Expression of Epstein-Barr virus in cutaneous T-cell lymphoma including mycosis fungoides

Increased Levels of Plasma Epstein Barr Virus DNA Identify a Poor-Risk Subset of Patients With Advanced Stage Cutaneous T-Cell Lymphoma

INTRODUCTION

Outcomes in advanced stage (AS) cutaneous T-cell lymphomas (CTCL) are poor but with great variability. Epstein-Barr virus (EBV) is associated with a subset of non-Hodgkin lymphomas. Frequency of plasma EBV-DNA (pEBVd) detection, concordance with EBV RNA (EBER) in tumor tissue, codetection of plasma cytomegalovirus DNA (pCMVd), and prognostic effect in AS CTCL are unknown.

PATIENTS AND METHODS

Patients (n = 46; 2006-2013) with AS CTCL (≥IIB) were retrospectively studied. pEBVd and pCMVd were longitudinally measured using quantitative real-time polymerase chain reaction. EBER in situ hybridization (ISH) was performed on tumor samples. Survival from time of diagnosis (ToD) and time of progression to AS was assessed.

RESULTS

Plasma EBV-DNA and pCMVd were detected in 37% (17 of 46) and 17% (8 of 46) of AS CTCL patients, respectively. pCMVd detection was significantly more frequent in pEBVd-positive (pEBVd(+)) than pEBVd(-) patients (35% vs. 7%; P = .038). Tumor tissue for EBER-ISH was available in 14 of 17 pEBVd(+) and 22 of 29 pEBVd(-) patients; 12 of 14 (85.7%) pEBVd(+) patients were EBER(+) versus 0 of 22 pEBVd(-) patients. Frequency of large cell transformation (LCT) tended to be greater in pEBVd(+) patients, but was not significant (10 of 14 pEBVd(+) vs. 10 of 23 pEBVd(-); P = .17). No notable differences in rates of increased levels of serum lactate dehydrogenase (LDH) were observed (17 of 17 pEBVd(+) vs. 27 of 29 pEBVd(-)). pEBVd detection was associated with significantly worse survival from ToD (P = .021) and time of progression to AS (P = .0098).

CONCLUSION

Detection of cell-free plasma EBV-DNA was highly concordant with the presence of EBERs in tumor tissue, predicted survival independent of LDH and LCT, and should be further studied as a biomarker in AS CTCL.

Evaluation of the Association Between Epstein-Barr Virus and Mycosis Fungoides

INTRODUCTION

Mycosis fungoides (MF) is the most common cutaneous T-cell lymphomas. Despite extensive studies, etiopathogenesis of MF is unknown. Environmental, infectious and genetic factors have been proposed as potential risk factors of MF. Herpes virus family members, especially Epstein-Barr virus (EBV), have been among the viral factors of interest in recent years. The aim of this study was to investigate the possible association of EBV infection with MF.

MATERIALS AND METHODS

This case-control study was performed on skin biopsy samples of 57 MF patients referred to Pathology Department of Mashhad Emam Reza Hospital from 2000 to 2011 and also on 57 melanocytic nevus samples matched with patients for age and sex. The presence of EBV in samples was evaluated by polymerase chain reaction. Statistical analysis of the data was conducted with the Statistical Package for the Social Sciences version 11.5 (SPSS Inc., Chicago, IL, USA).

RESULTS

In this study, out of 57 MF samples, there were 34 male and 23 female patients, with male:female ratio of 1.04. Mean patient age was 51.4 years. There were 22 and 4 positive cases of EBV in the case and control groups, respectively. Chi-square statistical test showed that EBV was significantly higher in case group than control (P = 0.000). There was no correlation between the presence of EBV in samples with lesion type, age and gender of the patients.

CONCLUSION

According to our study results, EBV is a likely etiologic agent or potential promoter in the pathogenesis of MF.

