Epstein-Barr virus-associated multicentric leiomyosarcoma in an adult patient after heart transplantation: case report and review of the literature

Epstein-Barr virus-associated leiomyosarcoma of the larynx in an adult patient with human immunodeficiency virus infection: Case report and review of the literature

We investigated the clinical features, treatment, and prognosis of laryngeal leiomyosarcoma (LLMS) and Epstein-Barr virus-associated (EBV-associated) LMS. We report a case of EBV-associated LLMS in an adult patient with HIV infection. We also conducted a review of the English-language literature on LLMS and EBV-associated leiomyosarcoma. To the best of our knowledge, 62 cases of LLMS and EBV-associated leiomyosarcoma have been reported to date. Of patients with LLS, 18.9% had distant metastases and 17.0% had local recurrence. The overall 5-year survival rate was 64.0%. Distant metastases affected the survival of patients with LLMS (p = 0.04). EBV-positive patients had a low survival rate (p = 0.01). Among patients with EBV-associated LMS, 8.2% had distant metastases and recurrence and the overall 5-year survival rate was 50.0%. EBV-associated LLMS is rare. The EBV infection might be a poor prognostic factor of LLMS.

Immunosuppressive Tumor Microenvironment and Immunotherapy of Epstein–Barr Virus-Associated Malignancies

The Epstein–Barr virus (EBV) can cause different types of cancer in human beings when the virus infects different cell types with various latent patterns. EBV shapes a distinct and immunosuppressive tumor microenvironment (TME) to its benefit by influencing and interacting with different components in the TME. Different EBV-associated malignancies adopt similar but slightly specific immunosuppressive mechanisms by encoding different EBV products to escape both innate and adaptive immune responses. Strategies reversing the immunosuppressive TME of EBV-associated malignancies have been under evaluation in clinical practice. As the interactions among EBV, tumor cells, and TME are intricate, in this review, we mainly discuss the epidemiology of EBV, the life cycle of EBV, the cellular and molecular composition of TME, and a landscape of different EBV-associated malignancies and immunotherapy by targeting the TME.

Epstein-Barr Virus-Associated Smooth Muscle Tumor and Its Correlation With CD4 Levels in a Patient With HIV Infection

Epstein-Barr virus-associated smooth muscle tumor (EBV-SMT) is a rare tumor found in immunocompromised patients, and its treatment is not well-established. A role for antiretroviral therapy in human immunodeficiency virus (HIV)-related EBV-SMT has been proposed; however, the relevance of tumor size, CD4 levels, and immune reconstitution inflammatory syndrome (IRIS) has not been previously reported. We present the first case, to our knowledge, of a tumor that shrank in association with elevated CD4 counts. IRIS occurred in this case following antiretroviral therapy. This finding highlights the importance of the immune response in HIV-related EBV-SMT.

Lessons from Epstein-Barr virus DNA detection in cerebrospinal fluid as a diagnostic tool for EBV-induced central nervous system dysfunction among HIV-positive patients

Polymerase chain reaction (PCR) analysis of Epstein-Barr virus (EBV) DNA in cerebrospinal fluid (CSF) remains vital for evaluating active EBV infection involving the central nervous system (CNS). CSF EBV DNA was often found in conjunction with other microbial infection affecting the CNS among patients infected with human immunodeficiency virus (HIV). Sometimes CSF EBV DNA is detectable in patients without neurological symptoms. This review focused on the clinical and laboratory features of CNS EBV infection among patients with HIV, and discussed various types of EBV-associated CNS infections, and predominant neoplasms involving CNS such as primary central nervous system lymphoma (PCNSL), CNS-non-Hodgkin's lymphoma, smooth muscle tumors and leiomyosarcomas, EBV encephalitis or myelitis, EBV meningitis and EBV coinfection with other causative agents were also included. Furthermore, the metagenomic next-generation sequencing technique with high sensitivity for the detection of pathogenic coinfection in the CSF were also reviewed. We concluded that CSF EBV-DNA detection with high sensitivity and specificity could be a useful diagnostic tool for CNS lymphoma among HIV patients; however, it is still unknown for other CNS diseases. We further summarized and conclude that positive CSF EBV-DNA detection combined with specific brain focal lesions could be a minimally invasive method to diagnose PCNSL. The occurrence of positive CSF EBV-DNA was influenced by PCR detection limit, PCR methods, immunocompromised status, the possible influence of anti-herpetic therapy and anti-HIV therapy, and the size and location of a tumor mass. Uniform PCR methods as vital diagnostic tools and optimal EBV-DNA load threshold need to be established.

The first case of gastric leiomyosarcoma developed through malignant transformation of leiomyoma

Malignant transformation of gastric leiomyoma has not been reported, and therefore it is considered to have virtually no malignant potential. We report a case of gastric leiomyosarcoma arising from leiomyoma. The patient is a 72-year-old man with a submucosal mass measuring 20 mm in diameter, which was incidentally identified by an endoscopic surveillance. A biopsy suggested a diagnosis of leiomyosarcoma, and local excision was performed. Pathological examination revealed that the tumor was composed of two distinct components: typical leiomyoma-like area in the periphery and leiomyosarcoma component exhibiting higher cellularity, prominent nuclear atypia, necrosis, and increased mitosis. Immunohistochemically, in the latter, p53 overexpression, increased Ki-67 labeling index, and attenuated expression of smooth muscle markers were noted. This is the first report to demonstrate the presence of leiomyoma-leiomyosarcoma sequence in the stomach that is well recognized in the uterus. Our observation highlights the potential occurrence of malignant transformation of gastrointestinal leiomyoma.

