Epstein-Barr Virus-associated Malignancies Research Articles

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.

Induction of EBV latent membrane protein-2A (LMP2A)-specific T cells and construction of individualized TCR-engineered T cells for EBV-associated malignancies

BackgroundLatent membrane protein-2A (LMP2A)-specific TCR-engineered T cells could be a promising treatment approach to Epstein–Barr virus-associated malignancies. However, previous studies mainly reported LMP2A-reactive TCRs only focusing on specific HLA subtypes...

A Phase I/II Study of Arginine Butyrate and Ganciclovir in Patients with Epstein-Barr Virus-Associated Lymphoid Malignancies.

Malignancies associated with latent Epstein-Barr virus are resistant to nucleoside-type antiviral agents because the viral enzyme target of these drugs, thymidine kinase (TK), is not expressed. Short-chain fatty acids, such as butyrate, induce EBV-TK expression in latently-infected B cells. In preclinical studies, we have shown that butyrate sensitizes EBV(+) lymphoid cells and tumor lines to apoptosis induced by ganciclovir. We conducted a Phase I/II trial of Arginine Butyrate in combination with ganciclovir in patients with refractory EBV(+) lymphoid malignancies to evaluate toxicity, pharmacokinetic parameters, and clinical responses. Fifteen patients with refractory EBV(+) lymphoid malignancies, including monoclonal lymphoproliferative disease (PTLD), B cell non-Hodgkin's lymphomas (NHL), T cell NHL (including one panniculytic subcutaneous lymphoma), T/NK cell lymphomas, and Hodgkin's disease were studied. The patients had been relatively heavily pretreated with chemotherapy and/or radiation before entry into this study. In this study, ganciclovir was administered twice daily at approved doses and Arginine Butyrate (AB) was administered in an intra-patient dose-escalation. Arginine Butyrate was instituted at 500 mg/kg/day by continuous infusion, and escalated to 2000 mg/kg/day, as tolerated. Pharmacokinetic studies were performed. The MTD for Arginine Butyrate when administered in combination with ganciclovir was established as 1000 mg/kg/day by continuous infusion. Overall, the combination was well-tolerated, with the most common toxicities being nausea, headache. Complications from rapid tumor lysis occurred in three patients, including acute hepatic necrosis in one patient. Reversible somnolence or stupor occurred in three patients at Arginine Butyrate doses of greater than 1000 mg/kg/day. Ten of fifteen patients showed significant anti-tumor responses within 10 days of initiation of treatment, with 5 CR and 5 PR. In some of the patients who demonstrated a CR, subsequent pathological analysis showed no residual tumor cells. The combination of Arginine Butyrate and ganciclovir was reasonably well-tolerated and appears to have significant biological activity in vivo against EBV(+) lymphoid malignancies. Further trials, especially in patients with earlier stage disease, appear warranted.

Molecular Genetics in Epstein-Barr Virus-Associated Malignancies.

Global genomic studies have detected the role of genomic alterations in the pathogenesis of Epstein–Barr virus (EBV)-associated tumors. EBV oncoproteins cause a vital shift of EBV from an infectious virus to an oncogenic form during the latent and lytic phase within the lymphoid B cells and epithelial cells. This epigenetic alteration modulates the virus and host genomes and inactivates and disrupts numerous tumor suppressors and signaling pathways. Genomic profiling has played the main role in identifying EBV cancer pathogenesis and its related targeted therapies. This article reviews the role of genetic changes in EBV-associated lymphomas and carcinomas. This includes the prolific molecular genesis, key diagnostic tools, and target-specific drugs that have been in recent clinical use.

Preclinical assessment of off-the-shelf allogeneic T-cell therapy for the treatment of multiple Epstein-Barr virus-associated malignancies

Preclinical assessment of off-the-shelf allogeneic T-cell therapy for the treatment of multiple Epstein-Barr virus-associated malignancies

Lytic Induction Therapy against Epstein-Barr Virus-Associated Malignancies: Past, Present, and Future.

