EpsteinBarr Virus: Cancer and Immunosuppression

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Epstein-Barr Virus Cancer and Immunosuppression

• Jeffrey I. Cohen
• Head, Medical Virology Section
• Laboratory of Clinical Infectious Diseases
• NIH

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Pathogenesis of EBV Infection
Cohen
NEJM 2000
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Cellular Immune Responses Are Critical
For Control of EBV
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
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EBV Transforms B Cells In Vitro and the
Cells Express Limited Viral and Cellular Proteins
EBV LCLs
EBV Latency Proteins
Cell Genes Induced
Rickinson and Kieff, Fields Virology
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EBV Latency Proteins
Cohen NEJM 2000
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LMP-1 is the EBV Oncogene
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-?B Inhibits apoptosis
Upregulates Bcl-2, A20, Mcl-1
H E
LMP-1
(Kulwichit et al PNAS 1998)
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LMP-1 Mimics constitutively form of CD40 in B
cells
Thorley-Lawson, Nature Rev Immunol, 2001
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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 LPD

Liebowitz NEJM 1998
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Diseases Associated with EBV
EBV in B Cell Infectious mononucleosis X-Linke
d Lymphoproliferative Disease Chronic active
EBV Hodgkin Disease Burkitt Lymphoma Lymphopro
liferative 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  
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Diseases Driven by Epstein-Barr Virus
Infectious mononucleosis Chronic Active
EBV X-linked lymphoproliferative disease
Lymphoproliferative disease Oral hairy
leukoplakia Hodgkin disease
EBV EBV-Driven
Nasopharyngeal carcinoma Gene
Cell T cell lymphoma
Expression Proliferation Burkitt lymphoma
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Patterns of EBV Latent Infection

•  
• Latency
• Type EBER EBNA-1 EBNA-2 EBNA-3 LMP-1
  LMP-2 Disease
• 1 -
  - - - BL
• -
  - NPC, HD
• 
  IM, LPD
• Other /- -
  - - /- Carrier

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Burkitt Lymphoma
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 translocations Dysregulation
of c-myc oncogene Only EBV EBNA-1
expressed Therapy Chemotherapy
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Hodgkin Disease
  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
LMP-1 expression
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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
  immunosuppression

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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 2000
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Risk for EBV PTLD

• Primary infection- higher viral loads, no memory
  T cells to EBV
• CMV infection
• Polymorphisms corresponding to low production of
  IFN-?, TNF-? high levels of IL-10
• Level of intensity of T cell immunosuppression

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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 therapy
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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
  infusions

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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 lymphomasulcers,
  vesicles, nodules, papules on nose, checks, lips,
  extremities, trunk
• EBV subcutaneous T cell lymphoma plaques, fever,
  hepatosplenomegaly, pancytopenia, panniculitis,
  hemophagocytosis

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Cutaneous Lymphomas Associated with EBV-infected
B cellsImmunosuppressed 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
  stopped

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EBV LPD More Common at Sites with Chronic
Inflammation

• Disease 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 )

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Immunosuppressive Agents Associated with EBV LPD

• Steroids and Azathioprine
• Methotrexate Patients with RA, Polymyositits
• Antibodies
  ATG anti-thymocyte globulin
  ALG anti-lymphocyte globulin
  OKT3 anti-CD3
• Calcineurin inhibitors cyclosporine, tacrolimus
• Sirolimus

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Methotrexate, but not other Immunosuppressants,
Induces EBV Lytic Replication
Feng et al JNCI 2004
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Calcineurin Inhibitors and PTLD Cyclosporine,
Tacrolimus

• Inhibit generation of cytotoxic activity
• Induce 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 doses
• In children tacrolimus is associated with a
  higher risk of LPD than cyclosporine in some, but
  not all studies.

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Risk of PTLD in Pediatric Liver Transplant
Recipients for Primary Tacrolimus Therapy
                                                  
                                                 
Cacciarelli et at Pediatric Transplantation 2001
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Kaposis Sarcoma at the Site of Topical Tacrolimus
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 tacrolimus
Cho et al. J. Am Acad Dermatol. 50149-50, 2004
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Lymphoma at Site of ATG or ALG Injections

• Age Transplant AT/LG Sites of Lymphoma Ref
• kidney horse buttock, nodes
  1
• kidney horse buttock, nodes, liver
  2
• 32 heart rabbit thigh, brain,
  lung, nodes 3
• heart rabbit thigh, chest wall,
  3
• abdominal nodes

1. Deodhar et al N Engl J Med 2801104-6, 1969 2.
Cotton et al. Transplantation 16154-7, 1973
follow-up Herrera et al. Mil Med.
146652-4, 1981 3. Weintraub and Warnke
Transplantation 33347, 1982
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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 yr 6 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 liver
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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 OI

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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
  abdomen

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Summary EBV LPD in Persons Receiving
Immunosuppressants

• Most 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 inflammation
• Some occur at sites of local immunosuppression
  ATG or ALG injection sites all
  patients on other immunosuppression