HCV-associated non-Hodgkin's Lymphoma Research Articles

Hepatitis Virus-associated Non-hodgkin Lymphoma: Pathogenesis and Treatment Strategies.

Over the last decade, epidemiological studies have discovered a link between hepatitis C virus (HCV) and hepatitis B virus (HBV) infection and non-Hodgkin lymphoma (NHL). The regression of HCV-associated NHL after HCV eradication is the most compelling proof supporting HCV infection's role in lymphoproliferative diseases. HBV infection was found to significantly enhance the incidence of NHL, according to the epidemiological data. The exact mechanism of HCV leading to NHL has not been fully clarified, and there are mainly the following possible mechanisms: (1) Indirect mechanisms: stimulation of B lymphocytes by extracellular HCV and cytokines; (2) Direct mechanisms: oncogenic effects mediated by intracellular HCV proteins; (3) hit-and-run mechanism: permanent genetic B lymphocytes damage by the transitional entry of HCV. The specific role of HBV in the occurrence of NHL is still unclear, and the research on its mechanism is less extensively explored than HCV, and there are mainly the following possible mechanisms: (1) Indirect mechanisms: stimulation of B lymphocytes by extracellular HBV; (2) Direct mechanisms: oncogenic effects mediated by intracellular HBV DNA. In fact, it is reasonable to consider direct-acting antivirals (DAAs) as first-line therapy for indolent HCV-associated B-NHL patients who do not require immediate chemotherapy. Chemotherapy for NHL is affected by HBV infection and replication. At the same time, chemotherapy can also activate HBV replication. Following recent guidelines, all patients with HBsAg positive/HBV DNA≥2,000 IU/mL should be treated for HBV. The data on epidemiology, interventional studies, and molecular mechanisms of HCV and HBV-associated B-NHL are systematically summarized in this review.

Hepatitis C virus-associated B-cell lymphomas: The importance of the new direct antiviral agent therapy

Hepatitis C virus (HCV) is a hepatotropic and lymphotropic virus, responsible for both chronic hepatitis and extra-hepatic manifestations. Multiple epidemiologic, clinical, biological, and molecular studies have suggested that HCV plays a causal role also in the development of several lymphoproliferative disorders, either benign, such as mixed cryoglobulinemia, or malignant, such as B-cell non-Hodgkin lymphomas (NHL). Chronic viral antigenic stimulation of B-lymphocytes plays a fundamental basic role from the onset of lymphoma to its final steps. In the past, several studies demonstrated that the association of pegylated interferon plus ribavirin was able to eradicate HCV, with subsequent regression of indolent B-cell low-grade NHL. Other studies have demonstrated that direct antiviral agents (DAAs) therapy have some efficacy in HCV-associated NHL, particularly in patients with low-grade NHL or marginal zone-lymphoma, but these results need to be confirmed in larger studies with longer follow-up. The response rate of antiviral therapy seems favorable also in high grade NHL when DAAs therapy is administered in combination with chemotherapy and therefore antiviral therapy should be considered as a first-line approach in HCV-related NHL.

Risk of Non-Hodgkin's Lymphoma in HCV Patients in the United States Between 2013 and 2020: A Population-Based Study

Hepatitis C virus (HCV) is a significant healthcare problem affecting ~1% of the United States population. Meta-analyses of epidemiological studies reported a strong association between non-Hodgkin's lymphoma (NHL) and HCV. Direct oncogenic properties of HCV proteins and chronic antigenic stimulation are possible etiologies. We explored if NHL's prevalence has changed since older HCV therapy based on interferon that shared antiviral and anti-lymphoma properties was replaced with interferon-free direct-acting antivirals (DAA). We reviewed data from a nationwide database (Explorys, IBM) that aggregates records from 26 health-care-systems. We identified patients with chronic hepatitis C infection between June 2013 and June 2020. The control group was gender, race, and age-matched HCV-negative population. Statistical analysis used the odds ratio (OR) with P value <.001 for significance. There were 940 cases of NHL of 129,970 patients in the HCV group versus 107,480 cases of NHL of 37,961,970 in the control cohort [OR 2.6, 95% confidence interval (CI) 2.4-2.7]. A positive association was present for chronic lymphocytic leukemia, follicular lymphoma, marginal zone lymphoma, lymphoplasmacytic lymphoma, diffuse large B-cell lymphoma, Burkitt's lymphoma, non-Hodgkin T-cell lymphoma, and primary cutaneous T-cell lymphoma. There were no differences in Mantle cell lymphoma. The increased risk of HCV-associated lymphoma was persistent across genders, Caucasians and African-Americans, and age groups. While the risk of NHL in the HCV-negative population was higher in Caucasians than African-Americans (OR 1.8, 95% CI 1.7-1.8), the risk of HCV-associated NHL was not different. Further prospective studies examining the risk of HCV-associated lymphoma following DAA are warranted.

