Epstein-Barr Virus-positive Hodgkin Lymphoma Research Articles

Concurrent Epstein Barr Virus Viremia and Hodgkin Lymphoma In Two Patients With Chronic Lymphocytic Leukemia

IntroductionChronic lymphocytic leukemia (CLL) is a lymphoproliferative disorder (LPD) derived from mature B-cells with heterogeneous outcomes. High-grade lymphoma can arise from CLL in 3-10% of cases, a process known as Richter's transformation (RT). The majority of RT results in high grade B-cell lymphomas, though rarely transformation to Hodgkin lymphoma (HL) has been reported. Epstein Barr virus (EBV) viremia can arise in patients with CLL secondary to immunosuppression and can lead to an EBV driven LPD. In patients with CLL, this has been seen with fludarabine based treatments but has been reported with alemtuzumab. HL is also been associated with EBV virus in tumor cells but cases of HL and EBV viremia have not been reported. We report the first two cases in the English literature of CLL with EBV viremia and HL. CasesCase 1 A 66 year old male was diagnosed with a RAI stage I, del13q14, Zap-70 (-), IgvH mutated, CD38 (+) CLL in 2004. Worsening thrombocytopenia resulted in the initiation of treatment in April 2012 using Ofatumumab and high dose methylprednisolone followed by lenalidomide maintenance therapy (HiLOG clinical trial). The patient responded to induction therapy and was continued on lenalidomide maintenance for 12 cycles. In May of 2013 the patient developed progressive fevers, chills, cough, weakness, weight loss, and hypercalcemia. Evaluation revealed an EBV viremia with whole blood PCR titers of 484,550 copies/mL. Bone marrow biopsy was consistent with CLL and full body PET CT scan showed diffuse lymphadenopathy with max SUV of 30.7 and splenomegaly. Biopsy of a left external iliac node showed large atypical lymphoid cells that were surrounded by small lymphocytes. The large atypical lymphoid cells were CD30 (+), EBV (+), Pax-5 (+), CD 20 (-), CD15 (-), CD5 (-), and CD3 (-) confirming HL. The patient has currently received 4 weekly treatments with rituximab for EBV driven LPD and one cycle of Adriamycin, bleomycin, vinblastine, and dexamethasone (ABVD) for HL with resolution of symptoms and a whole blood EBV PCR to <500 copies/mL. Case 2A 68 year old male was diagnosed in England with an unknown stage del13q and IgVH unmutated CLL in 2002. He was started on treatment with 5 cycles of fludarabine, cyclophosphamide, rituximab in 2011 and achieved a complete response. His post therapy course was complicated with infection resulting in septic shock with renal failure resulting in dialysis. He stabilized but continued to have hypogammaglobulenemia and required intravenous immunoglobulin (IVIG) replacement. In April of 2013 he developed fevers to 104F, night sweats, weight loss and, fatigue. PET CT scan showed diffuse adenopathy with max SUV of 22.5, and bone marrow biopsy showed 60% CLL and a component of large cells that were CD 30 (+), CD15 (+), Mum1 (+), and EBER-ISH (+). The patient's whole blood EBV PCR was 276,600 copies/mL. Based on the clinical picture the patient was diagnosed with an EBV positive HL, EBV viremia, and chronic CLL. He has completed 4 weekly treatments with rituximab for EBV driven LPD and cycle 1 of ABVD for HL with resolution of symptoms and a whole blood EBV PCR of <500 copies/mL. DiscussionAlthough EBV viremia has been reported in CLL and EBV staining can be positive in HL, these two cases are the first to report CLL with EBV viremia and EBV positive HL. The high EBV viral load likely provided a base for an EBV driven LPD, in these cases HL. In patients with constitutional symptoms who have stable CLL disease burden, the clinician should screen for RT and EBV viremia. When a concurrent process is found, as in our cases, treatment against both the EBV driven LPD and HL should be initiated. Further research is needed to establish a biological relationship between EBV viremia and HL in patients with CLL. Disclosures:No relevant conflicts of interest to declare.

