title: Accuracy of Clinical Suspicion and Pathologic Diagnosis of Kaposi Sarcoma in East Africa.
abstract: BACKGROUND
  HIV-associated Kaposi sarcoma (KS) is one of the most common malignancies in sub-Saharan Africa. The diagnosis is often based on clinical suspicion, without histopathologic confirmation. When biopsies are performed, the accuracy of interpretation by local pathologists is poorly understood. We assessed the accuracy of clinical suspicion and pathologic diagnosis of KS in 2 East African countries.
  
  
  METHODS
  At 2 large HIV care sites in Uganda and Kenya, we evaluated consecutive biopsies performed from October 2008 to January 2013 on HIV-infected adults with clinically suspected KS. Biopsies were interpreted by both local African pathologists and a group of US-based dermatopathologists from a high volume medical center. For the purpose of this analysis, the US-based dermatopathologist interpretation was used as the gold standard. Positive predictive value was used to characterize accuracy of local African clinical suspicion of KS, and concordance, sensitivity, and specificity were used to characterize accuracy of local pathologic diagnosis.
  
  
  RESULTS
  Among 1106 biopsies, the positive predictive value of clinical suspicion of KS was 77% (95% confidence interval: 74% to 79%). When KS was not histopathologically diagnosed, clinically banal conditions were found in 35%, medically significant disorders which required different therapy in 59% and life-threatening diseases in 6%. Concordance between African pathologists and US-based dermatopathologists was 69% (95% confidence interval: 66% to 72%). Sensitivity and specificity of African pathologic diagnoses were 68% and 89%, respectively.
  
  
  CONCLUSIONS
  Among East African HIV-infected patients, we found suboptimal positive predictive value of clinical suspicion of KS and specific, but not sensitive, histopathologic interpretation. The findings call for abandonment of isolated clinical diagnosis of KS in the region and augmentation of local dermatopathologic services.
authors.affiliation: *Department of Dermatology, University of California-San Francisco, San Francisco, CA; †Yale School of Medicine, New Haven, CT; ‡Department of Dermatology, University of Pennsylvania, Philadelphia, PA; §Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, CA; ‖Department of Pathology and Laboratory Medicine, University of California-San Francisco, San Francisco, CA; ¶Infectious Disease Institute, Makerere University, Kampala, Uganda; #Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda; **Department of Pathology, Moi University School of Medicine, Eldoret, Kenya; ††Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya; ‡‡Department of Hematology and Oncology, Moi Teaching and Referral Hospital, Eldoret, Kenya; and §§Department of Medicine, Indiana University School of Medicine, Indianapolis, IN.
authors.forename: Erin
authors.initials: E
authors.lastname: Amerson
authors.forename: Carina Martin
authors.initials: CM
authors.lastname: Woodruff
authors.forename: Amy
authors.initials: A
authors.lastname: Forrestel
authors.forename: Megan
authors.initials: M
authors.lastname: Wenger
authors.forename: Timothy
authors.initials: T
authors.lastname: McCalmont
authors.forename: Philip
authors.initials: P
authors.lastname: LeBoit
authors.forename: Toby
authors.initials: T
authors.lastname: Maurer
authors.forename: Miriam
authors.initials: M
authors.lastname: Laker-Oketta
authors.forename: Winnie
authors.initials: W
authors.lastname: Muyindike
authors.forename: Mwebesa
authors.initials: M
authors.lastname: Bwana
authors.forename: Nathan
authors.initials: N
authors.lastname: Buziba
authors.forename: Naftali
authors.initials: N
authors.lastname: Busakhala
authors.forename: Kara
authors.initials: K
authors.lastname: Wools-Kaloustian
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Martin
mesh_terms: D001706:Biopsy; D015658:HIV Infections / Q000150:complications*; D006801:Humans; D007630:Kenya / Q000453:epidemiology; D012514:Sarcoma, Kaposi / Q000175:diagnosis* / Q000453:epidemiology / Q000473:pathology; D012680:Sensitivity and Specificity; D014454:Uganda / Q000453:epidemiology