Hepatitis C virus-associated non-Hodgkin lymphomas: the endless history.

Hepatitis C virus (HCV) is a global population problem due to its high prevalence worldwide. In the prognosis of patients with HCV not only hepatic but increasingly frequent of extrahepatic HCV manifestations, such as mixed cryoglobulinemia (MC) and non-Hodgkin's lymphoma (NHL), are important. The role of the HCV virus in the pathogenesis of lymphoproliferative diseases is confirmed by a large number of epidemiological studies, as well as by the effectiveness of antiviral therapy in patients with non-Hodgkin's lymphoma (NHL). The purpose of the review was to provide an overview of epidemiological and biological data explaining the role of HCV in the development of NHL. The review also discusses HCV-associated NHL treatment by the traditional antiviral therapy (interferon and ribavirin) and by the new direct antiviral agents.

Risk of Non-Hodgkin's Lymphoma in HCV Patients in the United States between 2013 and 2020: A Population-Based Study

Introduction Hepatitis C virus (HCV) is a major healthcare problem affecting ~ 1% of the United States population. HCV virus is known to have lymphotropic properties and metanalyses of epidemiological studies reported an association between HCV and non-Hodgkin's lymphoma (NHL) with a relative risk range (1.8 to 10.8). 1-4 Most studies included in these metanalyses were heterogenic with different control groups, and contained a relatively small number of patients that prevented the evaluation of racial differences or the association of HCV with distinct NHL subtypes. We conducted a population-based study to address these deficiencies and to explore if the prevalence of NHL has changed since older therapy of HCV based on interferon that shared both anti-viral and anti-lymphoma properties was replaced with the interferon-free direct-acting antivirals (DAA). Methods We reviewed data from a nationwide commercial database (Explorys, IBM) that aggregates records from 26 health-care-systems and includes 72 million patients. We identified adult patients aged ≥ 40 years with HCV between June 2013 and June 2020. The control population was HCV-negative matched for gender, race; Caucasian, and African-American, and two age groups; 40-64 years and ≥ 65 years. We excluded all patients who developed NHL before the study start date and patients with HIV. The association between NHL and HCV was evaluated using odds ratios (OR) with a 95% confidence interval. The differences were considered significant at a P value of less than 0.001. Results There were 940 cases of NHL among 129970 HCV individuals versus 107480 cases of NHL out of 37961970 persons in the control cohort [OR 2.6, 95% confidence interval (CI) 2.4-2.7]. A positive association was present in chronic lymphocytic leukemia (OR 1.4, 95% CI 1.2-1.6), follicular lymphoma (OR 2.7, 95% CI 2.2-3.4), marginal zone lymphoma (OR 5.2, 95% CI 3.8- 7.1), lymphoplasmacytic lymphoma (OR 2.6, 95% CI 1.8-3.8), diffuse large B-cell lymphoma (OR 4.4, 95% CI 3.4 - 5.6), Burkitt's lymphoma (OR 4.2, 95% CI 2.9-6.0), non-Hodgkin's T-cell lymphoma (OR 2.5, 95% CI 2.1-3.0) and primary cutaneous T-cell lymphoma (OR 2.8, 95% CI 1.9-3.3). There was no difference in Mantle cell lymphoma (see Figure 1, and Table 1). The increased risk of HCV-associated lymphoma was persistent when adjusted for gender, Caucasian and African-American races, and in age groups of 40-64 years and &amp;gt; 65 years (see Table 2). While in the control population, Caucasians had a higher risk of NHL compared to African-Americans (OR 1.8, 95% CI 1.75-1.84), there was no difference in HCV-associated lymphoma (see Tables 3 and 4). Discussion: Our study is the largest of population-based studies evaluating the risk of non-Hodgkin's lymphoma in patients with HCV. The Risk of HCV-associated NHL was higher with an OR of 2.6 compared to older studies in the US published before DAA therapy was available reporting an OR close to 1.5.5,6 The observation of increased risk of chronic lymphocytic leukemia, follicular lymphoma, marginal zone lymphoma, lymphoplasmacytic lymphoma, and diffuse large B-cell lymphoma was comparable with the prior meta-analysis. 1-4 However, we found an increased risk in Burkitt's lymphoma, non-Hodgkin's T-cell lymphoma and primary cutaneous T-cell lymphoma. Possible pathophysiology of HCV-associated lymphomagenesis is shown in Figure 2. Interestingly, while the risk of NHL lymphoma in HCV-negative Caucasians was higher than African-Americans in keeping with US-based epidemiologic studies.7 A novel finding of our study found was the lack of difference in HCV-associated lymphoma between Caucasians and African-Americans. Reason for possible increased oncogenicity of HCV in African-Americans is unclear. Limitations of the databased based project include inaccuracies and miscoding. Given the nature of the data it was not possible to study differences between patients who received interferon-based therapy versus DAA. In conclusion, despite recent advances in HCV treatment, the risk of NHL among HCV infected patients remains elevated and it was persistent in males and females. In contrast to non-HCV background population where Caucasians had a higher prevalence of NHL, there was no difference between Caucasians and African-Americans. An effort to early detect and treat HCV is needed along with establishing prospective studies to examine the impact of HCV therapy with DAA on NHL risk. Figure Disclosures No relevant conflicts of interest to declare.

