EBV-encoded RNA Research Articles

Reappraisal of the prognostic value of Epstein-Barr virus status in monomorphic post-transplantation lymphoproliferative disorders\u2013diffuse large B-cell lymphoma

The role of the Epstein-Barr virus (EBV) status in the blood for predicting survival in post-transplantation lymphoproliferative disorders–diffuse large B-cell lymphoma (PTLD–DLBCL) is unknown. We evaluated the prognostic values of pre-treatment EBV-encoded small RNA (EBER) detected with in situ hybridization in tissues and EBV DNA in the whole blood (WB) and plasma in 58 patients with monomorphic PTLD–DLBCL after solid organ transplantation. There were no significant differences in the rates of overall response, complete response, and survival according to EBER EBV and WB EBV status. In contrast, patients with positive plasma EBV DNA had significantly lower rates of overall response (60.0% vs. 94.4%, P = 0.043) and complete response (40.0% vs. 88.9%, P = 0.019) as well as worse progression-free survival (PFS) (P = 0.035) and overall survival (OS) (P = 0.039) compared with patients with negative plasma EBV DNA. In multivariate analysis, plasma EBV DNA positivity was a significantly unfavorable prognostic factor for PFS [hazard ratio (HR) 4.92, 95% confidence interval (CI) 1.22–19.86, P = 0.025] and OS (HR 4.48, 95% CI 1.14–17.63, P = 0.032). Despite small number of 6 patients with plasma EBV positivity, plasma EBV DNA positivity might be more prognostic for survival than EBER or WB EBV DNA positivity in patients with monomorphic PTLD–DLBCL.

Plasma Epstein-Barr Virus (EBV) DNA as a Biomarker for Diagnosis of Syrian EBV-Positive Burkitt’s Lymphoma

Epstein-Barr Virus -positive Burkitt’s Lymphoma is defined as the presence of Epstein-Barr virus (EBV) in tumor cells, the standard way to detect (EBV) in Burkitt’s Lymphoma is in situ hybridization (ISH) of EBV-encoded small RNA (EBERs) in tumor cells. The present study aimed to evaluate plasma Epstein-Barr virus (EBV) DNA as a noninvasive biomarker for diagnosis and prognosis of EBV-positive Burkitt’s lymphoma. The study included 40 newly diagnosed patients with Burkitt’s lymphoma, ranging in age from 4 to 60 years, and 55 sex and age-matched controls. (40) Formalin-fixed paraffin embedded blocks of Burkitt’s lymphoma tissue samples were used to investigate the EBV by in situ hybridization detection of the EBERs. Plasma EBV DNA was quantified by real-time quantitative polymerase chain reaction (PCR) for all Burkitt lymphoma patients prior to therapy and for control. The results showed that (22/40, 55%) of Burkitt lymphoma were positive for histological EBER, whereas plasma EBV DNA was detectable (range from 1.2 × 104 to 4.7 × 106 copies/mL) in all EBV-positive Burkitt lymphoma samples (22/22). EBV DNA was undetectable in all cases of EBV-negative Burkitt lymphomas (18/18) and all healthy control (55/55). It is worth mentioning that our results demonstrated that the EBV DNA load was significantly high in the EBV-positive BL patients suffering poor prognostic state. In conclusion: Plasma EBV-DNA can be used as a noninvasive biomarker for diagnosis and prognosis of EBV-positive Burkitt’s lymphoma.

The incidence of Epstein-Barr Virus-associated gastric cancer in an Irish population.

236 Background: Gastric adenocarcinoma is the fourth most frequent cancer worldwide and the second leading cause of cancer deaths. According to The Cancer Genome Atlas (TCGA) 9% of gastric carcinomas are associated with Epstein-Barr Virus (EBV). EBV- associated gastric carcinoma (EBV-GC) has distinct clinicopathological features, with a marked lymphocytic infiltrate, a generally diffuse histological type and a better prognosis. The immune cell infiltration in EBV-GC suggests a role for immune checkpoint inhibition, which currently has modest activity in unselected gastric cancer. Methods: All cases of gastric or junctional adenocarcinoma diagnosed between Jan 2019 and March 2020 in Mater Misericordiae University Hospital (MMUH) and Jan 2017 and Jan 2019 in Cork University Hospital (CUH) were identified. Electronic medical records were retrospectively reviewed to collect demographic and clinicopathological data such as AJCC TNM stage, tumour subtype and grade, HER-2 status, MMR proficiency and EBV status as determined by EBV-encoded RNA in situ hybridization. Results: N = 103 cases of gastric or junctional adenocarcinoma were identified. 67 male, 36 female, median age 64.5 (range 34 – 95). 40/103 had undergone surgical resection. EBER-ISH was assessed in all patients. 8 of 103 (7.8%) patients showed EBV positivity. These cases were all male patients, median age 62 (range 51-73). The tumours were located as follows; 2 in the cardia, 5 in the body and 1 not documented. The specimens were graded as; 87.5% (7/8) tumours being poorly differentiated and 1/8 moderate to poorly differentiated. The tumour subtypes were specified as; 62.5% (5/8) diffuse, 12.5% (1/8) intestinal and 25% (2/8) mixed intestinal and diffuse. 5/8 patients were locally confined and underwent resection for N0 disease. 3/8 (37.5%) patients had metastatic disease. None of the 8 EBV-GC cases were identified as being HER-2 positive or MMR-deficient. Conclusions: EBV-GC accounted for 7.8% of all gastric cancers in two large tertiary referral centres in Ireland. 37.5% of these patients had metastatic disease. Given this frequency and a possible predictive role in selecting for immunotherapy we conclude that routine assessment of EBV status is feasible in advanced gastric cancer.