Leiomyosarcoma After Liver Transplantation Is Unrelated to Epstein-Barr Virus: A Case Report

BACKGROUND

De novo malignancy is a severe complication after liver transplantation (LT), but de novo leiomyosarcoma is extremely rare.

METHODS

We reported de novo leiomyosarcoma occurring after LT. The patient's status for Epstein-Barr virus was negative. The donor was a 21-year-old man with a central nervous system malignancy who underwent surgery. Three months later brain death occurred and his organs were donated.

RESULTS

Leiomyosarcoma in the recipient was detected shortly after LT. It progressed after minimization of immunosuppression and apatinib therapy, and the patient died of cachexia 17 months after LT.

CONCLUSIONS

De novo leiomyosarcoma is a rare but serious event after LT, needing comprehensive management.

Gastric Leiomyosarcoma Unmasked by Bleeding From a Percutaneous Endoscopic Gastrostomy Tube

Gastrointestinal bleeding from percutaneous endoscopic gastrostomy tubes and malignancy are uncommon. Gastric leiomyosarcomas are rare and differentiated from other gastric tumors with histology and immunohistochemical staining. We present a case of upper gastrointestinal bleeding from a percutaneous endoscopic gastrostomy tube manifesting as a gastric leiomyosarcoma in a 50-year-old man with a medical history of Wilms tumor. We reviewed the epidemiology, diagnosis, and management of gastric leiomyosarcomas. We also explored the risk factors and potential mechanisms in the pathogenesis of gastric leiomyosarcoma in our patient.

Epstein-Barr Virus-Associated Smooth Muscle Tumour: A Case Series with a Significant Proportion of Tumours Showing Proclivity for Cutaneous Soft Tissues

Background

Epstein-Barr virus-associated smooth muscle tumours (EBV-SMTs) are rare neoplasms of uncertain biological potential. They are seen in the setting of immune suppression from a variety of causes, including HIV infection and post-transplant immunosuppression. Most of the literature pertaining to these neoplasms comprises case reports and small case series, with a dearth of documented cases from South Africa.

Objective

To expand on the literature of these rare neoplasms in the South African context, with an emphasis on a subset showing a predilection for the cutaneous soft tissues.

Method

Twenty-one EBV-SMTs from 19 consecutive patients were retrieved from the archives of the Division of Anatomical Pathology in the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, and the National Health Laboratory Service. Clinical and pathological characteristics of each case were recorded, including patient age, tumour site, H&E morphology, immunophenotypic features and the tumoural EBV status.

Results

The patients' ages ranged from 12 to 63 years, with a mean of 36 years. Thirteen (68%) of the patients in whom the HIV status was known were HIV-positive. Two of the 19 patients each had 2 tumours, thus accounting for the total of 21 neoplasms studied. Although 12 of the 21 tumours (57.1%) were from a variety of visceral organs, 9 (42.9%) originated in the dermis and superficial subcutaneous tissues, making the cutaneous soft tissues the most commonly affected site. Morphologically, all of the neoplasms were characterised by fascicles of myoid cells, admixed rounder tumour cells, scattered intratumoural lymphocytes and variable immunohistochemical staining with markers of smooth muscle differentiation. All 21 neoplasms were proven to harbour EBV DNA.

Conclusion

A significant proportion of EBV-SMTs may present in the cutaneous soft tissues. This neoplasm should, therefore, be included in the histopathological differential diagnosis of any cutaneous or superficial subcutaneous spindle cell tumour, especially in patients with a history of underlying immune suppression. Accurate diagnosis thereof and its distinction from other spindle cell neoplasms is important in view of management implications and the potential for multicentricity in some patients.

Treatment response with sirolimus for a pediatric patient with an EBV-associated smooth-muscle tumor after bone marrow transplantation

Epstein-Barr virus-associated smooth-muscle tumors (EBV-SMTs) are unique and rare neoplasms described in immunocompromised patients. The case describes a nine-year-old female with a history of acute lymphoblastic leukemia with relapse and subsequent allogeneic bone marrow transplantation who presented with multiple EBV-SMTs of the liver. EBV utilizes the mammalian target of rapamycin (mTOR) pathway for tumor growth, and sirolimus, a mTOR inhibitor, has shown to result in a short-term response. We now report an extended treatment response with sirolimus in a pediatric patient with an EBV-SMT.

Epstein-Barr virus associated smooth muscle tumors in solid organ transplant recipients: Incidence over 31 years at a single institution and review of the literature

INTRODUCTION

Epstein-Barr virus (EBV) associated smooth muscle tumors (EBV-SMT) are a rare complication of solid organ transplantation (SOT). Incidence data related to this EBV-SMT are limited. EBV DNA is universally present in these tumors. How these cells get infected with EBV, whether this is a result of primary EBV infection vs reactivation, and how persistent active EBV infection post-transplant influences EBV-SMT pathogenesis remains unknown.

METHODS

Among 5006 SOT recipients (474 pediatric, 4532 adult) receiving SOT at our center between Jan 1984 and Dec 2015, three cases of post-transplant EBV-SMT were identified.