Epstein-Barr virus: dermatologic associations and implications: part II. Associated lymphoproliferative disorders and solid tumors

Epstein-Barr virus (EBV) was the first human virus to be associated with oncogenesis. Over the past few decades, cumulative research has revealed that latent EBV infection may be implicated in the pathogenesis of a heterogeneous group of lymphoproliferative disorders and malignancies occurring in both immunocompetent and immunocompromised hosts. Many of these diseases have either primary or secondary cutaneous manifestations. Serologic studies and EBV-encoded RNA in situ hybridization stains have been used to show the association of EBV with disease; while these findings may imply a role, they do not equate with causation. In part II of this continuing medical education review, the salient features of EBV-associated lymphoproliferative disorders and solid tumors are detailed.

Significant role of macrophages in human cancers associated with Epstein-Barr virus (Review)

Epstein-Barr virus (EBV) is a ubiquitous pathogen that was first identified as a human cancer virus. Many human cancers are associated with EBV, and we demonstrated that EBV infects macrophages. Macrophages infected with EBV show a close correlation with many human cancers, and thus more attention must be given to the role of macrophages infiltrating into cancer tissues associated with EBV. In this review, I discuss the role of macrophages in the process of EBV-associated oncogenesis with regard to interleukin-10.

Role of infectious agents in cutaneous T-cell lymphoma: facts and controversies

The etiology of cutaneous T-cell lymphoma (CTCL) remains unknown, with potential infectious causes having been explored. This contribution evaluates the evidence suggesting an infectious etiology and pathogenesis of the disease, characterizes the relationships between various specific pathogens and CTCL, and discusses some of the difficulties in establishing a causal link between infectious agents and CTCL carcinogenesis. Researchers have evaluated CTCL specimens for evidence of infection with a variety of agents, including human T-lymphotropic virus, Epstein-Barr virus, human herpesvirus-8, and Staphylococcus aureus, although other pathogens also have been detected in CTCL. Although there is significant evidence implicating one or more infectious agents in CTCL, studies to date have not linked definitively any pathogen to disease development, and various studies have yielded conflicting results.

Infectious agents in cutaneous T-cell lymphoma

Infectious agents have long been suspected as potential causative agents in cutaneous T-cell lymphoma (CTCL). Tissues of patients with CTCL have been evaluated for evidence of infection with a number of agents, including Staphylococcus aureus, retroviruses, and herpesviruses. These studies have failed to reveal a consistent association of CTCL with investigated agents. However, there is substantial evidence suggesting a potential role of a yet unidentified virus in CTCL. This article will review the findings of studies exploring potential roles of infectious agents in CTCL. In addition, we investigated CTCL tissues for evidence of infection with Merkel cell polyomavirus, a novel polyomavirus that was recently discovered as a probable carcinogenic agent in Merkel cell carcinoma. Cutaneous lesions demonstrating mycosis fungoides were stained with a monoclonal antibody against the Merkel cell polyomavirus T antigen, along with appropriate positive and negative controls. Immunohistochemical stains produced negative results in all examined mycosis fungoides specimens. These findings, which suggest a lack of association of CTCL with Merkel cell polyomavirus, add to the current body of knowledge regarding infectious agents and CTCL.

Evidence of multiple infectious agents in mycosis fungoides lesions

The etiology of mycosis fungoides (MF) remains to be determined. Several studies have proposed a viral etiology with controversial results. In this case-control study we investigated the presence of Epstein-Barr virus (EBV) and the debated presence of Human T-cell lymphotrophic virus I (HTLV-I) sequences, by polymerase chain reaction on nucleic acid extracts from formalin-fixed paraffin-embedded skin biopsies. Moreover, by a multivariate approach we analyzed in the same case-control study also the contribution of two previously examined pathogens: Hepatitis C virus (HCV) and Borrelia burgdorferi (Bb). Significant differences in the frequency of infectious agents in cases and controls were detected for Bb, HTLV-I and EBV. In MF patients we found the concurrent presence of two or three of these pathogen sequences in 21 out of 83 cases, but only in 1 out of 83 healthy controls. Our results suggest that the persistence of multiple infectious agents may cause a long-term antigenic stimulation contributing to the malignant transformation of T lymphocytes, especially when associated with HTLV-I like sequences. However, these infectious agents do not seem to have effects on disease progression.