Characterizing EBV-associated lymphoproliferative diseases and the role of myeloid-derived suppressor cells

AbstractChronic active Epstein-Barr virus (CAEBV) typically presents as persistent infectious mononucleosis-like disease and/or hemophagocytic lymphohistocytosis (HLH), reflecting ectopic Epstein-Barr virus (EBV) infection and lymphoproliferation of T and/or NK cells. Clinical behavior ranges from indolent, stable disease through to rapidly progressive, life-threatening disease. Although it is thought the chronicity and/or progression reflect an escape from immune control, very little is known about the phenotype and function of the infected cells vs coresident noninfected population, nor about the mechanisms that could underpin their evasion of host immune surveillance. To investigate these questions, we developed a multicolor flow cytometry technique combining phenotypic and functional marker staining with in situ hybridization for the EBV-encoded RNAs (EBERs) expressed in every infected cell. This allows the identification, phenotyping, and functional comparison of infected (EBERPOS) and noninfected (EBERNEG) lymphocyte subset(s) in patients' blood samples ex vivo. We have characterized CAEBV and HLH cases with monoclonal populations of discrete EBV-activated T-cell subsets, in some cases accompanied by EBV-activated NK-cell subsets, with longitudinal data on the infected cells' progression despite standard steroid-based therapy. Given that cytotoxic CD8+ T cells with relevant EBV antigen specificity were detectable in the blood of the best studied patient, we searched for means whereby host surveillance might be impaired. This revealed a unique feature in almost every patient with CAEBV studied: the presence of large numbers of myeloid-derived suppressor cells that exhibited robust inhibition of T-cell growth. We suggest that their influence is likely to explain the host's failure to contain EBV-positive T/NK-cell proliferation.

Chronic active EBV infection in refractory enteritis with longitudinal ulcers with a cobblestone appearance: an autopsied case report

BackgroundChronic active Epstein–Barr virus infection (CAEBV) is defined as Epstein–Barr virus (EBV)-positive T/NK cell-related neoplasia, and its major clinical symptom is systemic inflammation presenting as infectious mononucleocytosis, whereas enteritis and diarrhea are minor clinical symptoms. The complex mixture of tumorigenic processes of EBV-positive cells and physical symptoms of systemic inflammatory disease constitutes the varied phenotypes of CAEBV. Herein, we describe a case of CAEBV that was initially diagnosed as Crohn’s disease (CD) based on ileal ulcers and clinical symptoms of enteritis.Case presentationA 19-year-old woman complained of abdominal pain and fever. Blood examination showed normal blood cell counts without atypical lymphocyte but detected modest inflammation, hypoalbuminemia, slight liver dysfunction, and evidence of past EBV infection. The esophagogastroduodenoscopic findings were normal. However, colonoscopy revealed a few small ulcers in the terminal ileum. The jejunum and ileum also exhibited various forms of ulcers, exhibiting a cobblestone appearance, on capsule endoscopy. Based on these clinical findings, she was strongly suspected with CD. In the course of treatment by steroid and biologics for refractory enteritis, skin ulcers appeared about 50 months after her initial hospital visit. Immunohistology of her skin biopsy revealed proliferation of EBV-encoded small RNA (EBER)-positive atypical lymphocytes. We retrospectively assessed her previous ileal ulcer biopsy before treatment and found many EBER-positive lymphocytes. Blood EBV DNA was also positive. Therefore, she was diagnosed with extranodal NK/T-cell lymphoma with CAEBV-related enteritis rather than CD. She was treated with cyclosporine and prednisolone combination therapy for CAEBV-related systemic inflammation and chemotherapy for malignant lymphoma. Unfortunately, her disease continued to progress, leading to multiple organ failure and death at the age of 23 years.ConclusionClinicians need to remember the possibility of CAEBV as a differential diagnosis of refractory enteritis. Enteritis with intestinal ulcer is a rare symptom of CAEBV, and it is impossible to acquire a definitive diagnosis by ulcer morphology only. In cases where the possibility of CAEBV remains, tissue EBVR expression should be checked by in situ hybridization and blood EBV DNA.