Expression of Epstein–Barr virus in Hodgkin lymphoma in a population of United Arab Emirates nationals

Hodgkin lymphoma (HL) shows wide geographic variation in histological subtypes and in its association with the Epstein–Barr virus (EBV). HL has three main epidemiological patterns (I, II and III). Type I pattern, which is prevalent in developing countries, shows a relatively high incidence in male children, a low incidence in the third decade and a second peak of high incidence in older age groups. Type III, which is usually seen in developed countries, is characterised by a low rate in children and a pronounced initial peak in young adults. The third pattern (Type II), which is described in many Asian countries, is intermediate and reflects a transition between types I and III. In this pattern there is both a childhood and a third decade peak. The proportion of EBV positive HL is low in industrialised countries, high in non-industrialised countries and intermediate in early-industrialised countries. Reports from the Arabian Gulf and Middle East are few. The aim of this study is to determine the epidemiology of HL in a population of United Arab Emirates (UAE) nationals, an early industrialised country in the Arabian Gulf, and to delineate the extent of its association with EBV. In total, 88 cases of HL were diagnosed in native patients during the period 1988 through 2004 at Tawam hospital. Forty-five paraffin blocks were available for this study. Five-micrometer sections were prepared and stained with hematoxylin and eosin and the immunohistochemical streptavidin–biotin methods for CD45, CD3, CD20, CD15 and CD30. Other sections were examined for the presence of EBV using the immunohistochemical streptavidin–biotin method for the latent membrane protein 1 and in situ hybridisation for EBV encoded RNA to determine the prevalence of EBV in Hodgkin cells and its possible role in the pathogenesis of HL. Nodular sclerosis (NS) subtype was the most common type of HL among UAE nationals followed by mixed cellularity (MC), lymphocytic predominant (LP), unclassified, lymphocytic depletion (LD) and lymphocyte rich (LR) subtypes, respectively. EBV was seen in 17 of 45 (38%) cases of HL and was predominately seen in the MC subtype followed by NS, LD and LR subtypes, respectively. EBV was more frequently expressed in HL in the pediatric age group than the adult age group. These data indicate that the epidemiology of HL in a native population of the UAE is suggestive of a type II epidemiologic pattern in terms of age distribution, and histopathologic subtypes, whereas the frequency of EBV expression is more suggestive of a type III epidemiologic pattern. The significant association between EBV and HL that we have found further strengthens the suggestion that all cases of HL should be assessed for EBV status, because its presence may have a significant impact on prognosis and response to therapy.

Rectal Epstein-Barr virus-positive Hodgkin's lymphoma in a patient with Crohn's disease: Case report and review of the literature

We present the case of a 35-year-old man with Crohn's disease diagnosed at the age of 27, several months after an operation for small-bowel adenocarcinoma. Seven years after the adenocarcinoma diagnosis, the patient presented with severe continuous anal pain and diarrhea. In parallel with antibiotic administration, the patient was given treatment with Infliximab, but without clinical symptom amelioration. Sigmoidoscopy and subsequent biopsies from an ulcerated rectal area supported the diagnosis of Epstein-Barr virus-positive (EBV(+)) primary Hodgkin's lymphoma. Infliximab administration was immediately discontinued and the patient underwent oncological follow-up and began a course of chemotherapy. Only a few cases with primary gastrointestinal Hodgkin's lymphoma in Crohn's disease patients have so far been reported, including a variety of scenarios on the causal relationship including disease duration, presence of EBV, long-term immunosuppressive treatment and, recently, anti-TNFα administration.

Haplotype-Based Sequencing To Delineate the Associated HLA Class I Region for EBV Positive Hodgkin Lymphoma.

Various studies have indicated that the human leukocyte antigen (HLA) region is associated with Hodgkin Lymphoma (HL). We recently demonstrated a specific association of the HLA class I region with Epstein-Barr virus (EBV) positive HL cases. The positively associated haplotype was characterized by alleles 126 and 284 of the consecutive microsatellite markers D6S265 and D6S510 while the negatively associated haplotype was characterized by alleles 130 and 302. Further fine mapping of this region is necessary to find the causative SNP(s). To select the most promising candidate SNPs for screening the total study population, known SNPs were sequenced in an individual homozygous for the positively associated haplotype and an individual homozygous for the negatively associated haplotype. Five SNPs (rs2530388, rs2523972, rs4713276, rs2256543, and rs6457110) that were selected on the basis of displaying different alleles in these two individuals were analysed in the total study population. The five SNPs showed significant association with the EBV-positive patient group, three of them revealed a stronger association than the previously identified associations (−log p difference = 1). These five SNPs were also analysed in a Scottish population, and four of them showed association in that population as well. The associated region was narrowed down from 310 kb in the original study to a region comprising less than 60 kb in the present study. Of the genes mapping to this candidate region, HLA-A represents the most interesting target because of its consistent expression in EBV positive HL cases and its ability to present EBV derived peptides to cytotoxic T cells.

