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Zeng M, Jia Q, Chen J. Enhanced prognostic evaluation of diffuse large B-cell lymphoma: A comprehensive surveillance study incorporating Epstein-Barr virus infection status and immunohistochemical markers. J Med Virol 2024; 96:e29834. [PMID: 39092825 DOI: 10.1002/jmv.29834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 07/02/2024] [Accepted: 07/18/2024] [Indexed: 08/04/2024]
Abstract
Emerging biologic subsets and new prognostic markers are significantly important for aggressive diffuse large B-cell lymphoma (DLBCL). Nevertheless, the high cost of testing limits the availability of these tests in most hospitals, thus making prognostic judgment based on basic immunohistochemical testing, whole blood Epstein-Barr virus DNA (WBEBV) surveillance and clinical features advantageous for hospitals and patients with poor medical conditions. We included 647 DLBCL patients treated in our hospital from January 2009 to March 2023. Non-germinal center B-cell like, Ki-67, and International Prognostic Index (IPI) scores were related to cMYC/B-cell lymphoma 2 (Bcl-2)-double expression. Age, Epstein-Barr virus-encoded small RNA (EBER) positivity, and IPI scores were associated with mortality. The cutoffs for differential overall survival (OS) of age, WBEBV, Bcl-2, and cMYC were 57 years, 1514 copies/mL (baseline), 5.89 × 104 copies/mL (treatment), 40%, and 55%, respectively. EBER positivity was significantly associated with a worse OS. Patients with newly defined DE (Bcl-2 ≥ 40 and cMYC > 55) had a worse prognosis than controls (p = 0.04). We found that cMYC with an optimal cutoff of 47.5 could effectively predict high-grade DLBCL with an area under the curve of 0.912, and the specificity and sensitivity were 70.7% and 100%, respectively. Our study provides valuable insights into the prognostic factors and biomarker cutoffs that influence OS in DLBCL patients, which may guide clinicians in tailoring treatment strategies and improving patient outcomes.
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Affiliation(s)
- Meichun Zeng
- Department of Pathology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Qingjun Jia
- Hangzhou Center for Disease Control and Prevention (Hangzhou Health Supervision Institution), Hangzhou, China
| | - Jingjing Chen
- Department of Pathology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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2
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Sakaguchi M, Nagata Y, Terasaki Y, Takeyoshi A, Yasuda S, Honma S, Kinoshita R, Marumo A, Asayama T, Yui S, Wakita S, Okamoto M, Kajimoto Y, Inokuchi K, Yamaguchi H. Epstein-Barr Virus-Related Hemophagocytic Lymphohistiocytosis with Central Nervous System Symptoms. J NIPPON MED SCH 2023; 90:126-135. [PMID: 36436914 DOI: 10.1272/jnms.jnms.2023_90-105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) involves pathological histiocytes and phagocytosis of normal blood cells through activation of inflammatory cytokines. We report a case of Epstein-Barr virus-HLH in a 75-year-old woman who presented with fever, thrombocytopenia, and loss of consciousness. Epstein-Barr virus-HLH was diagnosed after we identified massive hemophagocytosis in bone marrow and Epstein-Barr virus DNA in cerebrospinal fluid. The HLH-2004 protocol was applied, and lactate dehydrogenase levels-which reflect HLH disease status-decreased. However, persistent loss of consciousness and multiple organ failure led to the patient's death on day 18. Most cases of primary and secondary HLH involve pediatric patients; adult cases are rare. Few cases of central nervous system involvement in older adults have been reported. Therefore, accumulation of more data will help in developing better treatment strategies.