RESULTS

All cases were pediatric heart transplants who were EBV seronegative prior to transplant, and experienced primary EBV infection with persistently elevated EBV viral loads, despite antiviral therapy. Two are deceased at 3.2 and 0.9 years post-diagnosis, while one remains alive 6.2 years post diagnosis. The overall local incidence of post-transplant EBV-SMT at our institution was 0.7 (95% CI, 0.2-1.7) per 1000 patient years, and 2.6 (95% CI, 0.6-6.7) per 1000 patient years in pediatric heart transplants. A literature review identified 36 pediatric and 51 adult cases of post-transplant EBV-SMT.

CONCLUSIONS

We hypothesize that pre-transplant EBV seronegativity, followed by primary EBV infection and persistently high EBV viral loads, represents a unique risk factor for post-transplant EBV-SMT. Pediatric heart transplant recipients were found to be disproportionately affected by post-transplant EBV-SMT at our institution.

Primary intracranial leiomyosarcoma among patients with AIDS in the era of new chemotherapeutic and biological agents

Primary intracranial leiomyosarcoma (PIL) is a rare non-infectious aetiology of focal mass lesions among HIV-infected individuals. With only 16 published cases worldwide, information on its pathophysiology, risk factors, clinical course and management options is limited. We report two cases of PIL in HIV-infected Filipino men who presented with 1-3 months history of persistent headache, progressing in severity. Both had cranial MRI revealing intracranial mass diagnosed as leiomyosarcoma by excision biopsy and immunohistochemical staining. Both patients underwent adjuvant cranial radiotherapy and chemotherapy. Biologics were initiated in one patient. Both patients were alive with evidence of the disease.

Laryngeal Epstein-Barr Virus-Associated Smooth Muscle Tumor in an Undernourished Child

Smooth muscle tumors associated with Epstein-Barr virus infections (EBV-SMT) of laryngeal origin are exceedingly rare and have been reported in few adult patients, but not in children. This reported case describes a lesion found in the larynx of an 8-year-old Guatemalan undernourished girl. Microscopically, the lesion showed a highly cellular mesenchymal spindle cell tumor, containing frequent lymphocytes. The immunohistochemical analysis revealed positivity for α-smooth muscle actin and h-caldesmon. In addition, most of the tumor cells were positive for EBV by in situ hybridization. To the best of the author's knowledge, this is the first literature-reported case of laryngeal EBV-SMT occurring in an undernourished child.

A rare case of Epstein-Barr virus-associated hepatosplenic smooth muscle tumors after kidney transplantation

A 27-year old caucasian male was diagnosed 2.7 years after kidney transplantation with Epstein-Barr virus (EBV)-associated smooth muscle tumors in liver and spleen. The reduction in immunosuppression and conversion from tacrolimus to sirolimus did not lead to a regression of the tumors. Additionally, the patient developed a cellular rejection of his renal allograft, which was successfully treated. A combined approach with stereotactic radiofrequency ablation (SRFA) and surgical resection was effective in the treatment of the tumors.

Leiomyosarcoma of the stomach with metastasis to the liver: a case report with review of the literature

Leiomyosarcoma of the stomach is a very rare malignancy that was not distinguished from the more frequent gastrointestinal stromal tumors until early 2000s. Here we report on a case of a metastatic disease that developed in a 47-year-old man 2 years after he was diagnosed with the primary tumor and treated with curative surgical excision and adjuvant doxorubicin. The primary and metastatic lesions were positive for smooth muscle markers α-smooth muscle actin and h-caldesmon and negative for CD117, DOG-1 and S100 by immunohistochemistry. Metastatic disease progressed on additional monotherapy with doxorubicin and docetaxel-gemcitabine combination, and stable disease was achieved upon treatment with pazopanib. Patient is surviving 35 months since diagnosis of the primary tumor and 11 months since diagnosis of metastatic disease.

Disseminated and late metastatic disease from nasal pit leiomyosarcoma after radical surgical resection. Case report of a singular presentation of a rare disease

Background

Leiomyosarcoma of the head and neck is a rare cancer with high local aggressiveness. Radical surgery and adjuvant treatment offer the best chance for cure, nonetheless 5-years recurrence rate remains high. Despite international guidelines are available for soft tissue sarcomas, no recommendations are specifically endorsed for leiomyosarcoma of the head and neck, due to the rarity of its presentation and consequently scarcity of data on long-term outcome.

Case presentation

A 50-year old woman, operated 10 years before for leiomyosarcoma of the nasal pit and with negative 5-years follow-up, was admitted to our ward for impairment of the hepatic function. Total-body CT scan detected multiple localizations at lungs, kidneys, pancreas, bones, muscles, lymph nodes and thyroid. The pathologic report after lung biopsy confirmed the diagnosis of metastasis from leiomyosarcoma and the patients was scheduled for first line chemo-radiotherapy.

Conclusions

Despite adequate primary treatment, distant and disseminated metastatic disease may be not excluded in leiomyosarcoma of the head and neck.

Epidemiology and Etiology of Sarcomas

Sarcomas are rare malignancies of mesenchymal origin and are broadly divided into soft tissue sarcomas and bone sarcomas. The etiology of these tumors is largely unknown, and most sarcomas are sporadic. A small subset of sarcomas is associated with certain genetic syndromes and environmental factors. Ionizing radiation is the strongest environmental factor linked to sarcoma development.