Latent Epstein–Barr virus infection status and prognosis in patients with newly diagnosed Hodgkin lymphoma in Southeast China: a single-center retrospective study

ABSTRACT Purpose This study aimed to investigate the latent Epstein–Barr virus (EBV) infection status of patients with newly diagnosed Hodgkin lymphoma (HL) and to discuss the relationship between tumor cell EBV status and the prognosis of HL patients. Patients and methods A total of 134 previously untreated HL patients were analyzed in the study. Epstein–Barr virus encoded RNAs (EBERs) in situ hybridization was performed to detect the EBV status of tumor cells. Results EBV positive status correlated with sex (p=0.046) and the proportion of extranodal lesions(p=0.037). There was no obvious correlation between EBV status and overall survival (OS) or failure-free survival (FFS) in all cases, but in cases over 50 years old, EBV positive group had an inferior 5-year FFS compared with EBV negative group (38.5%±13.5% vs 90.9%±8.7%, p=0.012). In FFS multivariate analysis of this age subgroup, EBV positive status was associated with significantly inferior survival (HR, 10.10; 95% CI, 1.26–81.08; p=0.030). Conclusion This study demonstrates positive tumor cell EBV status is an unfavorable prognostic factor in elder HL patients.

Relationship of Tumor-Associated Macrophage Population Detected by CD68 PG-M1, CD68 KP1, and CD163 with Latent EBV Infection and Prognosis in Classical Hodgkin Lymphoma.

To evaluate the quantity of tumor-associated macrophages (TAMs) in cases of Hodgkin Lymphoma of classical type (cHL), and to reveal possible associations between TAM intensity and latent Epstein-Barr virus (EBV) infection, overall survival, progression-free survival, prognostic indices, and clinicopathological parameters. A total 46 cases of cHL with complete clinical records were selected and re-evaluated histopathologically. Staining for CD68 (PG-M1; KP1 clones) and CD163 was evaluated and the cut-off values were defined. Also, all cases were evaluated using the chromogen in situ hybridization (CISH) method with EBER (Epstein-Barr virus-encoded RNA) probes for the presence of possible EBV infection. It was found that high expression levels of PG-M1 and high International Prognostic Scores (IPS) were associated with shortened overall survival (p=0.047, p=0.013). Cases with 2 or less areas of nodal region involvement were observed to have longer progression-free survival period (p=0.043). Higher expression levels of CD68 PG-M1, CD68 KP1, and CD163 were found to show significant associations with the presence of some clinical parameters such as the presence of B symptoms, spleen involvement, and the presence of EBV infection. Our findings suggest that increase of PG-M1+ TAM is associated with shortened overall survival, while higher expressions of all immunohistochemical markers are statistically significantly associated with the presence of EBV infection and clinical parameters mentioned above. These findings indicate that highlighting the TAM rate via macrophage markers in cases of cHL could be helpful in determining the prognostic risk groups and the relevant results should be mentioned in pathology reports.

Sequence Variations of Epstein-Barr Virus-Encoded Small Noncoding RNA and Latent Membrane Protein 1 in Hematologic Tumors in Northern China

Objective: To investigate the relationship between hematologic tumors and Epstein-Barr virus (EBV)-encoded small noncoding RNA (EBER) variations as well as latent membrane protein 1 (LMP1) variations. Methods: Patients with leukemia and myelodysplastic syndrome (MDS) were selected as subjects. Genotypes 1/2 and genotypes F/f were analyzed using the nested PCR technology, while EBER and LMP1 subtypes were analyzed by the nested PCR and DNA sequencing. Results: Type 1 was more dominant than type 2, found in 59 out of 82 (72%) leukemia and in 31 out of 35 (88.6%) MDS, while type F was more prevalent than type f in leukemia (83/85, 97.6%) and MDS (29/31, 93.5%) samples. The distribution of EBV genotypes 1/2 was not significantly different among leukemia, MDS, and healthy donor groups, neither was that of EBV genotypes F/f. EB-6m prototype was the dominant subtype of EBER in leukemia and MDS (73.2% [30/41] and 83.3% [10/12], respectively). The frequency of EB-6m was lower than that of healthy people (96.7%, 89/92), and the difference was significant (p < 0.05). China 1 subtype was the dominant subtype of LMP1 in leukemia and MDS (70% [28/40] and 90% [9/10], respectively), and there was no significant difference in the distribution of LMP1 subtypes among the 3 groups (p > 0.05). Conclusion: The distribution of EBV 1/2, F/f, EBER, and LMP1 subtypes in leukemia and MDS was similar to that in the background population in Northern China, which means that these subtypes may be rather region-restricted but not associated with leukemia and MDS pathogenesis.

Aberrant thyroid transcription factor-1 expression in ovarian and nasopharyngeal carcinoma: Case reports with review of literature