Genetic susceptibility to Hodgkin's lymphoma associated with the human leukocyte antigen region

Based on the presence of an abundant inflammatory infiltrate, expression of a broad spectrum of cytokines and the professional antigen presenting phenotype of Hodgkin Reed-Sternberg cells it can be anticipated that immunological mechanisms play a major role in the pathogenesis of Hodgkin's lymphoma (HL). Genetic susceptibility to HL probably relates to functionality of the immune system and the large number of associations with the human leukocyte antigen (HLA) region in family and population-based studies supports this relation. In Epstein-Barr virus (EBV) positive HL cases, which usually demonstrate HLA class I expression, HRS cells should be able to present EBV derived antigenic peptides and trigger the immune system. This process depends on the affinity of the HLA binding groove for binding immunogenic peptides and thus on the HLA alleles. It can be anticipated that certain combinations of alleles predispose to or protect from the development of EBV positive HL. In EBV negative HL cases other antigenic peptides, related to malignant transformation, in combination with other HLA alleles may be involved. In addition, differential attraction and activation of inflammatory cells may influence HL subtype. In this article, possible roles of HLA in HL pathogenesis are explored and genetic associations of HLA with HL are reviewed and commented on.

Epstein-Barr virus expression in Hodgkin's lymphoma in Kuwait.

The epidemiology of Hodgkin's lymphoma (HL) shows wide geographic variation in histological subtypes and in its association with the Epstein-Barr virus (EBV). The proportion of EBV positive HL is low in industrialized countries, high in non-industrialized countries and intermediate in early-industrialized countries. Reports from the Persian Gulf and Middle East are very limited. The aim of this study was to determine the epidemiology of HL in Kuwait, an early-industrialized country in the Persian Gulf, and to delineate the extent of its association with EBV. We reviewed 134 cases of HL for histological classification and demographic data. 107 cases were examined for the presence of EBV using immunohistochemistry (IHC) for the latent membrane protein I (LMPI) and in-situ hybridization (ISH) for EBVencoded RNA (EBER). 70.4% of the patients were males and 29.6% were females. The male: female ratio was 2.4:1. The mean age was 30.6 years (range, 4-71 years). Mixed cellularity HL (MCHL) was the most common subtype (45.5%), followed by nodular sclerosis (37.3%), nodular lymphocyte predominant (6.7%), lymphocyte rich (3%) and lymphocyte depletion (3%). 4.5% of cases were unclassifiable. EBV expression was seen in 56%, was significantly higher in MCHL, in children, and in males. Our findings suggest that the frequency of EBV expression in HL in Kuwait is similar to other early-industrialized countries. Further research from other countries in the Persian Gulf and the Middle East should shed more light on the epidemiology of HL and its relation to EBV in this region.

Adenoviral gene transfer into dendritic cells efficiently amplifies the immune response to LMP2A antigen: a potential treatment strategy for Epstein-Barr virus--positive Hodgkin's lymphoma.

The EBV-encoded LMP2A protein is consistently expressed in EBV(+) Hodgkin's lymphoma and can be targeted by CTLs. CTLs stimulated conventionally by LCLs have little activity against LMP2A(+) target cells. Here, we describe an alternative approach, based on the in vitro stimulation of CTLs with DCs genetically modified with 2 E1/E3-deleted recombinant adenoviruses, AdGFPLMP2A, encoding a fusion gene of GFP and LMP2A, and AdLMP2A, encoding LMP2A only. Transduction of DCs with AdGFPLMP2A at MOI 1,000 resulted in LMP2A expression in up to 88% of DCs. LMP2A protein was expressed in 40% of DCs transduced with AdLMP2A at an MOI of 100. Higher MOI resulted in DC death. CTL lines activated by transduced DCs had a higher frequency of LMP2A tetramer-specific CTLs than CTL lines activated by LCLs. CTLs stimulated with transduced DCs lysed both autologous fibroblasts infected with vaccinia virus LMP2A (FBvaccLMP2A) and autologous LCLs, which express LMP2A at lower levels. In contrast, CTLs generated from the same donors by stimulation with autologous LCLs showed minimal lysis of FBvaccLMP2A. Moreover, 1 donor who did not respond to LMP2A when CTLs were stimulated with LCLs became a responder when LMP2A was expressed by transduced DCs. Hence, recombinant adenoviruses encoding LMP2A effectively transduce DCs and direct the generation of LMP2A-specific CTLs. This approach will be a potent strategy in Hodgkin's lymphoma immunotherapy.