Primary intracranial leiomyosarcoma of the torcular Herophili associated with Fanconi anemia and allogenic stem cell transplantation

PURPOSE

Fanconi anemia is associated with a high risk for developing malignant tumors. The occurrence of primary intracranial leiomyosarcoma, however, which in general has a poor prognosis, has not been described thus far. The purpose of this study is to report on management and outcome of leiomyosarcoma of the torcular Herophili associated with Fanconi anemia in a pediatric patient.

CASE REPORT

A 12-year-old girl with Fanconi anemia presented with a primary intracranial leiomyosarcoma arising from the torcular Herophili and infiltrating the adjacent venous sinuses after previous allogenic hematopoietic stem cell transplantation. Radical tumor resection followed by radiotherapy resulted in tumor-free survival and good outcome at a 2-year follow-up.

CONCLUSION

Despite occurrence of leiomyosarcoma in a site thought unfavorable for surgery, combined tumor resection and radiosurgery may yield excellent outcome.

Smooth muscle tumors of soft tissue and non-uterine viscera: biology and prognosis

Smooth muscle tumors are here considered an essentially dichotomous group composed of benign leiomyomas and malignant leiomyosarcomas. Soft tissue smooth muscle tumors with both atypia and mitotic activity are generally diagnosed leiomyosarcomas acknowledging potential for metastasis. However, lesions exist that cannot be comfortably placed in either category, and in such cases the designation 'smooth muscle tumor of uncertain biologic potential' is appropriate. The use of this category is often necessary with limited sampling, such as needle core biopsies. Benign smooth muscle tumors include smooth muscle hamartoma and angioleiomyoma. A specific category of leiomyomas are estrogen-receptor positive ones in women. These are similar to uterine leiomyomas and can occur anywhere in the abdomen and abdominal wall. Leiomyosarcomas can occur at any site, although are more frequent in the retroperitoneum and proximal extremities. They are recognized by likeness to smooth muscle cells but can undergo pleomorphic evolution ('dedifferentiation'). Presence of smooth muscle actin is nearly uniform and desmin-positivity usual. This and the lack of KIT expression separate leiomyosarcoma from GIST, an important problem in abdominal soft tissues. EBV-associated smooth muscle tumors are a specific subcategory occurring in AIDS or post-transplant patients. These tumors can have incomplete smooth muscle differentiation but show nuclear EBER as a diagnostic feature. In contrast to many other soft tissue tumors, genetics of smooth muscle tumors are poorly understood and such diagnostic testing is not yet generally applicable in this histogenetic group. Leiomyosarcomas are known to be genetically complex, often showing 'chaotic' karyotypes including aneuploidy or polyploidy, and no recurrent tumor-specific translocations have been detected.

MicroRNA expression in Epstein-Barr virus-associated post-transplant smooth muscle tumours is related to leiomyomatous phenotype

Epstein-Barr virus (EBV)-associated post-transplant smooth muscle tumours (PTSMT) are rare complications. In our previous molecular analysis, we have evaluated the expression of regulatory microRNA which are known to be EBV-related (miR-146a and miR-155) but found no deregulation in PTSMT. In this current analysis, we aimed to characterize the expression profiles of several hundred microRNA. Tissue samples from PTSMT and uterine leiomyomas were analysed by quantitative real-time PCR for the expression of 365 mature microRNA. PTSMT and leiomyomas share a highly similar microRNA profile, e.g. strong expression of miR-143/miR-145 cluster and low expression of miR-200c. Among EBV-related microRNA (miR-10b, miR-21, miR-29b, miR-34a, miR-127, miR-146a, miR-155, miR-200b, miR-203 and miR-429) only miR-10b and miR-203 were significantly deregulated. The expression pattern of microRNA in PTSMT is not associated with EBV infection but reflects the leiomyomatous differentiation of the tumour cells.

Epstein-Barr virus associated smooth muscle tumors in post transplant pediatric patients two cases of rare locations, and review of the literature

Epstein-Barr virus (EBV) may present few or no symptoms in immunocompetent individuals; however, in immunocompromised patients as in the case of AIDS and post-transplant patients, the virus occasionally stimulates neoplastic transformations. Epstein-Barr virus may play a role in the development of smooth muscle tumors (SMT). In the case of Epstein-Barr associated smooth muscle tumors (EBV+SMT), the virus is thought to be the leading factor to the tumorigenic pathway. We report two pediatric patients (6 and 13 years old) who underwent liver transplantation and developed EBV+SMT in the colon and orbit. These two cases represent rare locations for this kind of lesion.

Sarcomas other than Kaposi sarcoma occurring in immunodeficiency: interpretations from a systematic literature review

PURPOSE OF REVIEW

In immunodeficiency, an increased sarcoma risk is confirmed for Kaposi's sarcoma. Whether rates of other sarcoma subtypes are elevated in the setting of immunodeficiency is not known. We therefore reviewed published case reports on HIV and AIDS patients and organ transplant recipients with sarcomas. For comparison, we assessed sarcomas in the U.S. general population using Surveillance Epidemiology End Results (SEER) data.