Epstein–Barr virus (EBV) lytic induction therapy is an emerging virus-targeted therapeutic approach that exploits the presence of EBV in tumor cells to confer specific killing effects against EBV-associated malignancies. Efforts have been made in the past years to uncover the mechanisms of EBV latent-lytic switch and discover different classes of chemical compounds that can reactivate the EBV lytic cycle. Despite the growing list of compounds showing potential to be used in the lytic induction therapy, only a few are being tested in clinical trials, with varying degrees of success. This review will summarize the current knowledge on EBV lytic reactivation, the major hurdles of translating the lytic induction therapy into clinical settings, and highlight some potential strategies in the future development of this therapy for EBV-related lymphoid and epithelial malignancies.

Using glycyrrhizic acid to target sumoylation processes during Epstein-Barr virus latency.

Cellular sumoylation processes are proposed targets for anti-viral and anti-cancer therapies. We reported that Epstein-Barr virus (EBV) latent membrane protein 1 (LMP1) dysregulates cellular sumoylation processes, contributing to its oncogenic potential in EBV-associated malignancies. Ginkgolic acid and anacardic acid, known inhibitors of sumoylation, inhibit LMP1-induced protein sumoylation; however, both drugs have adverse effects in hosts. Here we test the effects of glycyrrhizic acid, a medicinal botanical extract with anti-inflammatory, anti-carcinogenic, and anti-viral properties, on cellular sumoylation processes. While glycyrrhizic acid is known to inhibit EBV penetration, its affect on cellular sumoylation processes remains to be documented. We hypothesized that glycyrrhizic acid inhibits cellular sumoylation processes and may be a viable treatment for Epstein-Barr virus-associated malignancies. Results showed that glycyrrhizic acid inhibited sumoylation processes (without affecting ubiquitination processes), limited cell growth, and induced apoptosis in multiple cell lines. Similar to ginkgolic acid; glycyrrhizic acid targeted the first step of the sumoylation process and resulted in low levels of spontaneous EBV reactivation. Glycyrrhizic acid did not affect induced reactivation of the virus, but the presence of the extract did reduce the ability of the produced virus to infect additional cells. Therefore, we propose that glycyrrhizic acid may be a potential therapeutic drug to augment the treatment of EBV-associated lymphoid malignancies.

Epstein-Barr Virus-Associated Malignancies: Roles of Viral Oncoproteins in Carcinogenesis.

The Epstein–Barr virus (EBV) is the first herpesvirus identified to be associated with human cancers known to infect the majority of the world population. EBV-associated malignancies are associated with a latent form of infection, and several of the EBV-encoded latent proteins are known to mediate cellular transformation. These include six nuclear antigens and three latent membrane proteins (LMPs). In lymphoid and epithelial tumors, viral latent gene expressions have distinct pattern. In both primary and metastatic tumors, the constant expression of latent membrane protein 2A (LMP2A) at the RNA level suggests that this protein is the key player in the EBV-associated tumorigenesis. While LMP2A contributing to the malignant transformation possibly by cooperating with the aberrant host genome. This can be done in part by dysregulating signaling pathways at multiple points, notably in the cell cycle and apoptotic pathways. Recent studies also have confirmed that LMP1 and LMP2 contribute to carcinoma progression and that this may reflect the combined effects of these proteins on activation of multiple signaling pathways. This review article aims to investigate the aforementioned EBV-encoded proteins that reveal established roles in tumor formation, with a greater emphasis on the oncogenic LMPs (LMP1 and LMP2A) and their roles in dysregulating signaling pathways. It also aims to provide a quick look on the six members of the EBV nuclear antigens and their roles in dysregulating apoptosis.

The Microenvironment in Epstein-Barr Virus-Associated Malignancies.