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Affiliation(s)
| | | | - Yasuhiro Terasaki
- Department of Analytic Human Pathology, Nippon Medical School.,Division of Pathology, Nippon Medical School Hospital
| | | | | | | | | | | | | | | | | | | | - Yusuke Kajimoto
- Department of Analytic Human Pathology, Nippon Medical School
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Kirkegaard MK. Ocular adnexal lymphoma: Subtype‐specific clinical and genetic features. Acta Ophthalmol 2022; 100 Suppl 270:3-37. [DOI: 10.1111/aos.15248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Marina Knudsen Kirkegaard
- Department of Pathology, Eye Section, Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
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4
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Song J, Kim JY, Kim S, Park Y. Utility of Epstein-Barr Viral Load in Blood for Diagnosis and Predicting Prognosis of Lymphoma: A Comparison with Epstein-Barr Virus-Encoded RNA in Situ Hybridization. J Mol Diagn 2022; 24:977-991. [PMID: 35718093 DOI: 10.1016/j.jmoldx.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 04/09/2022] [Accepted: 06/07/2022] [Indexed: 10/18/2022] Open
Abstract
Epstein-Barr virus (EBV) is a ubiquitous pathogen that persists in a small portion of B cells after primary infection and is etiologically associated with multiple lymphoma subtypes. Herein, we evaluated the clinical utility of EBV real-time quantitative PCR in comparison with the widely used Epstein-Barr virus-encoded RNA (EBER) in situ hybridization (ISH) method in 912 patients with four lymphoma subtypes: diffuse large B-cell lymphoma (DLBCL), extranodal natural killer/T-cell lymphoma (ENKTCL), peripheral T-cell lymphoma (PTCL), and Hodgkin lymphoma. We also assessed the impact of EBV positivity determined from each method or a combination of both methods on mortality using Kaplan-Meier survival analysis and Cox proportional hazard regression. EBV real-time quantitative PCR identified more positive cases than EBER-ISH for all subtypes, except ENKTCL. EBV DNA-positive patients with ENKTCL and PTCL displayed poorer overall survival (OS) than EBV DNA-negative patients (P = 0.0016 and P = 0.0013, respectively). In addition, among those with EBER-positive DLBCL and ENKTL and those with EBER-negative PTCL, OS was significantly worse for EBV DNA-positive patients (P = 0.027, P = 0.0016, and P = 0.0018, respectively). EBER positivity was associated with worse OS for DLBCL (P = 0.037), in reanalyses including only the 862 patients with unambiguous EBER-ISH results. Overall, EBV DNA positivity is a more effective prognostic marker than EBER-ISH status for patients with certain lymphoma subtypes.
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Affiliation(s)
- Junhyup Song
- Department of Laboratory Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Yong Kim
- Department of Pathology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sinyoung Kim
- Department of Laboratory Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Younhee Park
- Department of Laboratory Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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5
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Wong Y, Meehan MT, Burrows SR, Doolan DL, Miles JJ. Estimating the global burden of Epstein-Barr virus-related cancers. J Cancer Res Clin Oncol 2022; 148:31-46. [PMID: 34705104 PMCID: PMC8752571 DOI: 10.1007/s00432-021-03824-y] [Citation(s) in RCA: 90] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 09/28/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND More than 90% of the adult population globally is chronically infected by the Epstein-Barr virus (EBV). It is well established that EBV is associated with a number of malignancies, and advances in knowledge of EBV-related malignancies are being made every year. Several studies have analysed the global epidemiology and geographic distribution of EBV-related cancers. However, most have only described a single cancer type or subtype in isolation or limited their study to the three or four most common EBV-related cancers. This review will present an overview on the spectrum of cancers linked to EBV based on observations of associations and proportions in the published literature while also using these observations to estimate the incidence and mortality burden of some of these cancers. METHOD We have reviewed the literature on defining features, distribution and outcomes across six cancers with a relatively large EBV-related case burden: Nasopharyngeal carcinoma (NPC), Gastric carcinoma (GC), Hodgkin lymphoma (HL), Burkitt lymphoma (BL), Diffuse large B-cell lymphoma (DLBCL) and Extranodal NK/T-cell lymphoma, Nasal type (ENKTL-NT). We retrieved published region-specific EBV-related case proportions for NPC, GC, HL and BL and performed meta-analyses on pooled region-specific studies of EBV-related case proportions for DLBCL and ENKTL-NT. We match these pooled proportions with their respective regional incidence and mortality numbers retrieved from a publicly available cancer database. Additionally, we also reviewed the literature on several other less common EBV-related cancers to summarize their key characteristics herein. CONCLUSION We estimated that EBV-related cases from these six cancers accounted for 239,700-357,900 new cases and 137,900-208,700 deaths in 2020. This review highlights the significant global impact of EBV-related cancers and extends the spectrum of disease that could benefit from an EBV-specific therapeutic.