RECENT FINDINGS

A total of 176 non-Kaposi sarcoma were identified, 75 in people with HIV and AIDS and 101 in transplant recipients. Leiomyosarcomas (n = 101) were the most frequently reported sarcomas, followed by angiosarcomas (n = 23) and fibrohistiocytic tumors (n = 17). Leiomyosarcomas were reported with two age peaks, in children and young adults. Epstein-Barr virus (EBV) was detected in the tumor cells in 85 and 88% of leiomyosarcomas in HIV-infected people and transplant recipients, respectively. Angiosarcomas and fibrohistiocytic tumors were most frequently reported in men. Among kidney transplant recipients, 20% of sarcomas arose at the site of an arteriovenous fistula. In comparison, leiomyoscarcomas, angiosarcomas, and fibrohistiocytic tumors comprised 16.9, 3.8, and 18.7% of sarcomas in the U.S. general population.

SUMMARY

Leiomyosarcoma and angiosarcoma may occur disproportionately in immunodeficiency. Leiomyosarcomas appear causatively linked to EBV, whereas angiosarcomas might be correlated with an arteriovenous fistula. Additional studies are necessary to understand the contribution of immunodeficiency to the cause of these sarcomas.

Molecular and clinicopathological analysis of Epstein-Barr virus-associated posttransplant smooth muscle tumors

Epstein-Barr virus (EBV)-associated posttransplant smooth muscle tumors (PTSMT) are very rare complications. We aimed to provide a clinicopathological characterization which is based on our own case series (n = 5) as well as previously reported PTSMT cases (n = 63). Meta-analysis of PTSMT and molecular analysis of tumor cells from our cohort was performed. Most PTSMT developed in kidney-transplanted patients (n = 41/68, 60%). Liver/transplant liver was the main site of manifestation (n = 38/68, 56%). Tumors occurred after a median interval of 48 months (range 5-348) and developed earlier in children than in adults. Most tumors showed no marked cellular atypia, low mitosis rate and no tumor necrosis. Gene expression analysis of 20 EBV-related genes, including two microRNAs, revealed overexpression of MYC (p = 0.0357). Therapy was mainly based on surgical resection or reduced immunosuppression but no significant differences in overall survival were evident. Lower overall survival was associated with multiorgan involvement (n = 33/68, 48.5%) and particularly with intracranial PTSMT manifestation (n = 7/68, 10%; p < 0.02), but not transplant involvement (n = 11/68, 16%). In summary, PTSMT differ from conventional leiomyosarcomas by their lack of marked atypia, unusual sites of involvement and defining EBV association. Surgery and reduced immunosuppression show comparable clinical results and prognosis is associated with intracranial manifestation.

Local recurrence and multi-organ metastasis of primary retroperitoneal leiomyosarcoma in unusual locations after surgical resection

We report a case of retroperitoneal leiomyosarcoma in a 52-year-old woman, who developed local recurrence, pulmonary, hepatic, peritoneal, pancreatic, subcutaneous and intramuscular metastases two years after surgical resection of the primary tumor. Metastasis to the pancreas, subcutaneous or muscular tissue is very rare; however, presence of a lesion in these locations in a known case of leiomyosarcoma might indicate a metastatic tumor deposit.

Synchronous hepatic, mesenteric and pulmonary Epstein-Barr virus-associated smooth muscle tumors in a renal transplant recipient

Epstein-Barr virus-associated smooth muscle tumors (EBV-SMT) are distinct lesions that occur in immunocompromised patients. EBV-SMT following solid organ transplantation are rare and generally have an indolent biological behavior. Post-transplant EBV-SMT have been reported in various anatomical locations. This report describes a synchronous and multicentric development of EBV-SMT in liver, mesentery, and lung of a 33-yr-old male patient, 10 yr after a deceased allograft renal transplantation. The hepatic and mesenteric tumors were available for study. These tumors were composed of bland looking, desmin-positive, spindle-shaped cells which showed a strong nuclear staining for EBV with in situ hybridization technique. A literature review of post solid organ transplant EBV-SMT in the liver and lung, particularly regarding their pathogenesis, synchronicity and biological behavior would be provided.

Epstein-barr virus-associated smooth muscle tumor of the larynx: report of a rare case mimicking leiomyosarcoma

We present a patient (male 54 years) with a history of renal transplant who 14 years post transplantation developed a symptomatic (stridor) laryngeal Epstein Barr virus (EBV)-associated smooth muscle tumor (EBV-SMT) in the absence of concomitant disease elsewhere. Nine years post transplantation the patient developed a subcutaneous EBV-SMT tumor located on the calf. The laryngeal tumor displayed low-grade nuclear atypia and was infiltrating into the surrounding soft tissue, focally ulcerating through the overlying epithelium. Histologic features included: neoplastic cells with myoid differentiation, a component of primitive appearing small mesenchymal cells with hyperchromatic nuclei, mitotic activity, intralesional small to medium sized blood vessels and T-lymphocytes. Both the myoid and small cell mesenchymal components strongly expressed smooth muscle actin and h-caldesmon, but not desmin, cytokeratins, CD34 or S-100 protein. There was strong positive nuclear reaction for EBV-RNA on in situ hybridization (EBER). No other tumor was detected on clinical and radiological examinations and no evidence of tumor in other sites, over 8 months of follow-up, till death was detected. This case emphasizes the importance of considering this pathologic entity when solitary smooth muscle actin-expressing tumors are encountered in the larynx of immunocompromised patients.

