Epstein-Barr Virus: - PowerPoint Presentation

Slide1

Epstein-Barr Virus: Cancer and Immunosuppression Slide2

Pathogenesis of EBV Infection

Cohen

NEJM 2000Slide3

Early IM: NK cells

non-HLA specific CTLs

Late IM: HLA-restricted CTLs (CD8 and CD4):

Lytic epitopes - up to 40% of CD8 cells Latent epitopes - up to 2% of CD8 cells

Healthy EBV seropositive persons: Latent epitopes- 4% of CD8 cells Lytic epitopes- 0.1 to 5% of CD8 cells

Cellular Immune Responses Are Critical For Control of EBVSlide4

EBV Transforms B Cells In Vitro and the Cells Express Limited Viral and Cellular Proteins

Rickinson and Kieff, Fields Virology

EBV LCLs

EBV Latency Proteins

Cell Genes InducedSlide5

EBV Latency Proteins

Cohen NEJM 2000Slide6

Oncogene

Expression in transgenic mice leads to B cell lymphoma; expression in fibroblasts leads to tumors in nude mice

B Cell Proliferation Upregulates adhesion molecules, CD23, CD40, IL-6, IL-10, etc. Activates NF-

BInhibits apoptosis Upregulates Bcl-2, A20, Mcl-1

LMP-1 is the EBV Oncogene

LMP-1

H & E

(Kulwichit et al PNAS 1998)Slide7

LMP-1 Mimics constitutively form of CD40 in B cells

Thorley-Lawson, Nature Rev Immunol, 2001Slide8

Liebowitz NEJM 1998

Activation of NF-



B in Tumor from Patient with Post-Transplant EBV Lymphoproliferative Disease

Lane 1: EBV- B cell

Lane 2: EBV+ B cell

Lane 3: EBV- LPD

Lane 4: EBV+ LPDSlide9

EBV in B Cell

Infectious mononucleosis

X-Linked Lymphoproliferative Disease Chronic active EBV Hodgkin Disease

Burkitt Lymphoma Lymphoproliferative disease  EBV in Other Cells Nasopharyngeal carcinoma Gastric carcinoma Nasal T/NK cell lymphomas Peripheral T cell lymphomas Oral hairy leukoplakia

Smooth muscle tumors in transplant patients

Diseases Associated with EBVSlide10

Diseases Driven by Epstein-Barr Virus

Infectious mononucleosisChronic Active EBV X-linked lymphoproliferative disease Lymphoproliferative diseaseOral hairy leukoplakia

Hodgkin disease EBV EBV-Driven

Nasopharyngeal carcinoma Gene Cell

T cell lymphoma Expression Proliferation

Burkitt lymphomaSlide11

Latency

Type

EBER

EBNA-1 EBNA-2 EBNA-3 LMP-1 LMP-2 Disease1 + + - - - - BL + + - - + + NPC, HD + + + + + + IM, LPD

Other + +/- - - - +/- Carrier

Patterns of EBV Latent InfectionSlide12

EBV+: 90% of cases in developing countries – jaw tumors

20% cases in US – children with abdominal tumors

AIDS patients – tumors in lymph nodes

EBV may be one “hit” but all tumors have c-myc translocationsDysregulation of c-myc oncogene

Only EBV EBNA-1 expressedTherapy: Chemotherapy

Burkitt Lymphoma

Slide13

EBV+: 60-70% of cases in developing countries

35-50% cases in US

EBV in Reed-Sternberg cells

Therapy: Chemotherapy, radiation Anti-EBV CTLs effective in some cases

Hodgkin Disease

LMP-1 expressionSlide14

EBV-Associated Smooth Muscle Tumors Occur in transplant recipients, AIDS patients, congenitial immunodeficiency

Pathology: leiomyosarcomas and leiomyomas in various organs (especially transplant) and lymph nodes

Some tumors regress with reduced immunosuppressionSlide15

EBV Lymphoproliferative Disease

Occurs with immunodeficiency (AIDS, congenital) or after transplantation, RA and MTX

Symptoms: Infectious Mononucleosis Mass lesions in organs (less often lymph nodes)

Risk Factors: Primary infection GVHD with increased immune suppression T cell depleted bone marrow CMV

Cohen NEJM 2000Slide16

Risk for EBV PTLDPrimary infection- higher viral loads, no memory T cells to EBVCMV infection

Polymorphisms corresponding to low production of IFN-

, TNF-; high levels of IL-10

Level of intensity of T cell immunosuppressionSlide17

EBV Viral Load is Increased in Patients

with Lymphoproliferative Disease

Riddler, Blood 1994

Viral Load Used to Monitor Transplant Patients: Increased EBV load at onset of LPD Used to initiate preemptive therapySlide18

Treatment of EBV Lymphoproliferative Disease

Reduce immunosuppression- Early, polymorphic lesions often responsive Later monomorphic lesions can have chromosomal changes

Excise localized lesions

Radiation therapy (for CNS lesions) or chemotherapy

Anti-CD20 monoclonal antibody (rituximab)Interferon-

For stem cell transplant recipients: donor lymphocyte infusions or donor EBV-specific cytotoxic T cell infusions

For solid organ transplant recipients: autologous or HLA-matched, EBV-specific, cytotoxic T cell infusionsSlide19

Cutaneous Lymphomas Associated with EBV-infected T cellsNon-immunosuppressed Patients More often in Asians

Hydroa vacciniforme: vesciulopapular lesions on face and hands, fever, can progress to T cell lymphoma

Angiocentric NK/T cell lymphomas:ulcers, vesicles, nodules, papules on nose, checks, lips, extremities, trunk

