Kaposi Sarcoma in Afghanistan: A Case Series from a Tertiary Referral Center

Round 1

Reviewer 1 Report

This is a well-written and very nicely illustrated report of seven cases of Kaposi sarcoma from Afghanistan. It is noteworthy that only one case was HIV-associated. Further discussion around the clinico-pathological classification/categorization of the other six cases (i.e. the vast majority), however, is a noteworthy omission. Is it the authors' view that these latter cases are best regarded as examples of "classic" Kaposi sarcoma? If so, did any of the patients have other neoplasms known to occur in this setting (e.g. non-Hodgkin lymphoma) at the time of diagnosis, or a history of the later develop a second neoplasm? A statement to this effect would add some weight to the Discussion and/or the individual Case Reports. 

Author Response

Your thorough and insightful feedback is much appreciated.  Based on your feedback, the following changes have been addressed:

1. It is noteworthy that only one case was HIV-associated. Further discussion around the clinico-pathological classification/categorization of the other six cases (i.e. the vast majority), however, is a noteworthy omission. Is it the authors' view that these latter cases are best regarded as examples of "classic" Kaposi sarcoma? If so, did any of the patients have other neoplasms known to occur in this setting (e.g. non-Hodgkin lymphoma) at the time of diagnosis, or a history of the later develop a second neoplasm? A statement to this effect would add some weight to the Discussion and/or the individual Case Reports.
   1. In our view, these cases are best classified as examples of “Classic” KS. Due to the limited resources of many of these patients, additional health history is limited.  To the best of our knowledge, there was no associated underlying malignancy, and this would be a wonderful area of inclusion for future studies.

Reviewer 2 Report

The reviewer would like to thank both the editor and authors for the opportunity to review this manuscript.  The manuscript itself is an expertly written and well-illustrated article that raises awareness to the various clinical and histopathologic presentations of Kaposi sarcoma (KS) in the Afghan population. However, perhaps more importantly this article stresses that collaboration not only within single institutions but indeed across multiple disciplines, institutions and even countries is ongoing and is actively helping to improve out-comes in underserved populations.

Given that the article nicely summarizes the different forms of KS and the histology, perhaps a mention of the variability of HHV-8 staining that can be expected in a case may help readers better interpret or understand the variability in the HHV-8 stains presented in the body of the manuscript.

As Figure 1D appears blurred in the lower right hand corner of the image, modification of this image may make the figure more attractive to readers.

Table 1 nicely summarizes the clinical characteristics of the seven patients; however, the histologic features are comparatively difficult to read.  Perhaps additional columns subdividing different key histopathologic findings may be of help. 

Author Response

Your thorough and insightful feedback is much appreciated. Based on your feedback, the following changes have been addressed:

1. Given that the article nicely summarizes the different forms of KS and the histology, perhaps a mention of the variability of HHV-8 staining that can be expected in a case may help readers better interpret or understand the variability in the HHV-8 stains presented in the body of the manuscript.
   1. A small summary of the interpretation of the immunohistochemical interpretation of HHV-8 IHC has been included in the introductory portion of the manuscript.
2. As Figure 1D appears blurred in the lower right hand corner of the image, modification of this image may make the figure more attractive to readers.
   1. Unfortunately, the image used for Figure 1D is the only image available of the HHV-8 IHC for this case. This image has been re-formatted to improve image quality and remove the blurred portion of the lower right-hand side.  All additional histologic images are re-formatted to match this change.
3. Table 1 nicely summarizes the clinical characteristics of the seven patients; however, the histologic features are comparatively difficult to read.  Perhaps additional columns subdividing different key histopathologic findings may be of help. 
   1. Table 1 has been altered for ease of reading with altered spacing and introduction of bullet point list to better categorize salient histologic features.