Epstein-Barr virus associated primary intracranial leiomyoma in organ transplant recipient: case report and review of the literature

INTRODUCTION

A 45 year old female renal transplant recipient presented with headaches of 3 months duration. Clinical and radiological evaluation revealed an approximately 4x4 cm rounded, enhancing mass at the left temporal pole. At surgery, the mass had dural attachment and clinically, radiographically, and macroscopically resembled a meningioma. Histopathological analysis revealed a leiomyoma. Epstein-Barr virus (EBV) DNA was demonstrated within the tumour cell nuclei by the in situ hybridisation technique.

DISCUSSION

This is the first documentation of an EBV-associated primary intracranial leiomyoma in an organ transplant recipient and provides additional evidence of a possible relation between EBV infection and development of smooth-muscle tumours (SMT).

CONCLUSION

With increasing numbers of individuals being on long-term immuno-suppression, EBV-associated SMTs may be encountered more frequently in the future.

EBV-associated hepatic smooth muscle tumor after lung transplantation: report of a case and review of the literature

Post-transplant smooth muscle tumors (PTSMTs) are a rare and recently recognized neoplasm associated with Epstein-Barr virus (EBV). We describe the clinicopathologic, immunohistochemical and molecular features of a new case of EBV-associated PTSMT arising in the liver of a 55-year-old lung transplant recipient for lymphangioleiomyomatosis. To our knowledge, this is the third smooth muscle tumor (the second one proved to be associated with EBV) after lung transplantation. The 2 previous cases are reviewed and the differential diagnosis is also discussed.

Expression of EBV latent antigens, mammalian target of rapamycin, and tumor suppression genes in EBV-positive smooth muscle tumors: clinical and therapeutic implications

PURPOSE

EBV-positive smooth muscle tumor (EBV+SMT) is a rare disease with no established therapy. We describe the largest single institution analysis in renal transplant recipients. It aims to define its clinical features and determine the expression of EBV latent genes as well as key molecular pathways.

EXPERIMENTAL DESIGN

Patients with EBV+SMT were identified from the Singapore General Hospital Renal Transplant Registry database. These tumors were investigated for expression of EBV latent genes with Southern blots, EBV latent antigens, mammalian target of rapamycin (mTOR), Akt, p70 S6 kinase, and vascular endothelial growth factor using immunohistochemistry, as well as methylation status of cancer-related genes using methylation-specific PCR.

RESULTS

Eight were found to be EBV+SMT in 1,123 transplant patients. All displayed indolent clinical courses and were unresponsive to immunosuppression reduction. Complete tumor regression was seen in one patient following administration of sirolimus. These tumors display the full range of known EBV latent genes. Immunohistochemistry with total and phosphorylated mTOR and Akt were positive for all patients, and vascular endothelial growth factor was positive in 25% of patients, suggesting activation of the mTOR/Akt pathway. Methylation of RASSF1A was found in all tissue samples, whereas promoter hypermethylation of RARbeta, GSTP1, DAPK, and p14 was observed in some samples.

CONCLUSIONS

Our results suggest that these tumors display a EBV type III latency pattern. The mTOR pathway is also activated. EBV may play a role in silencing RASSF1A. EBV-specific immunotherapy, mTOR inhibitors, and demethylating agents are possible therapeutic options in this disease.

EBV-Associated Smooth Muscle Neoplasms: Solid Tumors Arising in the Presence of Immunosuppression and Autoimmune Diseases

Background. Epstein-Barr virus (EBV)-related smooth muscle neoplasms (SMNs) have been associated with immune dysregulation, most notably in patients who have undergone solid organ transplantation or in patients with HIV/AIDS. Objective. to report our experience with EBV-related neoplasms as well as describing the first EBV-related SMN in the setting of administration of glucocorticoids and the tumor necrosis factor inhibitor etanercept. Design. We have case reports, of minimum 3-year follow-up, 2002–2005. Setting. It was held in an academic and tertiary referral cancer center. Patients. Patients are with dysregulated immunity after solid organ transplantation, HIV/AIDS, or with psoriasis after treatment with etanercept. Interventions. There were discontinuation of etanercept, right hepatic trisegmentectomy, and chemotherapy. Measurements. We use survival as a measurement here. Results. Patients who were able to withstand reduction in immunosuppression survived. Surgical resection or chemotherapy was successful in delaying progression of disease. Limitations. There was a relatively short follow-up for these slow-growing neoplasms. Conclusion. EBV-related SMNs have variable aggressiveness. While chemotherapy may slow disease progression, resection and improving the host immune status provide the best opportunity for primary tumor control.

Epstein-Barr virus-associated epithelial and mesenchymal neoplasms

Epstein-Barr virus (EBV) is a ubiquitous human pathogen that usually maintains a harmonious relationship with its host. Rarely, this host-virus balance is perturbed, causing a diverse group of malignancies in both immunocompetent and immunosuppressed patients. In addition to its role in hematologic malignancies (Burkitt lymphoma, subsets of Hodgkin and T-cell lymphomas, posttransplant lymphomas), EBV has been implicated in both epithelial (undifferentiated nasopharyngeal carcinoma, a subset of gastric adenocarcinomas) and mesenchymal (EBV-associated smooth muscle tumor, inflammatory pseudotumor-like follicular dendritic cell tumor) neoplasms. This review will focus on EBV-associated epithelial and mesenchymal neoplasms.