Clearance of Hepatitis C Virus (HCV) Is Associated With Improved Outcomes in HCV-Associated Lymphoma

BackgroundImproved hepatitis C virus (HCV) clearance due to directly acting antiviral agents has led to remarkably improved outcomes of indolent HCV-associated non-Hodgkin lymphoma (NHL). The impact of directly acting antivirals on the outcomes of aggressive NHL is still under investigation. Characteristics of HCV-associated NHL in black patients are not well characterized. We report outcomes of HCV-associated NHL compared to their HCV-negative counterparts in a predominantly black population. Patients and MethodsPatients with lymphoma between January 2007 and December 2017 were retrospectively studied. Depending on presence or absence of HCV RNA, patients were grouped into HCV positive (HCV+) and HCV negative (HCV−) cohorts. Depending on virologic clearance (VC), HCV+ were classified into HCV+ with VC and HCV+ without VC. Overall response rate (ORR), complete response, overall survival (OS), and progression-free survival (PFS) of HCV+ patients with and without VC were compared to HCV− patients. ResultsOf 397 patients with lymphoma, 40 had HCV. Black comprised 90% of HCV+ patients. Diffuse large B-cell lymphoma was most frequent (47%) in the HCV+ group. HCV+ patients without VC had significantly worse OS and PFS compared to HCV− patients. There were no differences in ORR, complete response, PFS, and OS of HCV+ patients with VC and HCV− patients. These results were consistent in subgroups of diffuse large B-cell lymphoma and aggressive lymphoma. ConclusionHCV clearance is positively associated with lymphoma outcomes in black patients. Patients who clear HCV have noninferior outcomes to HCV− patients, while those who fail to clear HCV have significantly worse outcomes.

Direct-acting antiviral agents in lymphoproliferative disorders: more complex than expected.

Direct-acting antiviral agents in lymphoproliferative disorders: more complex than expected.

HCV-associated mixed cryoglobulinemia and b-cell non-Hodgkin's lymphoma - pathogenetically related problems.

Hepatitis C virus (HCV) is a global population problem due to its high prevalence, usually late diagnosis, the difficulties of treatment. In the prognosis of patients with HCV not only hepatic, but increasingly frequent of extrahepatic HCV manifestations, such as mixed cryoglobulinemia (CG), are important. Mixed CG is currently considered as a B-cell benign lymphoproliferative disorders. The role of HCV virus in the pathogenesis of lymphoproliferative diseases is confirmed by a large number of epidemiological studies, as well as by the effectiveness of antiviral therapy in patients with non-Hodgkin's lymphoma (NHL). The purpose of the review was to provide an overview of recent literature data and the meta-analysis of epidemiological data explaining the role of HCV in the development of NHL. The review also discusses the treatment for HCV-associated NHL by antiviral therapy or other therapeutic options, such as chemotherapy.

Expert opinion on managing chronic HCV in patients with non-Hodgkin lymphoma and other extrahepatic malignancies.