Macrophage involvement in Epstein-Barr virus-related tumors

Epstein-Barr virus (EBV) is known as a causative agent of Burkitt's lymphoma, nasopharyngeal carcinoma and approximately 10% of stomach carcinoma cases. In other human cancers, EBV gene expression including lytic infection protein detected using in situ hybridization and immunofluorescence staining has been reported. Moreover, the expression and replication of EBV genes in cultured normal macrophages and in histiocytes of Langerhans' cell histiocytosis have been identified. The aim of this study was to examine EBV expression in macrophages in other EBV-associated human tumors. Forty-one cases of EBV-associated tumors, which had been confirmed to express EBV, were examined. Tissue sections after in situ hybridization were double-stained immunohistochemically with the monoclonal anti-CD68 antibody. EBV expression in macrophages in the lesions of nasopharyngeal carcinoma, oral cancer, thyroid carcinoma, renal cell carcinoma, testicular carcinoma, uterine carcinoma, cutaneous T-cell lymphoma and anaplastic large-cell lymphoma was identified, whereas macrophages in normal or non-cancerous lesions showed no EBV expression. Many tumor-associated macrophages in EBV-related tumors carry EBV, which appears to induce the EBV lytic infection of macrophages. Therefore, the possibility that the lytic infection of macrophages by EBV and the resulting inflammation play certain roles in the oncogenesis of EBV-associated human tumors was raised.

Cytomegalovirus: its potential role in the development of cutaneous T-cell lymphoma

To investigate the potential role of CMV in cutaneous T-cell lymphoma (CTCL), we studied cytomegalovirus (CMV) seroprevalence in parapsoriasis (PP), mycosis fungoides (MF) and Sézary syndrome (SS) compared with healthy control patients. In cases where CMV seropositivity was observed, CMV PCR analyses were performed on skin biopsies. CMV seroprevalence was 37.1% in the control group, 50.68% in the PP + MF + SS group (P = 0.08), 56.2% in the MF + SS group (P = 0.07), 40% in the PP group (P = 0.9), 66.67% in the MF group (P = 0.009), 42.86% in the SS group (P = 0.9). CMV PCR in initial skin biopsies were all negative. However, PCR CMV was positive in two SS skin biopsies realized at an advanced stage. Our results show that latent CMV infection may play a role in the susceptibility of MF in predisposed subjects by inducing T-cell proliferation and resistance to apoptosis. Concerning SS, an immunosuppressive state may be responsible for CMV reactivation that in turn may interfere with evolution of the disease.

Epstein-Barr virus in cutaneous T-cell lymphomas: evaluation of the viral presence and significance in skin and peripheral blood

The importance of viral agents in the development of cutaneous T-cell lymphomas (CTCL) is still debated. For this purpose, we retrospectively evaluated the Epstein-Barr virus (EBV) presence in Sézary syndrome (SS), mycosis fungoides (MF), inflammatory dermatoses (ID), and healthy donors (HD) using different approaches: EBV-DNA was quantified in skin biopsies and peripheral blood using real-time PCR, EBV-encoded small RNA (EBER) transcripts were detected by in situ hybridization (ISH), and latent membrane protein1-2 antigens were detected by immunohistochemistry. Skin biopsies were EBV-DNA-positive in 8/30 (27%) SS, 7/71 (10%) MF, and 2/18 (11%) ID patients and in none of the 25 normal skin samples. Positive mRNA (EBER) signals, always confined to cerebriform T lymphocytes, were found in 5/30 SS patients (17%), whereas signals in all MF and ID patients were negative. The presence of EBV-DNA in skin and blood samples was associated with a significantly lower survival in MF/SS patients. In evaluating EBV serological status, most (>70%) SS, MF, and ID patients showed a serological reactivation demonstrated by the presence of anti-EA IgG. In conclusion, although the finding of EBV-DNA in CTCL does not prove its etiopathogenetic role and may be related instead to immunosuppression, our study demonstrates that it has prognostic relevance.