EBV subcutaneous T cell lymphoma: plaques, fever, hepatosplenomegaly, pancytopenia, panniculitis, hemophagocytosisSlide20

Cutaneous Lymphomas Associated with EBV-infected B cells

Immunosuppressed Patients

Cutaneous ulcerated nodules- B cell lymphomas after transplant or in patients with AIDS

Cutaneous B cell lymphomas in patients with rheumatoid arthritis or polymyositis receiving methotrexate- resolution in some after drug stoppedSlide21

EBV LPD More Common at Sites with Chronic InflammationDisease more frequent in transplanted organ Higher frequency of EBV+ cells Antigenic stimulation with B cell proliferation

Cytokine activation in organ

Reports of EBV+ pyothorax-associated pleural lymphomas at site of pleural inflammation after tuberculosis

(Arch Pathol Lab Med. 1996) Report of 3 cases of EBV+ large B cell lymphomas in patients with chronic inflammation (osteomyelitis- tumor at site of bone, chronic venous ulcers- tumor at site of ulcer) (J Pathol. 1997 )Slide22

Immunosuppressive Agents Associated with EBV LPDSteroids and AzathioprineMethotrexate: Patients with RA, Polymyositits

Antibodies: ATG: anti-thymocyte globulin ALG: anti-lymphocyte globulin OKT3: anti-CD3

Calcineurin inhibitors: cyclosporine, tacrolimus

SirolimusSlide23

Methotrexate, but not other Immunosuppressants, Induces EBV Lytic Replication

BMRF1

CY (100

g/ml)

Prednisone (10

m)

_

AZA (1

g/ml)

CsA (1

g/ml)

CY (10

g/ml)

MPA (10

g/ml)

Prednisone (1

m)

MTX (5

g/ml)

AZA (10

g/ml)

CsA (10

g/ml)

MPA (100

g/ml)

MTX (50

g/ml)

DRUG:

-actin

Feng et al JNCI 2004Slide24

Calcineurin Inhibitors and PTLD: Cyclosporine, TacrolimusInhibit generation of cytotoxic activityInduce expression of IL-6 and TGF-

 that supports B cell activation and proliferation

Enhance survival of EBV-transformed cells in vitro by protecting from Fas-mediated apoptosis

Lower doses of cyclosporine allow T cell responses to EBV in vitro and are associated with lower rates of lymphoma than higher dosesIn children tacrolimus is associated with a higher risk of LPD than cyclosporine in some, but not all studies.Slide25

Risk of PTLD in Pediatric Liver Transplant Recipients for Primary Tacrolimus Therapy

Cacciarelli et at Pediatric Transplantation 2001Slide26

Kaposi’s Sarcoma at the Site of Topical Tacrolimus

Cho et al. J. Am Acad Dermatol. 50:149-50, 2004

28 yo AIDS patient on HAART (CD 143) with psoriasis and seborrheic dermatitis treated with topical tacrolimus 0.1% ointment to axilla, groin, head for 1 month

Developed KS at these sites and in lungs while on tacrolimusSlide27

Lymphoma at Site of ATG or ALG InjectionsAge

Transplant

AT/LG Sites of Lymphoma Ref kidney horse buttock, nodes 1 kidney horse buttock, nodes, liver 232 heart rabbit thigh, brain, lung, nodes 3 heart rabbit thigh, chest wall, 3

abdominal nodes

1. Deodhar et al N Engl J Med 280:1104-6, 1969

2. Cotton et al. Transplantation 16:154-7, 1973; follow-up Herrera et al. Mil Med. 146:652-4, 1981

3. Weintraub and Warnke Transplantation 33:347, 1982Slide28

Lymphoma at Site of ALG

(Cotton et al 1973; Herrera et al 1981)

47 y.o. renal transplant recipient

thoracic duct canulation before and 3 wks after transplant to deplete lymphocytes; prednisone, azothioprine

Horse ALG i.m. in buttocks post transplant on x 14 d, 3 x/wk x 1 yr6 months after last ALG nodule at site >reticulum cell sarcoma (no EBV studies), immunosuppression reduced, radiation to site; One year later draining lymph nodes had histiocytic lymphoma, radiation (no EBV studies)

2 years later died of bacteremia-lymphoma in liverSlide29

Lymphoma at Site of ALG(Deodhar et al 1969)32 y.o. renal transplant recipient on azathioprine and prednisone

Rejection 7 months after transplant: treated with actinomycin C and graft irradiation

Horse ALG i.m. in buttocks: 6 weeks later nodule at site, enlarge over 10 months; excised-reticulum cell sarcoma with lymph node involvement (no EBV studies); died of OISlide30

Lymphoma at Site of ALG(Weintraub and Warnke 1982)7 patients with NHL/182 heart transplants, 2 developed lymphoma at site of ATG

32 yo cardiac transplant recipient underwent two allogeneic heart transplants

Developed high grade immunoblastic lymphoma in thigh at site of rabbit ATG, later in brain and lung

18 yo cardiac transplant recipient underwent two allogeneic heart transplants Developed large noncleaved cell lymphoma in thigh at site of rabbit ATG, later chest wall and abdomenSlide31

Summary: EBV LPD in Persons Receiving ImmunosuppressantsMost early, polymorphic lesions are EBV driven, and may respond to reduction in immunosuppression

Later monomorphic lesions may have chromosomal changes and often require chemotherapy

More common with primary EBV infection

May have genetic component (cytokine polymorphisms)More common at site of chronic inflammationSome occur at sites of local immunosuppression: ATG or ALG injection sites – all patients on other immunosuppression