HCV is a carcinogen that is well established as a major risk factor for hepatocellular carcinoma. Evidence that HCV plays a role in the development of extrahepatic malignancies is less robust; however, epidemiological studies have consistently demonstrated an association between HCV infection and B-cell non-Hodgkin lymphoma (NHL). The strongest evidence for a link between HCV and tumourigenesis is the clear association between viral eradication, as indicated by achievement of sustained virological response, and remission of B-cell NHL. All-oral direct-acting antiviral-based therapies are effective in patients with HCV-associated NHL and well tolerated. For this reason, it is important that clinicians assess HCV-infected patients for HCV-associated extrahepatic malignancies so patients can receive timely diagnosis and treatment.

Sofosbuvir-based therapy in patients with chronic hepatitis C virus infection and malignancies: A prospective study of 143 patients.

e18152 Background: Data on the management of chronic hepatitis C virus (HCV) infection in cancer patients (pts) are sparse with many of them excluded from cancer clinical trials (CCT). We evaluated the efficacy and safety of sofosbuvir-based therapy (SOFBT) in such pts. Methods: Consecutiveptstreated with SOFBT at MD Anderson (1/2014-2/2017) were included in a prospective observational study. Efficacy (sustained virological response 12 weeks [SVR12] after SOFBT) was assessed based on intention to treat (ITT) analysis. A posthoc per-protocol analysis (PPA) was performed on pts with 12 weeks of follow-up post SOFBT. Adverse events (AEs) and drug-drug interactions (DDIs) were evaluated. Results: Of the 143 pts studied, the majority were men (102; 89%), white (89; 62%) and had genotype 1 (103; 72%). The most common cancers were non-Hodgkin lymphoma (NHL), hepatocellular carcinoma (HCC) (24; 17%, each) and breast cancer (11; 8%). Of the 31 infected pts excluded from CCTs, 27 (87%) were granted access after SVR. The overall SVR12 were 90% ITT (129/143) and 91% PPA (118/130). SVR12 ITT were 80% (8/10) for SOF+peg-interferon+ ribavirin, 86% (24/28) for SOF+ ribavirin, 95% (20/21) for SOF+simeprevir, 90% (64/71) for SOF/ledipasvir, 100% (8/8) for SOF+daclatasvir and 100% (5/5) for SOF/velpatasvir. The most common AEs were grade 1 (50; 35%), predominantly anemia (22%). DDIs or grade 4 AEs did not occur. Two pts died during the study period, both from reasons unrelated to SOFBT. In 3 pts with HCV-associated NHL, SOFBT was used alone without chemotherapy. Two of them had splenic marginal zone NHL and achieved complete remission (CR); the remaining pt had follicular lymphoma with stable cancer (SC) after SOFBT. No cases of de novo HCC occurred within 6 months of SOFBT. In the same period, 10% (4/40) of pts with SC had progression (acute leukemia, breast cancer, HCC and NHL in 1 each) and 5% (4/75) of pts with CR developed relapse (acute leukemia in 3, NHL in 1). More pts who failed SOFBT had cirrhosis (77% vs 27%, P = .001) and poorer adherence (≥ 2 missed appointments) (43% vs 4%, P = .001) than those with SVR. Conclusions: SOFBT is effective and safe in cancer pts; it improves access to CCT and may induce CR in selected NHL pts.

Direct-acting Antivirals Induce Lymphoproliferative Disease Response in HCV-infected Patients: A Prospective Case Series

Background Hepatitis C virus (HCV) infection is associated with the development of B-cell Non-Hodgkin lymphoma (NHL). Several studies report regression of indolent NHL in HCV-infected patients treated with interferon (IFN)-containing therapy without chemotherapy. We are describing, herein, the oncologic response of patients with such cancers treated with only direct antiviral agents (DAAs).Methods Patients with HCV-associated NHL seen at MD Anderson Cancer Center (6/2014 to 6/2017) and treated with DAAs were followed and those with indolent NHL treated with DAAs were further analyzed. DAA regimens were administered according to guidelines for HCV-infected patients without cancer. Efficacy was calculated on the basis of achieving sustained virologic response 12 weeks (SVR12) after end of treatment (EOT). NHL status was evaluated at the time of DAAs initiation and response was prospectively analyzed at 6 months after EOT using WHO criteria.ResultsSix patients received DAAs alone as first-line management of their NHL. Most patients 5/6 (83%) did respond to such treatment avoiding or delaying the use of chemotherapy (Table).Conclusion As described with IFN-containing therapy, the oncologic outcome of HCV-infected patients with indolent NHL could also improve by using only DAAs.Table: Characteristics of six patients with indolent NHL treated with DAAs.Number of patients (%) N = 6Median age (IQR), years60 (55- 65)Gender, male4 (67)NHL subtypeMarginal zone lymphomaa6 (100)HCV genotype13 (50)23 (50)rs12979860 genotypebCC2 (33)CT3 (50)TT1 (17)Cirrhosis0History of HCV treatment0DAA therapySofosbuvir + ribavirin2 (33)Sofosbuvir + simeprevir1 (17)Sofosbuvir + daclatasvir2 (33)Sofosbuvir + ledipasvir1 (17)DAA treatment duration of 12 weeks6 (100)NHL response after SVRComplete response2 (33)Partial response1 (17)Stable disease2 (33)Persistent disease1 (17)Chemotherapy needed after SVR3 (50)Abbreviations: IQR, interquartile range; NHL, Non-Hodgkin lymphoma; HCV, hepatitis C virus; DAA, direct acting agents; SVR, sustained virologic response. aNodal (n = 1), Extranodal (n = 2) splenic (n = 1), and mucosa-associated lymphoid tissue lymphomas (n = 2). bFormerly known as interleukin 28b genotype.Disclosures H. Torres, Gilead Sciences: Consultant and Grant Investigator, Consulting fee, Grant recipient and Research support. Merck & Co: Consultant and Grant Investigator, Consulting fee and Grant recipient. Janssen Pharmaceuticals, Inc.: Consultant, Consulting fee. Dynavax Technologies: Consultant, Consulting fee