Introduction: Thyroid transcription factor-1 (TTF-1) is the recommended and sensitive immunohistochemical (IHC) marker for diagnosing lung adenocarcinomas and thyroid neoplasms, at the primary as well as the metastatic site, and is useful to rule out these sites in cases with adenocarcinomas of unknown primary. However, aberrant nuclear TTF-1 expression has also been reported in malignancies arising from gastrointestinal tract (GIT), breast carcinoma, female genital tract (FGT), and colon. Here, we present our experience of aberrant expression of TTF-1 in ovarian and nasopharyngeal carcinoma (NPC). Materials and Methods: TTF-1 immunostain was performed on 16 cases of NPC using clones SP141 and 8G7G3/1. A case of ovarian serous carcinoma with aberrant TTF-1 expression has also been discussed. Results: Of 16 cases of NPC, 2 cases (12.5%) showed strong TTF-1 expression with clone SP141, while all were negative with 8G7G3/1. In one of the case initial diagnosis of metastatic lung adenocarcinoma was made on cervical node biopsy as the tumor was negative for p40 and showed strong nuclear positivity for TTF-1 (SP141 clone). However, on clinical suspicion of NPC Epstein-Barr virus-encoded small RNA (EBER) by in situ hybridization was performed which was positive, and repeat TTF-1 using clone 8G7G3/1 was negative, suggested a NPC. In the case of ovarian tumor, cells were strongly positive for CK7 and TTF-1 (SP141 clone) expression, and thus the tumor was erroneously diagnosed as metastatic adenocarcinoma from a primary lung. However, IHC in the resected specimen showed strong expression for PAX-8 and TTF-1 using SP141 clone, while negative with clone 8G7G3/1 clone (Ventana), leading to final diagnosis of high-grade serous carcinoma of ovary with aberrant TTF-1 expression. In this case, addition of PAX-8 in initial biopsy diagnosis would have saved from labeling it as primary from lung. Conclusion: The sensitivity and aberrant expression vary between the various antibody clones used, with increased expression seen by SP141 clone as compared to 8G7G3/1 in our cases. Our findings highlight the significance of using a panel of diagnostic IHC markers before final diagnosis and importance of clinical details.

Clinicopathological Analyses of Solitary Plasmacytoma in a Single Institution of China

Background: Solitary plasmacytoma (SP), accounting for less than 5% of all plasma cell dyscrasias, is a rare disorder with localized proliferation of neoplastic monoclonal plasma cell. Due to the rarity of SP, further understanding of the spectrum of clinicopathologic features is needed. Methods: A 5-year retrospective analysis of cases from a single institution was conducted. Specifically, clinical characteristics of all SP patients were collected, and quantitative immunohistochemical analysis on tissue microarray was performed. Findings: Thirteen cases were identified from our pathology archives, with solitary plasmacytoma of bone (SPB) accounting for 30.8% and extraosseous plasmacytoma (EP) for 69.2% of the cases. The mean age of EP is one decade older than SPB. No gender disparity is identified. The most common sites involved are the vertebrae and nasopharynx. Histologically, the tumors consist of plasmacytoid cells diffusely infiltrating the involved tissue, and can be classified into two grades based on the degree of differentiation. Immunohistochemically the tumor cells are positive for CD38, CD138, MUM-1, and exhibit light chain restriction. Ki-67 proliferation index averages at 30%. Quantitative immunohistochemistry stain analysis showed the neoplastic cells exhibiting decreased CD38 in integrated optical density (IOD). Epstein-Barr virus-encoded small RNAs (EBER) was negative in all six cases tested. Two cases were positive for IgH gene rearrangement. Interpretation: SP is a rare plasmacytoid tumor that occurs more frequently in older patients. Diagnosis requires a systematic approach, combined with the pathological characteristics of plasmacytoid morphology, immunophenotype and the light chain restriction. Furthermore In our study the data shows that the cases of EP is more than SPB, Which is opposite from the litterature. Further studies with more patients and long-time follow-up may provide more information to understand risk of recurrence and progression from SP to multiple myeloma (MM). Funding: Department of Science and Technology, Hubei Provincial People's Government (2020CFB343). Declaration of Interest: None to declare. Ethical Approval: This study was approved by the Ethics Committee of Zhongnan Hospital for discarded diagnostic material (no consent required).

1091. Incidence of Post-Transplant Lymphoproliferative Disorders among Epstein-Barr Virus Donor Positive, Recipient Negative Adult Solid Organ Transplant Recipients

BackgroundEpstein-Barr virus (EBV) donor positive (D+), recipient negative (R-) serostatus is a major risk factor for post-transplant lymphoproliferative disorder (PTLD) in adult solid organ transplant recipients (SOTR). Few studies have systematically characterized absolute organ transplant type-specific incidence, timing, and outcomes of PTLD in adult EBV D+R- SOTR.MethodsWe retrospectively assessed the incidence, timing, and associated morbidity and mortality of biopsy-confirmed PTLD (WHO classification) among consecutive adult SOTR between Jan 1, 2000 and Apr 30, 2018 at a single university center, and who had a minimum 2 years of follow-up. Antibodies to EBV (viral capsid antigen and nuclear antigen) were assessed in candidates and donors by FDA-cleared ELISA assay. Donors with unknown serology were considered seropositive based on the known prevalence of >93% seropositivity in this donor population.ResultsAmong 4,923 SOTR, prior to transplant, 4,770 (96.9%) were R+ (regardless of donor status), 144 (2.9%) were D+R-, and 9 (0.2%) were D-R-. PTLD incidence by last follow-up was higher among D+R- (15/144 [10.4%]) than R+ (61/4,770 [1.2 %]), P < 0.0001, and occurred earlier after transplant (median 9.6 months [IQR 6.1-34.2] versus 35.1 months [IQR 7.1-73.1]), P= 0.003, respectively. Among D+R-, incidence was higher among recipients of non-kidney versus kidney organs (13/89 [14.6%] vs. 2/55 [3.6%], P = 0.05, respectively). Incidence in rank order was: pancreas (2/9 [22.2%]), lung (6/29 [20.7 %]), heart (2/21 [9.5%]), and liver (3/30 [6.7%]). PTLD histopathology was monomorphic in 9/15 [60%] and EBV-encoded RNA-1 (EBER-1) positive in 12/12 evaluable cases. Outcomes among the 15 PTLD cases included: graft failure without transplant in 3 (20%), graft failure with re-transplant in 2 (13.3%), and death within 6 months in 3 (20%).Table 1: Characteristics of the EBV Donor seropositive, Recipient seronegative (D+R-) cohort Figure 1: Cumulative Incidence of PTLD among the EBV D+R- cohort (all organs) Figure 2: Incidence of PTLD among the D+R- cohort, stratified by organ transplant type ConclusionAlthough rare overall, we identified a specific subgroup of adult SOT patients (EBV D+R- non-kidney recipients) whose absolute PTLD incidence and associated morbidity and mortality are high, and who should be targeted for future mechanistic or therapeutic studies.Disclosures All Authors: No reported disclosures