Low frequency of Epstein Barr virus association and high frequency of p53 overexpression in an Argentinean pediatric T-cell lymphoma series

T-cell non-Hodgkin's lymphomas (NHLs) represent 10% to 15% of all diagnosed lymphomas in Western countries. Various geographic frequencies of T-cell NHL have been documented, in part reflecting increased exposure to pathogenic factors such as Epstein-Barr virus (EBV). Our aims were to assess EBV and p53 expression in Argentine pediatric T-cell lymphoma and to correlate them with patients' survival. Epstein-Barr encoded RNAs (EBERs) in situ hybridization and LMP1 and p53 immunohistochemical staining were performed on formalin-fixed paraffin-embedded lymph node biopsies from 25 pediatric T-lymphoma patients. In 17 of 25 samples good-quality DNA was obtained, and EBER polymerase chain reaction was assessed to confirm in situ hybridization and immunohistochemical results. Epstein-Barr virus expression was found in 8.0% of cases. p53-positive staining was distributed in 92% of pediatric cases. Kaplan-Meier survival analysis showed that neither EBV nor p53 expression was statistically significantly associated with event-free survival. Our data showed a low frequency of EBV association with pediatric T-cell lymphoma. It seems that p53 plays an important role in proliferation in our studied population, since it is overexpressed in 92% of T-cell lymphoma cases.

Pyothorax-associated lymphoma: a case showing transition from T-cell-rich polymorphic lesion to diffuse large B-cell lymphoma

Pyothorax-associated lymphoma was found in a man who had a history of collapse therapy for pulmonary tuberculosis about 50 years ago. An autopsy specimen revealed histology of diffuse large B-cell lymphoma with latency III Epstein-Barr virus (EBV) infection. However, an open biopsy 2 years and 7 months before death showed a polymorphic appearance with abundant T-lymphocytes. Most of the EBV-infected atypical lymphocytes did not express either B- or T-cell markers as far as examined in the paraffin-embedded biopsy specimen, and rearrangements of immunoglobulin and T-cell receptors were not found. It seemed difficult to diagnose a B-cell lymphoma at the time of biopsy. However, retrospectively considered, if a phenotype of EBV-infected atypical lymphocytes is uncertain in cases showing polymorphic appearance, it might be better to consider the future evolution to overt B-cell lymphoma. Since pyothorax-associated lymphoma shows latency III infection of EBV, at least the immunohistochemistry of EBNA-2 and LMP-1 seems helpful for the diagnosis to prove which cells are infected by EBV.

Cutaneous malignant lymphomas: Update 2006

Cutaneous lymphomas represent a unique group of lymphomas and are the second most frequent extranodal lymphomas. As with other neoplasias, the pathogenesis is based mainly on a stepwise accumulation of mutations of suppressor genes and oncogenes caused by genetic, environmental or infectious factors. The diagnostic work-up includes clinical, histological, imaging and hematological investigations and in many cases immunohistochemical and molecular biological analyses. The current WHO/EORTC classification of cutaneous lymphomas differentiates "mature T-cell and NK-cell lymphomas", "mature B-cell lymphomas" and "immature hematopoietic malignancies", their variants and subgroups. It is compatible with the WHO classification for neoplasias of the hematopoietic and lymphoid tissue and respects the organ-specific peculiarities of primary cutaneous lymphomas. The assignment of the various types of cutaneous lymphomas into prognostic categories (pre-lymphomatous "abortive" disorders; definite malignant lymphomas of low-grade malignancy; definite malignant lymphomas of high-grade malignancy) provides essential information on the biological behavior and allows an appropriate planning of the therapeutic strategy, which may be topical or systemic and aggressive or non-aggressive. Besides the classical options for therapy, there are new and "experimental" strategies, the efficacy of which has to be studied in clinical trials.