Antiviral therapy of hepatitis C as curative treatment of indolent B-cell lymphoma.

The association of hepatitis C virus (HCV) and B-cell non-Hodgkin lymphomas (NHL) has been highlighted by several epidemiological and biological insights; however the most convincing evidence is represented by interventional studies demonstrating the capability of antiviral treatment (AT) with interferon (IFN) with or without ribavirin to induce the regression of indolent lymphomas, especially of marginal-zone origin. In the largest published retrospective study (100 patients) the overall response rate (ORR) after first-line IFN-based AT was 77% (44% complete responses) and responses were sustainable (median duration of response 33 mo). These results were confirmed by a recent meta-analysis on 254 patients, demonstrating an ORR of 73%. Moreover this analysis confirmed the highly significant correlation between the achievement of viral eradication sustained virological response (SVR) and hematological responses. Two large prospective studies demonstrated that AT is associated with improved survival and argue in favor of current guidelines’ recommendation of AT as preferential first-line option in asymptomatic patients with HCV-associated indolent NHL. The recently approved direct-acting antiviral agents (DAAs) revolutionized the treatment of HCV infection, leading to SVR approaching 100% in all genotypes. Very preliminary data of IFN-free DAAs therapy in indolent HCV-positive NHL seem to confirm their activity in inducing lymphoma regression.

Hepatitis C virus and non-Hodgkin's lymphomas: Meta-analysis of epidemiology data and therapy options.

Hepatitis C virus (HCV) is a global health problem affecting a large fraction of the world's population: This virus is able to determine both hepatic and extrahepatic diseases. Mixed cryoglobulinemia, a B-cell "benign" lymphoproliferative disorders, represents the most closely related as well as the most investigated HCV-related extrahepatic disorder. Since this virus is able to determine extrahepatic [non-Hodgkin's lymphoma (NHL)] as well as hepatic malignancies (hepatocellular carcinoma), HCV has been included among human cancer viruses. The most common histological types of HCV-associated NHL are the marginal zone, the lymphoplasmacytic and diffuse large cell lymphomas. The role of the HCV in the pathogenesis of the B-cell lymphoproliferative disorders is confirmed also by the responsiveness of the NHL to antiviral therapy. The purpose of this review is to provide an overview of the recent literature and a meta analysis of the epidemiology data, to explain the role of HCV in the development of NHL's lymphoma. Furthermore, the possibility to treat these HCV-related NHL with the antiviral therapy or with other therapeutic options, like chemotherapy, is also discussed.