Regional distribution and clinicopathological characteristics of Epstein-Barr virus associated gastric cancer

Objective: To investigate regional distribution and clinicopathological features of Epstein-Barr virus associated gastric cancer (EBVaGC). Methods: Epstein-Barr virus encoded RNA (EBER)was detected in 4 081 cases of gastric adenocarcinoma in Cancer Hospital, Chinese Academy of Medical Sciences by using in situ hybridization. EBVaGCs were identified and their proportions in different provinces, autonomous regions and municipalities were compared. The correlation between EBVaGC and clinicopathological features was also analyzed. Results: A total of 3.0% (123/4 081) patients with gastric adenocarcinoma are EBVaGCs. Among the areas with cases more than 90, the highest proportion of EBVaGC was found in Jilin province, accounting for 7.6%, and then followed by 5.4% in Liaoning province, 4.1% in Anhui province, 3.9% in Beijing, 3.7% in Inner Mongolia Autonomous Region, 3.4% in Shanxi province, 3.0% in Heilongjiang province, 2.1% in Shandong province, 1.6% in Hebei province, and no EBVaGC was found in Henan province. EBVaGC proportions are significantly different in these provinces, autonomous regions and municipalities (P<0.05). Multivariate analysis of logistic regression revealed that gender (OR=2.231, 95%CI: 1.290~3.858), WHO classification (OR=2.338, 95%CI: 2.051~2.664) and N stage (OR=0.420, 95%CI: 0.284~0.621) were independent impact factors for EBVaGC. The proportion of EBVaGC was higher in males, gastric carcinomas accompanied with lymphoid stroma and patients without lymph node metastasis. Conclusions: The proportion of EBVaGC in gastric adenocarcinoma displays area distribution disparity in China. The gender, WHO classification and N stage are closely associated with EBVaGC.

Safety and Preliminary Efficacy of Sintilimab Plus P-Gemox (Pegaspargase, Gemcitabine and Oxaliplatin) Regimen As First-Line Treatment for Patients with Advanced Extranodal Natural Killer/T Cell Lymphoma, Nasal Type: An Open-Label, Multicenter, Phase 2 Study