Spectrum of Epstein-Barr virus-associated diseases

The association between Epstein-Barr virus (EBV) and a large number of benign and malignant diseases is unique among DNA viruses. Within infected tissues, proteins that are expressed during the normal lytic and latent viral life cycle lead to cellular alterations that contribute to these EBV-associated diseases. Although the early events of EBV infection are poorly understood, increasing knowledge of the viral processes that govern viral latency has shed light upon the potential mechanisms by which EBV infection can lead to cellular transformation. Our current understanding of the role of EBV in the development of Burkitt lymphoma, Hodgkin lymphoma, nasopharyngeal carcinoma, and other EBV-associated diseases is discussed.

Gastrointestinal malignancies in HIV-infected or immunosuppressed patients: pathologic features and review of the literature

The gastrointestinal (GI) tract is a common internal organ to be involved by human immunodeficiency virus (HIV)-related malignancies. It is the second most common site for Kaposi sarcoma after skin, and the commonest visceral site, for Kaposi sarcoma in AIDS patients. GI lymphomas have been documented in approximately 25% of AIDS patients with systemic lymphomas. Moreover, GI involvement of AIDS-lymphoma has been associated with poor prognosis and short survival. Several other malignancies that occur in the GI tract are also closely related to HIV-infected or immunosuppressed individuals; these include posttransplant lymphoproliferative disorder, Epstein-Barr virus-associated smooth muscle tumors, anal precancerous lesions, and squamous cell carcinoma. As a result of active antiretroviral therapy, patients infected with HIV are living longer and are consequently at increased risk for development of cancer. Therefore, it is possible that the number of AIDS-associated malignancies will rise and the pattern of tumors may change in the future. In this paper, the clinicopathologic features of GI malignancies associated with AIDS patients are reviewed and the differential diagnosis with other mimic lesions is discussed.

Epstein-Barr virus–associated smooth muscle tumor presenting as a vulvar mass in an acquired immunodeficiency syndrome patient: a case report

Smooth muscle tumors in immunocompromised patients have a strong association with Epstein-Barr virus (EBV) infection. EBV-associated smooth muscle tumors (EBV-SMT) are considered as a distinct group of smooth muscle tumors with different clinicopathologic features from conventional smooth muscle tumors. A 31-year-old female patient presented with a 2-cm mass at the left labium majus, the clinical diagnosis of which was a Bartholin lesion. She had acquired immunodeficiency syndrome diagnosed 29 months before. Excisional biopsy revealed a cellular tumor composed of round- to spindle-shaped cells with mild to moderate nuclear atypia. The tumor cells were immunoreactive for smooth muscle actin and muscle actin (HHF-35). Evidence of EBV infection was confirmed by in situ hybridization for EBV-encoded small RNA-1. To our knowledge, this is the first case of EBV-SMT presenting as a vulvar mass. EBV-SMT should be included in the differential diagnoses of mesenchymal tumor in patients with immunosuppression and in the differential diagnoses of smooth muscle tumor in uncommon sites, including the vulva.

Epstein–Barr Virus–associated Multifocal Leiomyosarcomas Arising in a Cardiac Transplant Recipient: Autopsy Case Report and Review of the Literature

Epstein-Barr virus (EBV) associated smooth muscle tumors (SMTs) have been described in patients with acquired immune deficiency syndrome (AIDS) and, more recently, in association with immunosuppression after solid-organ transplantation. We present the autopsy findings of multiple leiomyosarcomas (LMSs) in a 24-year old man who died 18 months after undergoing orthotopic cardiac transplantation for idiopathic cardiomyopathy. The recognition of EBV-driven LMS developing in cardiac transplant recipients in multiple unusual sites is crucial for the management of these patients and should include complete surgical removal anti-viral therapy and modulation of immunosuppression.

Cranial leiomyosarcoma in an Epstein-Barr virus (EBV)-mismatched lung transplant recipient

Leiomyosarcoma is a rare Epstein-Barr virus (EBV)-related complication of solid-organ transplantation. We report the case of a 19-year-old woman with cystic fibrosis who presented with protracted headaches 15 months after an EBV-mismatched bilateral sequential lung transplant. A parasagittal lesion was found on cranial magnetic resonance imaging; surgical resection revealed a leiomyosarcoma. We discuss treatment options of what is, to our knowledge, the first described case of a cranial leiomyosarcoma in a lung transplant recipient.

Epstein-Barr-associated leiomyomatosis and T-cell chimerism after haploidentical bone marrow transplantation for severe combined immunodeficiency disease

BACKGROUND

The clinical course of Epstein-Barr virus (EBV)-associated smooth muscle tumors is variable and there are no reports in patients with mixed T-cell chimerism after bone marrow transplantation (BMT).

OBSERVATIONS

A child with X-linked severe combined immunodeficiency disease developed multiple renal and pulmonary leiomyomata 8 years after haploidentical BMT. Epstein-Barr viral DNA was detectable in the blood and in situ hybridization for EBV-encoded RNAs was positive in the tumor. The tumors have been radiographically stable, chimerism remains mixed, and plasma EBV DNA has been repeatedly negative for over 2 years after donor lymphocyte infusion.

CONCLUSIONS

EBV-associated smooth muscle tumors may occur in patients who are partially reconstituted after BMT for severe combined immunodeficiency and may not require surgery or chemotherapy.