The Epstein–Barr virus (EBV) can cause a wide variety of cancers upon infection of different cell types and induces a highly variable composition of the tumor microenvironment (TME). This TME consists of both innate and adaptive immune cells and is not merely an aspecific reaction to the tumor cells. In fact, latent EBV-infected tumor cells utilize several specific mechanisms to form and shape the TME to their own benefit. These mechanisms have been studied largely in the context of EBV+ Hodgkin lymphoma, undifferentiated nasopharyngeal carcinoma, and EBV+ gastric cancer. This review describes the composition, immune escape mechanisms, and tumor cell promoting properties of the TME in these three malignancies. Mechanisms of susceptibility which regularly involve genes related to immune system function are also discussed, as only a small proportion of EBV-infected individuals develops an EBV-associated malignancy.

High post-treatment serum levels of soluble programmed cell death ligand 1 predict early relapse and poor prognosis in extranodal NK/T cell lymphoma patients.

The impact of serum levels of soluble programmed cell death ligand 1 (sPD-L1) on prognosis in patients with Epstein-Barr virus-associated malignancies has never been investigated. We prospectively measured pre- and post-treatment serum sPD-L1 levels and evaluated their prognostic value in 97 patients with newly diagnosed, early stage extranodal NK/T-cell lymphoma (ENKTCL) treated with asparaginase-based chemotherapy followed by radiotherapy. For predicting survival outcomes, serum sPD-L1 levels of 3.23 ng/mL and 1.12 ng/mL were respectively identified for pre- and post-treatment cut-off levels. Patients with high pretreatment (>3.23 ng/mL) had shorter progression-free survival (PFS) and overall survival (OS). In a multivariate survival analysis, post-treatment sPD-L1 >1.12 ng/mL, treatment response (complete vs. non-complete response), and stage II disease were independent prognostic factors for shorter PFS and OS. In patients with a complete response, post-treatment sPD-L1 >1.12 ng/mL was associated with shorter PFS and OS. In patients with high pretreatment sPD-L1 levels (>3.23 ng/mL), low post-treatment sPD-L1 level (≤1.12 ng/mL) correlated with longer PFS and OS. Our data suggest the post-treatment sPD-L1 level is a potent biomarker for predicting early relapse and poor prognosis in early stage ENKTCL patients treated with asparaginase, and may be a useful marker of minimal residual disease.

Epigenetic alterations in nasopharyngeal carcinoma and Epstein-Barr virus (EBV) associated gastric carcinoma: a lesson in contrasts

Epstein-Barr virus (EBV) is associated with diverse hematological and epithelial malignancies, such as Burkitt lymphoma, Hodgkin lymphoma, nasopharyngeal carcinoma, gastric carcinoma, and others. Upon infection of B‑lymphoid and epithelial cells, the virus adopts distinct gene expression patterns which depend on the cellular epigenetic machinery. Moreover, virus infection regularly induces modifications of the viral and host cell transcriptomes and epigenomes through the interaction of viral proteins with cellular epigenetic regulators. Viral latent and immediate early proteins may principally contribute to the reprogramming of the cellular epigenome. While EBV-immortalized B lymphoblastoid cell lines are characterized by a massive hypomethylation of the cellular genome and genome-wide reorganization and loss of heterochromatic histone marks, EBV associated malignancies are characterized by local hypermethylation of CpG islands (CGI) at specific gene sets characteristic for each tumor type. Groups of hypermethylated promoters may represent unique EBV associated epigenetic signatures in EBV-associated gastric carcinomas (EBVaGC) and nasopharyngeal carcinomas (NPC). Here, we review the similarities and differences between EBVaGC and NPC with an emphasis on the epigenetic perspective. Both tumors exhibit a CpG island methylator phenotype (CIMP) and a very high load of hypermethylated tumor suppressor genes, EBVaGC more so than the EBV-negative GC subtypes. However, according to present knowledge, there is only a very small set of hypermethylated gene loci which EBVaGC and NPC have in common. Construction of whole genome comparative methylomes and genome-wide analysis of further epigenetic marks may illuminate the patho-epigenetics of these EBV-associated carcinomas.