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Affiliation(s)
- Yide Wong
- Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, QLD, 4878, Australia.
- Centre for Molecular Therapeutics, James Cook University, Cairns, QLD, 4870, Australia.
- Centre for Tropical Bioinformatics and Molecular Biology, James Cook University, Cairns, QLD, 4878, Australia.
| | - Michael T Meehan
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, 4811, Australia
| | - Scott R Burrows
- QIMR Berghofer Medical Research Institute, Herston, QLD, 4006, Australia
- Faculty of Medicine, The University of Queensland, Herston, QLD, 4006, Australia
| | - Denise L Doolan
- Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, QLD, 4878, Australia
- Centre for Molecular Therapeutics, James Cook University, Cairns, QLD, 4870, Australia
- Centre for Tropical Bioinformatics and Molecular Biology, James Cook University, Cairns, QLD, 4878, Australia
| | - John J Miles
- Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, QLD, 4878, Australia
- Centre for Molecular Therapeutics, James Cook University, Cairns, QLD, 4870, Australia
- Centre for Tropical Bioinformatics and Molecular Biology, James Cook University, Cairns, QLD, 4878, Australia
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6
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Chabay P. Advances in the Pathogenesis of EBV-Associated Diffuse Large B Cell Lymphoma. Cancers (Basel) 2021; 13:2717. [PMID: 34072731 PMCID: PMC8199155 DOI: 10.3390/cancers13112717] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/18/2021] [Accepted: 05/27/2021] [Indexed: 11/16/2022] Open
Abstract
Diffuse large B-cell lymphoma (DLBCL) is the most common non-Hodgkin's lymphoma (NHL) in adults. Epstein-Barr virus (EBV) positive DLBCL of the elderly was defined by the World Health Organization (WHO) in 2008, it was restricted only to patients older than 50 years old, and it was attributed to immunesenescence associated with physiological aging. After the description of EBV-associated DLBCL in children and young adults, the WHO redefined the definition, leading to the substitution of the modifier "elderly" with "not otherwise specified" (EBV + DLBCL, NOS) in the updated classification, and it is no more considered provisional. The incidence of EBV + DLBCL, NOS varies around the world, in particular influenced by the percentage of EBV+ cells used as cut-off to define a case as EBV-associated. EBV has effect on the genetic composition of tumor cells, on survival, and at the recruitment of immune cells at the microenvironment. In this review, the role of EBV in the pathogenesis of DLBCL is discussed.