EBV-associated diseases in the AIDS patient

EBV-associated malignancies remain a considerable problem in HIV-infected individuals, even in the era of HAART. Although EBV is a common factor, each disease has a unique pathogenesis. Study of these diseases reveals the viral proteins expressed in the malignancies that might contribute to the development of the disease as well as the molecular basis for pathogenesis. It is likely that this knowledge will contribute to the development of novel therapeutics that will result in more favorable outcomes in the future.

Adrenal Leiomyoma Treated by Hand-Assisted Laparoscopic Adrenalectomy: A Case Report

A left adrenal incidentaloma was found by abdominal ultrasound and computed tomography (CT) in a 53-year-old woman who had a history of non-insulin dependent diabetes mellitus. Abdominal CT showed a well-circumscribed adrenal mass (5.5 x 4.5 x 3.5 cm) with low density (32HU) on precontrast scan and heterogeneous enhancement on postcontrast scan. Laboratory examinations revealed a nonfunctional adrenal tumor. As the malignant potential of the tumor could not be ruled out, the patient underwent hand-assisted laparoscopic adrenalectomy. Postoperative recovery was uneventful, and pathologic examination revealed leiomyoma.

Early post-transplant smooth muscle neoplasia of the colon presenting as diminutive polyps: a case complicating post-transplant lymphoproliferative disorder

A 44-year-old woman, 3 years post-transplant for pulmonary sarcoidosis, developed abdominal pain and diarrhea 13 months subsequent to an eradicated diffuse large B-cell-type, post-transplant lymphoproliferative disorder (PTLD) of the cecal region. Endoscopic examination identified multiple pale tan 5-to-9 mm rubbery nodules of the transverse and right colon in an otherwise unremarkable mucosa. Histology was characterized by bland smooth muscle proliferations, focally pushing into the mucosa. Immunohistochemistry (IHC), in situ hybridization (ISH), and polymerase chain reaction (PCR) of the sampled nodules confirmed Epstein-Barr virus (EBV) infection of neoplastic cells. To our knowledge, this is the first reported case of EBV-related post-transplant lymphoproliferative and smooth muscle neoplasms (PTSN) having distinct tropism for the colon. Endoscopic features of early PTSN, which in this case presented as diminutive polypoid lesions, have not been described previously.

Primäre Sarkome und Sarkommetastasen in der Leber

The considerable progress made in radiology, in surgical management with curative intent, and in the identification of molecularly targeted small molecules, such as the tyrosine kinase inhibitor imatinib mesylate, in the treatment of gastrointestinal stromal tumors has greatly influenced the treatment of sarcoma manifestations within the liver. This requires not only the unequivocal pathomorphological differentiation of sarcomas from other tumor entities, e. g. spindle cell dedifferentiated/pleomorphic carcinomas, aggressive non-Hodgkin lymphomas or amelanotic malignant melanomas, but also an accurate subtyping of this complex group of tumors. Additionally to macroscopic and histological findings, the recognition of characteristic immunophenotypic constellations and, at least in some types of sarcoma, the identification of molecular signatures, have greatly expanded the diagnostic tools in pathology.

Epstein-Barr Virus-Associated Smooth Muscle Tumors Are Distinctive Mesenchymal Tumors Reflecting Multiple Infection Events

Epstein-Barr virus-associated smooth muscle tumors (EBV-SMT) are rare lesions that occur in immunocompromised patients. Because they have not been fully characterized pathologically or at the molecular level, we have studied 29 tumors from 19 patients, the largest series to date. Cases coded as EBV-SMT were identified in 19 patients from consultation files and from the renal transplant database at Singapore General Hospital. EBV-SMT occurred in adults (mean age 39 years; range, 21-57 years) and predominantly affected males (12 male, 7 female). Causes of immunocompromise were renal transplantation (10), AIDS (8), and steroid therapy (1). Tumors were located in soft tissue (5), lung (5), liver (4), and miscellaneous sites (15). In 13 patients (68%), the tumors were multiple. Infection with EBV was confirmed in all cases by in situ hybridization for EBV early RNAs (EBER). EBV-SMT were typically well-differentiated smooth muscle tumors with little atypia and usually a low level of mitotic activity. Unlike classic leiomyosarcomas, they lacked significant pleomorphism but frequently displayed primitive round cell areas and prominent intratumoral T lymphocytes. No consistent relationship between histologic features and clinical outcome was noted. All expressed actin (29 of 29) and less frequently desmin (14 of 26). Multiple tumors in a given patient were clonally distinct as assessed by the long terminal repeat region of the virus, supporting the view that multifocal tumors arise from multiple infection events rather than from metastasis. Strain typing by analysis of the EBNA-3C gene confirmed the presence of EBV type 2. Two of four tumors assessed were positive for a 30-bp deletion in the LMP1 gene. EBV copy number per cell ranged greatly between patients and between tumors from the same patient. Follow-up information was available in 18 of 19 patients (mean, 25 months; range, 1-105 months). Fifteen patients were alive: 11 with disease and 4 without. Three patients died, 1 due to disease. We conclude that EBV-SMT are histologically distinct from classic soft tissue smooth muscle tumors, are not readily evaluated by means of conventional histologic criteria, and in the case of multifocal tumors are the result of multiple infection events rather than metastasis. EBV-2 can transform smooth muscle cells, independent of the presence of the LMP1 deletion associated with greater virulence.