Epstein-Barr virus-associated lymphoid malignancies: the expanding spectrum of hematopoietic neoplasms.

Ubiquitous Epstein-Barr virus (EBV) infects not only B cells but also T and NK cells, and is associated with various lymphoid malignancies. The spectrum of EBV-associated lymphoid malignancies is expanding from Burkitt lymphoma to the newly defined systemic EBV+ T cell lymphoproliferative disease of childhood and hydroa vacciniforme-like lymphoma. However, some EBV-associated malignancies are not defined well and overlap other diseases. Furthermore, the role of EBV in tumorigenesis of lymphoid malignancies is still not clear. Further studies are necessary to clarify the pathogenesis of EBV-associated lymphoid malignancies for a better classification of each disease and for the establishment of effective treatment.

Advances in Virus-Directed Therapeutics against Epstein-Barr Virus-Associated Malignancies

Epstein-Barr virus (EBV) is the causal agent in the etiology of Burkitt's lymphoma and nasopharyngeal carcinoma and is also associated with multiple human malignancies, including Hodgkin's and non-Hodgkin's lymphoma, and posttransplantation lymphoproliferative disease, as well as sporadic cancers of other tissues. A causal relationship of EBV to these latter malignancies remains controversial, although the episomic EBV genome in most of these cancers is clonal, suggesting infection very early in the development of the tumor and a possible role for EBV in the genesis of these diseases. Furthermore, the prognosis of these tumors is invariably poor when EBV is present, compared to their EBV-negative counterparts. The physical presence of EBV in these tumors represents a potential “tumor-specific” target for therapeutic approaches. While treatment options for other types of herpesvirus infections have evolved and improved over the last two decades, however, therapies directed at EBV have lagged. A major constraint to pharmacological intervention is the shift from lytic infection to a latent pattern of gene expression, which persists in those tumors associated with the virus. In this paper we provide a brief account of new virus-targeted therapeutic approaches against EBV-associated malignancies.

Cytolytic T lymphocytes from HLA-B8+ donors frequently recognize the Hodgkin's lymphoma associated latent membrane protein 2 of Epstein Barr virus

Epstein Barr virus (EBV) is a lymphotrophic γ-herpesvirus that infects more than 90% of the adult human population. It transforms B cells in vitro and is associated with lymphomas in vivo. In most EBV carriers the emergence of these malignancies, however, is prevented by T cell mediated immune control. Part of this control is mediated by CD8+ T cells, which mainly target a subset of viral nuclear antigens, EBNA3A, B and C, in healthy EBV carriers. In HLA-B8 positive individuals, the dominant CTL response is biased towards recognition of EBNA3A. However, spontaneously arising EBV-associated malignancies, such as Hodgkin's lymphoma and nasopharyngeal carcinoma do not express EBNA3s and instead express latent membrane protein 2 (LMP2) as well as LMP1 and EBNA1. Here we describe the new HLA-B8 restricted, LMP2 derived CD8+ T cell epitope, LMP2345-352. Although the frequency of LMP2345-352 specific CD8+ T cells is usually lower than immunodominant EBNA3A specific CD8+ T cells in fresh blood, the former can be expanded in the majority of HLA-B8+ EBV carriers after 1 week co-culture with peptide pulsed dendritic cells. We demonstrate that LMP2345-352 specific CD8+ T cells secrete IFN-γ and kill both peptide pulsed targets as well as HLA-B8 matched LCL and LMP2 expressing Hodgkin's lymphoma cells. We suggest that cytotoxic CD8+ T cell responses against LMP2 coexist with the immunodominant EBNA3 specific responses in healthy EBV carriers and help to resist EBV associated malignancies.

Non-Hodgkin's lymphomas.