Conjugal transformed mycosis fungoides: the unknown role of viral infection and environmental exposures in the development of cutaneous T-cell lymphoma

The etiology of mycosis fungoides (MF) is uncertain, although infectious agents and other environmental exposures have been implicated. We describe what appears to be the first case in which both a husband and his wife were diagnosed with large-cell transformation of MF. After 10 years of having stage I MF, the wife developed tumors that showed sheets of large transformed cells with dysplastic nuclei on skin biopsies, leading to a diagnosis of transformed MF. Her husband was diagnosed 14 months later with transformed MF following a biopsy of his right arm and leg after a 15-year history of presumed psoriasis. The fact that this rare occurrence happened in a couple who had been married for more than 25 years points to a common environmental exposure. Future studies should aim to clarify the potential role of infectious agents, such as human T-lymphotropic virus I and II, cytomegalovirus, Epstein-Barr virus, and other environmental exposures, in the development of MF.

Mycosis fungoides: is it a Borrelia burgdorferi-associated disease?

Mycosis fungoides (MF) is the most frequently found cutaneous T-cell lymphoma with an unknown aetiology. Several aetiopathogenetic mechanisms have been postulated, including persistent viral or bacterial infections. We looked for evidence of Borrelia burgdorferi (Bb), the aetiologic agent of Lyme disease (LD), in a case study of MF patients from Northeastern Italy, an area with endemic LD. Polymerase chain reaction for the flagellin gene of Bb was used to study formalin-fixed paraffin-embedded lesional skin biopsies from 83 patients with MF and 83 sex- and age-matched healthy controls with homolocalised cutaneous nevi. Borrelia burgdorferi-specific sequence was detected in 15 out of 83 skin samples of patients with MF (18.1%), but in none out of 83 matched healthy controls (P<0.0001). The Bb positivity rates detected in this study support a possible role for Bb in the aetiopathogenesis of MF in a population endemic for LD.

CD8+ T lymphocytes reactive against Epstein-Barr virus antigens in skin lesions of a patient with Sézary syndrome

Several studies have investigated the possible involvement of viral agents, and among them herpes viruses, in the development of cutaneous T-cell lymphoma. The aim of our study was to determine whether T cells specific to Epstein-Barr virus (EBV) antigens were detectable among tumor-infiltrating lymphocytes infiltrating cutaneous lesions of a patient with Sézary syndrome. To analyze responses to EBV, we used a transient SV-40 origin-defective transformed simian cells transfection assay that permits an estimation of CD8 T-cell responses against a large number of HLA/viral protein combinations. This technique allowed the detection of EBV-specific T lymphocytes mainly directed against epitopes generated during the lytic cycle in the cutaneous lesions. This is, to our knowledge, the first description of the presence of EBV-specific T lymphocytes among tumor-infiltrating lymphocytes infiltrating the lesional skin of a patient with Sézary syndrome.

Polymorphism analysis of Epstein–Barr virus isolates of lymphoblastoid cell lines from patients with mycosis fungoides

In order to determine whether there is an association between the presence of Epstein–Barr virus (EBV) and mycosis fungoides (MF) disease progression, PCR was performed to detect the EBV status of 20 MF patients; six EBV-positive patients were found. EBV variants may differ in their biological properties, such as their ability to transform cells; therefore, the ability of these variants to immortalize B cells in vitro was analysed. Six continuously growing cell lines were obtained from prolonged cultures of unstimulated peripheral blood mononuclear cells that were taken from the six EBV-positive patients with MF. In order to characterize the EBV strains, EBNA-2 and LMP-1/LMP-2 gene polymorphisms in the six cell lines were also analysed. All patients were followed up for 10 years and it was noticed that EBV-positive patients had a poor prognosis with rapid disease progression and high mortality rates, compared to EBV-negative patients. EBV may therefore constitute a co-factor that accelerates the progression of disease.

Cold urticaria in a patient with mycosis fungoides

We report what we believe to be the first documentation of a patient with both cold urticaria and mycosis fungoides. The patient described a marked worsening of his long-standing lesions of mycosis fungoides at the same time as the onset of cold sensitivity. We believe this suggests a possible association between these 2 rare diseases.