Background: Extranodal natural killer/T cell lymphoma, nasal type (ENKTL) is a highly malignant non-Hodgkin lymphoma (NHL), which has no standard treatment available for this subgroup. Conventional treatment approaches (L-asparaginase- or pegaspargase-based regimen) failed to achieve long-term clinical benefit. The prognosis of advanced ENKTL is poor even in newly diagnosed patients (pts) due to a high relapse rate of 70%. Substantial evidences indicate that anti-programmed death-1 (PD-1) monoclonal antibody has achieved promising efficacy in refractory or relapsed ENKTL (Kwong et al. Blood 2017, Li et al. Journal of Hematology &amp; Oncology 2018, Tao et al. JCO 2020). Results from our retrospective study demonstrated a manageable tolerability profile and favorable anti-tumor activity of anti-PD-1 antibody combined with P-GEMOX (pegaspargase, gemcitabine and oxaliplatin) regimen in untreated advanced ENKTL pts (unpublished data). Therefore, a phase 2 trial (NCT04127227) was initiated to evaluate safety and efficacy of sintilimab (a fully human anti-PD-1 monoclonal antibody) plus P-GEMOX regimen as first-line therapy in advanced ENKTL pts. Here, we report the preliminary results of the study. Methods: This study enrolled adult pts with untreated pathologically confirmed ENKTL with at least one measurable lesion. A sample size of 34 pts was preplanned, with 6 pts recruited for a safety run-in cohort. Pts received six 21-day cycles of sintilimab 200 mg, pegaspargase 2000 U/m2 (day 1), gemcitabine 1g/m2 (days 1 and 8), and oxaliplatin 130 mg/m2 (day 1), followed by sintilimab 200 mg maintenance every 3 weeks for up to 2 years or until documented confirmed disease progression or intolerable toxicity. Of the run-in cohort, preliminary safety and dose-limiting toxicity (DLTs) analyses were performed in the first cycle of treatment, primary endpoints were safety and tolerability of the combination therapy. DLTs were defined as grade 4 neutropenia that does not resolve to grade &amp;lt;/= 2 within 7 days; grade 4 thrombocytopenia that does not resolve within 7 days; any grade &amp;gt;/= 3 nonhematologic toxicity lasting for more than 7 days, and any treatment-related adverse events (TRAEs) that results in a delay for more than 14 days of initiating cycle 2. Of the entire cohort, primary endpoints were complete response (CR) rate and objective response rate (ORR), secondary endpoints included overall survival, progression-free survival, and safety. TRAEs were accessed according to CTCAE 5.0. Response assessments were performed using PET/CT or MRI scans every 6 weeks of the combined treatment and every 3 months of maintenance treatment. Results: Six pts with untreated ENKTL were enrolled between Sept 19, 2019 and Jul 26, 2020. Median age was 56 years (range 52-67). All pts were found to be found to be positive for EBV encoded RNA (EBER) by in situ hybridization. Clinical characteristics of all pts are listed in Table 1. Median number of treatment cycles was 7 (range 4-11). At data cut-off, 5 pts completed 6 cycles of combination therapy and entered the maintenance phase (median: 1, range 1-5). No DLTs were observed. The majority of TRAEs were reported during the first two cycles of the combination treatment. The most common TRAEs were anorexia (6/6, 100%), elevated transaminase (6/6, 100%), neutropenia (5/6, 3.3%), nausea (4/6, 66.7%), anemia (4/6, 66.7%), hypoproteinemia (4/6, 66.7%), vomiting (3/6, 50.0%) and thrombocytopenia (3/6, 33.3%). Grade 3/4 TRAEs occurred in 4 (66.7%) pts, including thrombocytopenia (1/6, 16.7%), anemia (2/6, 33.0%), and neutropenia (1/6, 16.7%). Details of all-grade TRAEs are listed in Table 2. All the TRAEs were manageable and reversible. No immune-related (ir) AE or treatment-related death was observed. Of the 6 pts received response assessments, ORR was 100% (6/6) and CR rate was 33.3% (2/6). After a median follow-up of 7.8 months, 5 pts were still on the planned treatment and maintained favorable outcomes. The updated data will be reported at the ASH conference. Conclusions: Sintilimab plus P-GEMOX regimen demonstrated manageable safety profile and promising anti-tumor activity in pts with untreated advanced ENKTL. The preliminary safety and efficacy profile of combination therapy support further study and the exploration of effective biomarkers for predicting the treatment response is under way. Disclosures No relevant conflicts of interest to declare. OffLabel Disclosure: Sintilimab is medication that is indicated for the treatment of relapsed or refractory classical Hodgkin's lymphoma after failure of at least second-line systemic chemotherapy.

EBV-Positive Primary CNS Lymphomas in Older Patients: Incidence, Characteristics, Tumor Pathology, and Outcomes across a Large Multicenter Cohort

EBV-Positive Primary CNS Lymphomas in Older Patients: Incidence, Characteristics, Tumor Pathology, and Outcomes across a Large Multicenter Cohort

Immune Evasion Phenotype Is Common in Richter Transformation Diffuse Large B-Cell Lymphoma and Correlates with CD30 Expression