Part 1 Lymphomagenesis: Lymphocyte differentiation Adult T-cell leukaemia/Lymphoma - a model of retrovirus-induced lymphomagenesis Burkitt's lymphoma and Epstein-Barr virus-associated lymphoid malignancies - models for lymphomagenesis T(14 18) translocation. Part 2 Methods: Histological and immunohistochemical methods Genotype. Part 3 Nodal Non-Hodgkin's Lymphomas: The normal lymph node - structure and function Histological classification Staging of NHLs Analytical study of the different subtypes of NHLs - clinical, histological and immunohistochemical aspects NHLs in childhood NHLs associated with HIV infection. Part 4 Extra-Nodal Non-Hodgkin's lymphomas: Malignant lymphomas of mucosa-associated lymphoid tissues Primary gastrointestinal NHLs Pathology of gastro-intestinal NHLs Cutaneous lymphomas NHLs of the Mediastinum NHLs of the lung Bone marrow involvement Blood involvement in chronic (mature) B & T lymphoproliferative syndromes Liver involvement Spleen involvement Extra-cranial head-and-neck NHLs Central nervous system involvement NHLs of bone Urogenital localizations. Part 5 Treatment of Non-Hodgkin's Lymphomas: Methodology and problems in the comparison of results Treatment of lowgrade NHLs The role of radiation therapy Treatment of aggressive lymphomas (intermediate and highgrade) Intensive chemoradiotherapy and bone-marrow transplantation Salvage therapy after failure Treatment of NHLs in childhood.

Immunotherapy for Epstein-Barr virus-associated malignancies

Epstein-Barr virus (EBV) is present in the malignant cells of several human cancers including post-transplant lymphoproliferative disease (PTLD), Hodgkin's lymphoma, nasopharyngeal carcinoma, natural killer/T lymphomas and Burkitt's lymphoma. Yet in > 90% of the world's adult population, who carry EBV as a lifelong asymptomatic infection, the oncogenic potential of this virus is controlled by a strong virus-specific T-cell response. Accordingly, EBV-associated malignancies represent good candidates for a T-cell-based therapy and provide an important model for developing such therapies for other human cancers. This review summarizes the impressive results seen with T-cell therapy for PTLD and discusses, in the light of recent technological advances, the prospects for developing more effective approaches for other EBV-associated cancers.

Guest editorial: Special section on the Symposium on Point-Based Graphics 2007

Epstein Barr virus (EBV) is a human γ-herpesvirus that was discovered in Burkitt's lymphoma more than 50 years ago. Since then it has been proposed as the causative agent of up to 2% of all tumors worldwide, mainly lymphomas and epithelial cell carcinomas. Surprisingly, persistent EBV infection is at the same time found in more than 90% of healthy human adults. Even the very same programs of EBV infection that are found in the associated malignancies are continuously present in healthy EBV carriers. We will discuss primary immunodeficiencies and immune compartment changes during the first decade of human life that give us insights into how tumorigenesis by persistent EBV infection and Hodgkin's lymphoma predisposing infectious mononucleosis is prevented during primary infection. These insights should allow identifying individuals at risk to develop EBV associated malignancies, who would benefit from EBV specific vaccination.

Multifocal Extranodal Non-Hodgkin Lymphoma Involving Both the Lungs and Brain in a Child With Primary Immunodeficiency

Immunodeficiency is associated with increased susceptibility to infections and B-cell lymphoproliferative disorders, which range from polyclonal proliferations to monoclonal lymphomas. In primary immunodeficiencies, the true incidence of lymphoproliferative disorders has been estimated between 1.4% and 24%. Recurrent or chronic infections resulting in continuous antigen exposure result in abnormal B-cell proliferation and ultimately lymphoma. Immunosuppression leads to increase in likelihood of Epstein-Barr virus-associated malignancies. We report a case of the child with multifocal extranodal non-Hodgkin lymphoma involving both the lungs and brain in a case of primary immunodeficiency.

