stage IIIA Hodgkin disease. The patient received six cycles of chemotherapy (with doxorubicin, bleomycin, vinblastine, and dacarbazine) and mantle radiotherapy for the treatment of Hodgkin disease and local radiotherapy for KS. At last follow-up the patient had been in complete remission for both diseases for Ͼ 3 years.
This third distinctive category is interesting because the etiopathogenesis of the synchronous occurrence of KS and LD should be somewhat different from the other groups mentioned in that neither LD nor KS could be the causative agent for each other. From the viewpoint of an etiologic agent, DNA sequences specific to a new herpesvirus (human herpesvirus type 8 or Kaposi sarcoma-associated herpesvirus [KSHV]) recently have been isolated in the lesions of all of variants of KS. 8 Although to our knowledge the KSHV antibody has not yet been detected in young adults with Hodgkin disease, 9 it would be interesting to investigate KSHV titers in cases of synchronously occurring KS and LD.