Genetic Variants of TNFAIP3 in Patients with HCV Related Lymphoma Are Associated with the Presence of Rheumatoid Factor (RF)

Background: HCV chronic infection is associated with an increased risk of non-Hodgkin lymphoma (NHL) occurrence. HCV-associated NHL share homologies with primary Sjögren Syndrome (pSS)-associated NHL, and especially an association with chronic antigenic stimulation and with auto-antibody presence, especially rheumatoid factor (RF) and mixed cryoglobulinemia (MC). TNFAIP3 encodes the A20 protein that plays a key role in controlling NF-kB activation. We have previously demonstrated that germline or tumor genetic impairment of A20 plays a role in lymphomagenesis in the context of pSS[1]. The aim of this study was to assess the role of variants of TNFAIP3 in patients with HCV related NHL.Methods: Sixty-one cases of HCV-associated lymphoma with available germline DNA were drawn from the 116 patients included in the LymphoC study. Total exon sequencing of TNFAIP3was performed in a discovery set of 31 cases. Then 30 additional cases and 53 controls (HCV patients without NHL) were used for extension (ie genotyping of the rs2230926 and the TT>A dinucleotide). All our cases and controls were European. Case-only associations were tested with Fischer’s exact test. Differences in lymphoma histologic type and immunological status were assessed using Fisher’s exact test.Results:Among the 61 cases, histology subsets were 23 diffuse large B cell lymphomas (DLBCL), 17 marginal zone lymphomas (MZL), 6 splenic marginal zone lymphoma (SMZL), 5 mantle cell lymphomas, 8 follicular lymphomas, 1 chronic lymphoid leukemia and 1 chronic EBV-related lymphoproliferation. RF and MC were present in 30/61 (49.2%) and 25/43 (58.1%) of the patients respectively. Among the 53 controls, RF and MC were present in 31/53 (58.5%) and 28/53 (52.8%) of the patients respectively. We found the rs2230926G variant in 6/61 (9.8%) patients with NHL and in 7/53 (13.2%) patients without NHL meaning that there was no association between this SNP and HCV-associated NHL (OR=0.72 [95%CI 0.22– 2.28] p=0.77). We did not find any association between the variant and the marginal zone subtype of the lymphoma.However, we found that, among NHL patients, the rs2230926G allele was associated with the positivity of RF (6/30 (20%) in RF+ patients compared to 0/31 (0%) in RF- patients, OR=16.7 [95%CI 0.9 – 311.5], p=0.01). We did not find any association between the rs2230926 variant and the presence of MC patients probably due to the amount of missing data and the variability of the technic of detection. Last, we previously showed that the rs2230926G was functional and able to impair the control of NF-kB activation[1].Conclusion:This study demonstrates that a germline coding mutation of TNFAIP3leading to a small functional defect of A20 function and of control of activation of NK-kB, plays a key role in lymphomagenesis in the context of chronic antigenic stimulation of RF+ B cells. It extends the scenario already demonstrated in Sjögren’s syndrome-associated lymphomas, a concept which is both novel and paradigm-shifting in the area of lymphomagenesis and autoimmunity. Interestingly, this coding mutation is associated only with HCV-associated lymphoma and presence of RF, which clearly supports different types of lymphomagenesis pathways in patients with HCV, one of them linked to the continuous stimulation of RF+ B cells by the immune complexes between HCV antigens and anti-HCV antibodies.Reference:1. Nocturne, G., et al., Germline and somatic genetic variations of TNFAIP3 in lymphoma complicating primary Sjogren’s syndrome. Blood, 2013 122(25): p. 4068-76. DisclosuresNo relevant conflicts of interest to declare.

Non-Hodgkin's Lymphomas Associated With Positive Hepatitis-C Virus Infection: A Prospective Multicentric Observational Study On Behalf Of The “Rete Ematologica Lombarda/Hematology Network Of Lombardia Region”