Phase I study of dexamethasone, methotrexate, ifosfamide, l‐asparaginase, and etoposide (SMILE) chemotherapy for advanced‐stage, relapsed or refractory extranodal natural killer (NK)/T‐cell lymphoma and leukemia

Extranodal natural killer (NK)/T-cell lymphoma, nasal type, and aggressive NK-cell leukemia are rare, and their standard therapy has not been established. They are Epstein-Barr virus-associated lymphoid malignancies, and tumor cells express P-glycoprotein leading to multidrug resistance of the disease. Patients with stage IV, relapsed or refractory diseases have a dismal prognosis, with survival measured in months only. To develop an efficacious chemotherapeutic regimen, we conducted a dose-escalation feasibility study of a new chemotherapeutic regimen, SMILE, comprising the steroid dexamethasone, methotrexate, ifosfamide, L-asparaginase, and etoposide. The components of SMILE are multidrug resistance-unrelated agents and etoposide. Etoposide shows both in vitro and in vivo efficacy for Epstein-Barr virus-associated lymphoproliferative disorders. Eligible patients had newly diagnosed stage IV, relapsed or refractory diseases after first-line chemotherapy, were 15-69 years of age, and had satisfactory performance scores (0-2). Four dose levels of methotrexate and etoposide were originally planned to be evaluated. At level 1, six patients with extranodal NK/T-cell lymphoma, nasal type, were enrolled. Their disease status was newly diagnosed stage IV (n = 3), first relapse (n = 2), and primary refractory (n = 1). All of the first three patients developed dose-limiting toxicities, and one of them died of sepsis with grade 4 neutropenia. A protocol revision stipulating early granulocyte colony-stimulating factor administration was made. Two out of three additional patients developed dose-limiting toxicities that were all manageable and transient. For the six enrolled patients, the overall response rate was 67% and the complete response rate was 50%. Although its safety and efficacy require further evaluation, we recommend a SMILE chemotherapy dose level of 1 for further clinical studies.

Phase I/II trial of Arginine Butyrate and ganciclovir in Epstein-Barr virus-associated lymphoid malignancies

7542 Background: Malignancies associated with latent Epstein-Barr virus (EBV) are resistant to nucleoside-type anti-viral agents because the viral enzyme target of these drugs, thymidine kinase (TK), is not expressed. Short-chain fatty acids, such as butyrate, induce EBV-TK expression in latently-infected B cells. In preclinical studies, we have shown that butyrate sensitizes EBV(+) lymphoblastoid cells, tumor lines and primary lymphoma cultures to apoptosis induced by ganciclovir. Methods: We conducted a Phase I/II trial of Arginine Butyrate in combination with ganciclovir in patients with refractory EBV(+) lymphoid malignancies to evaluate toxicity, pharmacokinetic parameters, and clinical responses. Fifteen patients with heavily-pretreated, refractory EBV(+) lymphoid malignancies, consisting of monoclonal refractory lymphoproliferative disease (PTLD), B cell non-Hodgkin’s lymphomas (NHL) (including one HIV-associated anaplastic B cell lymphoma), T cell NHL (including one cutaneous lymphoma), T/NK cell lymphomas, and Hodgkin disease were studied. Ganciclovir was administered twice daily and Arginine Butyrate was administered in an intra-patient dose-escalation. Arginine Butyrate was instituted at 500 mg/kg/day by continuous infusion, and escalated to 2000 mg/kg/day, as tolerated. Results: The MTD for Arginine Butyrate was established as 1000 mg/kg/day. Overall the combination was well-tolerated, with the most common toxicities being nausea and headache. Complications from rapid tumor lysis occurred in three patients, including acute hepatic necrosis in one patient. Reversible grade 3–4 somnolence or stupor occurred in three patients at Arginine Butyrate doses of greater than 1000 mg/kg/day. Ten of fifteen patients showed significant anti-tumor responses, with 5 CR and 5 PR. In certain patients who demonstrated a clinical CR, subsequent pathological analysis showed elimination of all tumor cells. Conclusions: The combination of Arginine Butyrate and ganciclovir was reasonably well-tolerated and appears to have significant biological activity in vitro and in vivo against refractory EBV(+) lymphoid malignancies. No significant financial relationships to disclose.