Engagement of ILT2/CD85j in Sézary syndrome cells inhibits their CD3/TCR signaling

Extensive phenotype analysis of cutaneous T-cell lymphoma (CTCL) malignant cell lines revealed surface expression of receptors usually not detected on normal circulating CD4(+)CD45RO(+) lymphocytes. We previously found that CTCL malignant cells express the killer cell immunoglobulinlike receptor (KIR) KIR3DL2/CD158k, whereas they fail to express the other KIRs. In the present study, we report for the first time that the CD85j/immunoglobulin (Ig)-like transcript 2 (ILT2) receptor is found on Sézary cell lines and on circulating Sézary malignant CD4(+) cells, while it is hardly detectable on circulating CD4(+) lymphocytes from healthy individuals. We demonstrate that ILT2 is functional on CTCL cells, as its triggering leads to the recruitment of Src homology 2 domain-containing tyrosine phosphatase (SHP-1) and to the specific inhibition of CTCL malignant cell proliferation induced by CD3/T-cell receptor (TCR) stimulation. Interestingly, we found that separated CD4(+)ILT2(+) circulating malignant Sézary cells are less susceptible to anti-CD3 monoclonal antibody (mAb)-induced cell death than autologous CD4(+)ILT2(-) lymphocytes. Therefore, the resistance to apoptosis of Sézary cells may result from distinct mechanisms including cytokine-induced high levels of bcl-2 and specific expression of inhibitory receptors involved in lymphocyte survival.

Association of Epstein-Barr virus with oral cancers

Epstein-Barr virus (EBV) persists in the epithelial cells of oral mucosa and often replicates on them. EBV is known to be a causative agent of nasopharyngeal carcinoma. We suspect that EBV may be associated with oral cancers, and thus examined EBV expression on 28 tongues and 9 other oral cancers. We also examined 6 metastatic lesions in the lymph nodes. All cancers were squamous cell carcinoma (SCC). We used mRNA in situ hybridization, immunofluorescence staining, reverse transcriptase-polymerase chain reaction (RT-PCR), and polymerase chain reaction (PCR). The mRNA in situ hybridization using a probe comprising the transcripts of the BamHIW fragment of the EBV genome demonstrated EBV mRNA in the majority of tumor cells in all cases of oral cancer, but in none of the normal tissues. RNA in situ hybridization using an EBER1 probe detected RNAs in 16 out of 24 cancers. Also, mRNA in situ hybridization using a probe of the EBV-determined nuclear antigen-2 (EBNA2) region detected positive signals in 9 out of 12 cancers. Furthermore, EBNA2, latent membrane protein-1 (LMP1) and BZLF1 were detected in these cancers by immunofluorescence staining, but were not detected in any of the epithelial cells of the normal tissues. Four out of 6 metastatic tissues showed stronger fluorescence than that in the primary tissues. RT-PCR analysis also showed EBER1 expression in 1 of the 3 tongue cancers. PCR detected the BamHIW sequence of EBV DNA in all cases, including the normal tissues tested. These findings indicate that EBV may be involved in neoplastic transformation in oral cancers, such as nasopharyngeal carcinoma.

Cutaneous manifestations of Epstein-Barr virus infection

The most common cutaneous manifestations of EBV include IM, OHL, and cutaneous lymphoproliferative disorders. Infectious mononucleosis is a self-limited manifestation of acute EBV infection. The transient rash that occurs quite commonly in patients with IM who have received antibiotic therapy is an erythematous, maculopapular eruption, usually located on the trunk and upper extremities. Oral hairy leukoplakia occurs in immunosuppressed HIV-positive and HIV-negative individuals. In HIV-positive individuals, it serves as an indicator of disease severity and rapid progression to AIDS. The presence of OHL in an individual should prompt the clinician to perform a through history-taking and investigation of immune status. Cutaneous lymphoproliferative disorders associated with EBV occur in individuals with congenital or acquired immunodeficiency syndromes.