IntroductionThe association between hepatitis-C virus (HCV) infection and non-Hodgkin's lymphomas (NHL) has been demonstrated in epidemiological studies. In Lombardia, a densely populated region of northern Italy with around 10 millions of inhabitants, the prevalence of infected people is around 5%. In 2008, the “Rete Ematologica Lombarda” (Hematology Network of Lombardia region) started a prospective multicentric observational study, with the aim to collect data on virological and hematological features, on treatment and outcome of HCV-related NHL. Herein, we present the final results of this study. MethodsBetween January 2008 and December 2012, 241 consecutive adult patients (pts) with first diagnosis of NHL associated with HCV-positivity were enrolled in this prospective observational study (“Registro Lombardo dei Linfomi HCV-positivi”), approved by the Regional Administration and by IRBs of 10 Hematology Centres of Lombardia region. All pts signed a written informed consent. HIV-positive pts were excluded. ResultsMedian age at lymphoma diagnosis was 69 years (yrs) (range 32-90); females were 60%. Histotypes were classified as follows: diffuse large B-cell lymphoma (DLBCL) (44%), marginal zone lymphoma (MZL) (28%), follicular lymphoma (10%), low-grade B-cell lymphoma NOS (10%), small lymphocytic lymphoma (SLL) (3%), lymphoplasmacytic lymphoma (3%), mantle cell lymphoma (1%), peripheral T-cell lymphoma NOS (1%). Ann Arbor stage was III-IV in 79% of pts, with bone marrow involvement in 47%. ECOG score was ≥ 2 in 16% of pts; 63% of pts showed at least one extranodal localization (spleen in 22%, skin in 11%, liver in 10%, Waldeyer's ring in 5%, ocular adnexa in 3%). Virological features and treatment details are summarized in Table 1. HCV-positivity was detected before the diagnosis of NHL in 166 pts (69%) and median time between HCV detection and NHL diagnosis was 11 yrs. Serum monoclonal component (p=0.003), autoimmunity manifestations (p<0.001) and cryoglobulinemia (p=0.002) resulted more frequent in indolent NHL respect to aggressive subtypes. A shorter overall survival (OS) was observed in pts with ECOG ≥ 2 (p<0.001), hemoglobin < 12 g/dl (p=0.008), albumin < 3.5 g/dl (p=0.005), platelets < 100 x 109/L (p<0.001) and lactate dehydrogenase ≥ UNL (p=0.031). Data on first line treatment for NHL were available in 231 pts: 178 pts (77%) received chemotherapy (CHT) [plus Rituximab (R) in 122]; anthracycline contain-regimens (+/- R) were used in 121 pts (52%). Forty pts (17%) developed liver toxicity of any grade (grade III-IV in 19 pts) and 22 pts (10%) interrupted early the treatment. Fifty-three pts were treated with antiviral therapy (AT) for active HCV infection and among them 12 pts (8 MZL, 3 low-grade B-cell lymphoma NOS, 1 SLL) were treated with AT as first anti-lymphoma therapy; 8 pts obtained a virological response and a complete lymphoma response, 2 pts had a partial response (HCV-RNA negative in 1), 1 pt had neither hematological nor virological response and 1 pt is still on therapy. After a median follow-up of 32 months, 47 pts (20%) died (24 with aggressive NHL, 23 with indolent NHL): 23 due to lymphoma, 10 due to cirrhosis/hepatocarcinoma, 7 due to other solid neoplasms, 7 due to other causes. ConclusionsIn this prospective study conducted in Lombardia, a northern region of Italy, the most common histologies of HCV-associated NHL are DLBCL and MZL. In nearly 70% of pts, first detection of HCV positivity preceded the lymphoma diagnosis. A proportion of pts developed meaningful liver toxicity and/or were not able to complete the therapeutic program. In the indolent lymphomas treated with AT as first anti-lymphoma approach, virological and hematological responses are achieved in about two thirds of pts. Disclosures:No relevant conflicts of interest to declare.

Role of MicroRNA Profile Modifications in Hepatitis C Virus-Related Mixed Cryoglobulinemia

Hepatitis C virus infection is closely related to lymphoproliferative disorders (LPDs), including mixed cryoglobulinemia (MC) and some lymphomas. Modification of the expression of specific microRNAs (miRNAs) has been associated with different autoimmune diseases and/or LPDs. No data exist about the modifications in miRNA expression in HCV-associated LPDs. The aim of this study was to analyze the expression levels of a panel of miRNAs previously associated with autoimmune/LPDs in a large population of HCV patients with and without MC or non-Hodgkin’s lymphoma (NHL), to identify potential markers of evolution of HCV infection. PBMC expression of miR-Let-7d, miR-16, miR-21, miR-26b, miR-146a and miR-155 was evaluated by real-time PCR in 167 HCV patients (75 with MC [MC-HCV], 11 with HCV-associated NHL [NHL-HCV], 81 without LPD [HCV]) and in 35 healthy subjects (HS). A significant increase in miR-21 (p<0.001), miR-16 (p<0.01) and miR-155 (p<0.01) expression was detected in PBMCs from only NHL patients whereas a significant decrease in miR-26b was detected in both MC and NHL subjects (p<0.01) when compared to HS and HCV groups. A restoration of miR-26b levels was observed in the post-treatment PBMCs of 35 HCV-MC patients experiencing complete virological and clinical response following antiviral therapy. This study, for the first time, shows that specific microRNAs in PBMC from HCV patients who developed MC and/or NHL are modulated differently. The specific, reversible downregulation of miR-26b strongly suggests the key role it plays in the pathogenesis of HCV-related LPDs and its usefulness as a biomarker of the evolution of HCV infection to these disorders.