BACKGROUND Richter transformation (RT), most commonly manifesting as diffuse large B-cell lymphoma (RT-DLBCL), occurs in 2-8% of patients with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). Patients who develop RT-DLBCL have a median overall survival (OS) of less than 12 months despite intensive chemoimmunotherapy. Immune checkpoint inhibitors (PD1 inhibitors) have shown clinical activity in RT-DLBCL, thus providing for a novel therapeutic approach. Such studies have shown a response to PD1 blockade associated with an immune evasion phenotype based on PD1 and/or PD-L1 expression on tumor cells, but the status of predictive biomarkers of response to PD1 blockade in RT-DLBCL remains largely unknown. Other lymphomas associated with PD-L1 expression often express CD30 and harbor Epstein-Barr virus (EBV), both presenting additional possible therapeutic targets, but few studies have assessed the frequency of these markers in RT-DLBCL. METHODS The study group consists of 64 patients with extramedullary biopsy confirmed RT-DLBCL. Expression of PD1, PD-L1, CD30, and microsatellite instability (MSI) status (hMLH1, hMSH2, hMSH6, PMS1) was assessed using immunohistochemistry on formalin-fixed paraffin-embedded pre-treatment tumor samples. EBV-encoded RNA was evaluated using colorimetric in situ hybridization. PD1 and PD-L1 expression levels were categorized on the basis of tumor cell expression as follows: negative (&amp;lt;5%), low-positive (5-50%), or high-positive (&amp;gt;50%). An "immune evasion phenotype" (IEP) was defined as RT-DLBCL cases having high-positive expression of PD1 and/or PD-L1 on tumor cells. The level of PD1-positive tumor-infiltrating lymphocytes (TILs) was estimated as a fraction of total lymphocytes and categorized as negative/low vs. brisk (&amp;gt;20%). Demographic and clinical features by IEP status were compared using chi-square/Fisher's exact tests for categorical variables and t-tests/Wilcoxon rank-sum tests for continuous variables. Kaplan-Meier analysis and corresponding log-rank tests were used to estimate and compare OS between groups defined by clinical features. RESULTS Patients included 41 men (64.1%) and 23 women with a median age of 66.2 years (range, 45.3-84.9 years). The interval from initial CLL/SLL diagnosis to RT-DLBCL was 4.8 years. PD-L1 expression on tumor cells was high-positive in 13 (20.3%), low-positive in 10 (15.6%), and negative in 41 (64.1%) cases. PD1 expression on tumor cells was high-positive in 19 (30.2%), low-positive in 4 (6.3%), and negative in 40 (63.5%) cases. Accordingly, 28/64 (43.7%) patients had IEP+ RT-DLBCL. A brisk level of PD1+ TILs was significantly more common in IEP1+ compared with IEP- tumors (17/28, 60.7% vs. 5/34, 14.7%; p=0.001). In addition, CD30 expression was significantly more common in IEP+ compared with IEP- RT-DLBCL (14/20, 70% vs. 1/27, 3.7%; p=0.0320). Two (2/36; 5.5%) cases were positive for EBV, both IEP+. There was no significant difference between the two groups in terms of age, sex, or time to transformation. Assessment of mismatch repair proteins demonstrated an MSI-stable phenotype in all but one (1/18; 5.5%) case; this case was MSI-high, IEP-, and had a brisk infiltrate of PD1+ TILs. Patients had a median OS of 13.6 months (95% CI: 10.0-19.5 months). Notably, patients with brisk PD1+ TILs had a significantly better OS compared to those with a negative/low infiltrate (p=0.0285). CONCLUSIONS We demonstrate that IEP+ status is common in RT-DLBCL and correlates with CD30 expression and a brisk infiltrate of PD1+ TILs. Our data also suggest that IEP+ status correlates with more favorable OS in RT-DLBCL. Disclosures Jain: Incyte: Research Funding; BeiGene: Honoraria, Membership on an entity's Board of Directors or advisory committees; Verastem: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Fate Therapeutics: Research Funding; Genentech: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Pharmacyclics: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; AbbVie: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Cellectis: Research Funding; Servier: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; TG Therapeutics: Honoraria, Membership on an entity's Board of Directors or advisory committees; ADC Therapeutics: Research Funding; BMS: Research Funding; Adaptive Biotechnologies: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Aprea Therapeutics: Research Funding; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; AstraZeneca: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Precision Bioscienes: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Research Funding.

Association of Epstein-Barr Virus with Advanced Stage and Survival Outcomes in Classic Hodgkin's Lymphoma

Association of Epstein-Barr Virus with Advanced Stage and Survival Outcomes in Classic Hodgkin's Lymphoma

Oral Nanatinostat (Nstat) and Valganciclovir (VGCV) in Patients with Recurrent Epstein-Barr Virus (EBV)-Positive Lymphomas: Initial Phase 2 Results

Oral Nanatinostat (Nstat) and Valganciclovir (VGCV) in Patients with Recurrent Epstein-Barr Virus (EBV)-Positive Lymphomas: Initial Phase 2 Results

Chronic active Epstein\u2013Barr virus infection manifesting as coronary artery aneurysm and uveitis

BackgroundChronic active Epstein–Barr virus (CAEBV) infection is a type of lymphoproliferative disorder characterized by chronic or recurrent infectious mononucleosis (IM)-like symptoms, which can have less-frequent clinical presentations. The prognosis of CAEBV is poor, and hematopoietic stem cell transplantation (HSCT) has been shown to be the only potentially effective treatment. In this article, we present a special CAEBV case of a patient who had no typical IM-like symptoms at the early stage, but manifested with severe and progressive coronary artery aneurysm (CAA), abdominal aortic lesions, and severe uveitis. These manifestations were uncommon features and could only be blocked by HSCT.Case presentationA 4-year-old girl with no special medical history complained of decreased vision for 10 months and cough after physical activities for three months. The blurred vision grew rapidly worse within one month, until only light perception remained. She was diagnosed with uveitis and cataract, and received prednisone and ciclosporin A treatment. However, her vision did not improve. Physical examination showed slight hepatosplenomegaly. Ultrasonic cardiogram showed bilateral CAA (5.0 mm and 5.7 mm for inner diameters), and abdominal CT scan revealed a thickened aortic wall, as well as stenosis and dilation of the segmental abdominal aorta. Other significant findings were increased EBV-DNA (3.29 × 104 copies/mL) from peripheral blood, positive EBV antibodies (EBV-CA-IgG, EBV-EA-IgA, and EBV-NA-IgG), and positive EBV-encoded small RNAs found by bone marrow biopsy. Based on her clinical manifestations and evidence for EBV infection, we diagnosed CAEBV. She received allogeneic HSCT, and the cataract operation was performed after HSCT. EBV-DNA could not be detected in peripheral blood after HSCT. Her CAAs did not progress, and uveitis was well controlled. Her vision recovered gradually over the 3 years after HSCT.ConclusionsWe present a rare CAEBV case of a patient who suffered from uncommon and severe cardiovascular and ocular involvement that was relieved by HSCT. Therefore, early recognition and diagnosis of CAEBV are of vital importance to improve its prognosis. In summary, this atypical CAEBV case could help us recognize similar cases more easily, make the right diagnosis as early as possible, and deliver proper and timely treatment.