Immune signatures in human PBMCs of idiotypic vaccine for HCV-related lymphoproliferative disorders

Hepatitis C virus (HCV) is one of the major risk factors for chronic hepatitis, which may progress to cirrhosis and hepatocellular carcinoma, as well as for type II mixed cryoglobulinemia (MC), which may further evolve into an overt B-cell non-Hodgkin's lymphoma (NHL).It has been previously shown that B-cell receptor (BCR) repertoire, expressed by clonal B-cells involved in type II MC as well as in HCV-associated NHL, is constrained to a limited number of variable heavy (VH)- and light (VL)-chain genes. Among these, the VK3-20 light chain idiotype has been selected as a possible target for passive as well as active immunization strategy.In the present study, we describe the results of a multiparametric analysis of the innate and early adaptive immune response after ex vivo stimulation of human immune cells with the VK3-20 protein. This objective has been pursued by implementing high-throughput technologies such as multiparameter flow cytometry and multiplex analysis of cytokines and chemokines.

Monoclonal B cell lymphocytosis in hepatitis C virus infected individuals

Monoclonal B cell lymphocytosis (MBL) is a preclinical condition characterized by an expansion of clonal B cells in the absence of B lymphocytosis (BALC < 5 × 10(9)/L) in the peripheral blood, without clinical signs, suggestive of a lymphoproliferative disorder. B cell clonal expansions are also associated with hepatitis C virus (HCV) infection and they can evolve into lymphoproliferative disorders such as mixed cryoglobulinemia and non-Hodgkin lymphomas (NHL). The relationship between MBL and HCV infection has not been established yet. By five-colour flow cytometry, we analyzed 123 HCV positive subjects with diagnosis of chronic hepatitis (94) or cirrhosis (29); 16 of those with cirrhosis had a diagnosis of hepatocellular carcinoma. MBL were identified in 35/123 (28.5%), at significantly higher frequency than in the general population. Sixteen/thirty-five were atypical-chronic lymphocytic leukemia (CLL) MBL (CD5(+), CD20(bright)), 13/35 were CLL-like MBL (CD5(bright), CD20(dim)), and 6/35 were CD5(-) MBL. Twenty-four/ninety-four (25.5%) patients affected by chronic hepatitis had MBL, whereas 11/29 (37.9%) patients with cirrhosis showed a B cell clone. A biased usage of IGHVgenes similar to HCV-associated NHL was evident. All three types of MBL can be identified in HCV-infected individuals at a higher frequency than in the general population, and their presence appears to correlate with a more advanced disease stage. The phenotypic heterogeneity is reminiscent of the diversity of NHL arising in the context of HCV infection. The persistence of HCV may be responsible for the dysregulation of the immune system and in particular of the B cell compartment.

HLA DR-DQ combination associated with the increased risk of developing human HCV positive non-Hodgkin's lymphoma is related to the type II mixed cryoglobulinemia

This investigation was focused on the contribution of individual human leukocyte antigen (HLA)-DR and -DQ alleles to the human hepatitis C virus (HCV)(+) non-Hodgkin's lymphoma (NHL), with and without mixed cryoglobulinemia (MC), to study whether individual HLA class II alleles are expressed preferentially or equally in human HCV-specific NHL. For this purpose, peripheral blood mononuclear cells were obtained from two groups of patients with HCV(+) NHL and with or without MC (70 and 71 cases, respectively), and from 4575 blood donors. Eighty-three subjects with HCV infection only, and 118 patients with MC, only without lymphoma, were added as additional control groups. Individual HLA-DR and -DQ alleles were determined using high-resolution sequence-based typing and then data were collected by considering the HLA-DRB1 and DQB1 supertypes on the basis of common structural and functional features, proposed by in silico Bioinformatic studies. From the data, it is evidenced that the DR5-DQ3 HLA combination was strongly associated with the HCV (+) MC (+) NHL group of patients compared with bone marrow donor population (P<or= 0.001, RR = 2.498), while the contribution of DR1-DQ1 was higher in HCV (+) NHL without MC (P<or= 0.001, RR = 2.519). Thus, cryoglobulinemia clinical manifestation was found to be correlated with the preferential use of HLA DR-DQ combination in HCV-associated NHL. These data provide new insight into HCV-associated lymphoproliferative pathogenesis.

Hepatitis C virus infection and non‐Hodgkin lymphoma: Interesting association or causal relationship?

Hepatitis C virus infection and non‐Hodgkin lymphoma: Interesting association or causal relationship?