An Interesting Case Report of A Concurrent Classic Hodgkin Lymphoma and Gray Zone Lymphoma in the Mediastinum

Abstract Casestudy A 52-year-old female presented with night sweats, chills, anorexia, and weight loss. Computed tomography and positron emission tomography showed a soft tissue infiltration in the anterior mediastinum and hypermetabolic bilateral supraclavicular, mediastinal, right hilar, and left internal mammary lymph nodes. An anterior mediastinal mass resection and thymectomy was subsequently performed. Results Sections of the mediastinal mass showed Hodgkin/Reed-Sternberg cells (HRS) admixed with small lymphocytes, histiocytes, plasma cells, and eosinophils. The HRS cells are positive for CD30, CD15, and MUM1, faintly positive for PAX5, and negative for CD20, CD45, CD79a, and BCL6. The morphology and immunophenotype is diagnostic of nodular sclerosis classic Hodgkin lymphoma (CHL). Sections of the thymectomy specimen showed similar morphology, however, in an area that represents 10-20% of the specimen, there are nodular and diffuse lymphoid infiltrates consisting of small lymphocytes, histiocytes, and large atypical cells. The large atypical cells are positive for CD20, CD23, CD30, CD45, CD79a, BCL2, BCL6, MUM-1, and PAX5, and negative for CD1a, CD3, CD57, and Cyclin D1. The background small CD3-positive lymphocytes form a rosette around most of the large atypical cells. CD21 and CD23 stains highlight residual follicular structures. In situ hybridization for EBV-encoded RNA (EBER) is negative. The presence of residual follicular meshwork with an immunophenotype of large B cell lymphoma supports a diagnosis of a gray zone lymphoma (GZL). Overall, CHL is involving 80-90% and GZL is involving 10-20% of the thymic tissue. The patient was subsequently placed on ABVD chemotherapy and achieved remission. Conclusion An accurate diagnosis of GZL is challenging. GZL is a rare type of lymphoma with morphological features between CHL and diffuse large B-cell lymphoma (DLBCL). It is even rarer to encounter a CHL concurrently present with a GZL. The optimal therapeutic approach for cases with concurrent lymphoma diagnosed with CHL and GZL needs further investigation.

Peripheral T-cell Lymphoma, NOS With Epstein-Barr Virus Positivity in an Elderly Patient With Myelodysplastic Syndrome: An Autopsy Case Report

Abstract Casestudy Epstein-Barr virus (EBV)-associated peripheral T-cell lymphomas are a group of aggressive neoplasms with a geographic predilection for South America and Asia, but are very rare in Western populations. Results We report a case of a 74-year-old Caucasian female who presented with pancytopenia and B symptoms with EBV-IgG detected on admission. Past medical history included: ITP, chronic urticaria, and recently diagnosed myelodysplastic syndrome (MDS) on bone marrow biopsy one month prior to admission. Excisional biopsies of an enlarged right neck lymph node (repeated within 6 months) and right axillary lymph node five years ago were negative for a lymphoproliferative disorder at the time. Repeated bone marrow biopsy, performed during the current admission, confirmed the diagnosis of MDS, with scattered T-cells without aberrant immunophenotype. Despite aggressive treatment from multiple specialties, the patient deteriorated and expired four weeks later from complications of MDS. At autopsy, there was diffuse lymphadenopathy involving the mediastinum, axilla, pelvis and peripancreatic fat. Lymph node sections demonstrated nodal architecture effacement by diffuse, vaguely nodular lymphoid infiltrates. Histologically, the infiltrates were composed of medium to large lymphocytes with round to slight irregular nuclei, rare Reed-Sternberg-like multinucleated cells, clumped chromatin, and indistinct nucleoli. Individual cell necrosis was abundant with mitotic figures readily identifiable. Immunohistochemistry revealed CD2+ CD3+ neoplastic T-cells that co-express MUM1 and a subset of CD30, while negative for CD4, CD5, CD8, CD56, ALK1, and TDT. EBV-encoded RNA in-situ hybridization was focally positive. The final postmortem diagnosis was peripheral T-cell lymphoma, not otherwise specified (NOS), with focal EBV positivity. Conclusion Co-existence of a de-novo MDS and non-Hodgkin lymphoma without any prior chemotherapeutic exposure is a highly unusual finding, although MDS-like presentations can occur with EBV-associated lymphomas. Peripheral T-cell lymphoma, NOS is an aggressive lymphoma and EBV positivity has been found correlated with a poor prognosis. This case demonstrates how postmortem examination remains an important tool in clinical- pathological correlation and highlights the potential pathogenetic role EBV plays in MDS and T-cell lymphoma.