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Affiliation(s)
- Paola Chabay
- Laboratory of Molecular Biology, Pathology Division, Multidisciplinary Institute for Investigation in Pediatric Pathologies (IMIPP-CONICET-GCBA), Ricardo Gutiérrez Children's Hospital, Gallo 1330, Buenos Aires C1425EFD, Argentina
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7
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The Incidence of Epstein-Barr Virus-Positive Diffuse Large B-Cell Lymphoma: A Systematic Review and Meta-Analysis. Cancers (Basel) 2021; 13:cancers13081785. [PMID: 33917961 PMCID: PMC8068359 DOI: 10.3390/cancers13081785] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 04/03/2021] [Accepted: 04/05/2021] [Indexed: 11/23/2022] Open
Abstract
Simple Summary The worldwide prevalence of Epstein-Barr virus-positive (EBV+) diffuse large B-cell lymphoma (DLBCL) is undetermined. There is no clearly defined cut-off for EBV-encoded RNA (EBER) positivity in tumor cells by in situ hybridization. A lack of common criteria for positive expression of EBER has been raised as a limitation for interpreting and understanding the geographic and ethnic disparity of prevalence of EBV+ DLBCL. We conducted a systematic literature review and meta-analysis to establish the proportions of EBV+ DLBCL patients. Results showed that the pooled proportion of EBER positivity was 7.9% in patients with de novo DLBCL. The prevalence of EBV+ DLBCL was significantly higher in Asia and South America compared with Western countries. A tendency for lower pooled proportions was observed in studies using a higher cut-off for EBER positivity. The patients’ age did not significantly affect the prevalence. These findings may improve our current knowledge of the EBV+ DLBCL. Abstract The worldwide prevalence of Epstein-Barr virus-positive (EBV+) diffuse large B-cell lymphoma (DLBCL) is undetermined. There is no clearly defined cut-off for EBV-encoded RNA (EBER) positivity in tumor cells by in-situ hybridization. The purpose of this study was to establish the proportions of EBV+ DLBCL patients and influence of the different cut-offs for EBER positivity, geographical location, and age on the prevalence of EBV+ DLBCL. PubMed and EMBASE were searched for studies published up to May 28, 2020 that reported proportions of EBER positivity in immunocompetent and de novo DLBCL patients. The pooled proportions were computed by an inverse variance method for calculating the weights and the DerSimonian–Laird method. Multiple subgroup analyses were conducted to explore any heterogeneity. Thirty-one studies (8249 patients) were included. The pooled proportion of EBV+ DLBCL was 7.9% (95% CI, 6.2–10.0%) with significant heterogeneity among studies (p < 0.001). The prevalence of EBV+ DLBCL was significantly higher in Asia and South America compared with Western countries (p < 0.01). The cut-offs for EBER positivity (10%, 20%, 50%) and patients’ age (≥50 years vs. <50 years) did not significantly affect the prevalence (p ≥ 0.10). EBV+ DLBCL is rare with a pooled proportion of 7.9% in patients with DLBCL and the geographic heterogeneity was confirmed.
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8
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Lanamtieng T, Teawtrakul N, Ungarreevittaya P. Prevalence and clinical characteristics of EBV-positive diffuse large B-cell lymphoma in adult patients: a single center study in Thailand. Leuk Lymphoma 2020; 61:2262-2264. [PMID: 32406784 DOI: 10.1080/10428194.2020.1765240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Theerin Lanamtieng
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Nattiya Teawtrakul
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Piti Ungarreevittaya
- Department of Pathology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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9
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Holm A, Schindele A, Allard A, Eriksson I, Sandström K, Laurell G, Nylander K, Olofsson K. Mapping of human papilloma virus, p16, and epstein-barr virus in non-malignant tonsillar disease. Laryngoscope Investig Otolaryngol 2019; 4:285-291. [PMID: 31236460 PMCID: PMC6580074 DOI: 10.1002/lio2.260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 03/04/2019] [Accepted: 03/11/2019] [Indexed: 12/30/2022] Open
Abstract
Objectives Due to their location in the entrance of the aero-digestive tract, tonsils are steadily exposed to viruses. Human papilloma virus (HPV) and Epstein-Barr virus (EBV) are two potentially oncogenic viruses that tonsils encounter. The incidence of HPV positive tonsillar cancer is on the rise and it is unknown when infection with HPV occurs. Aim To investigate if tonsils are infected with HPV and EBV, to study the co-expression of HPV and its surrogate marker p16, and to evaluate the number of EBV positive cells in benign tonsillar disease. Materials and Methods Tonsils from 40 patients in a university hospital were removed due to hypertrophy, chronic or recurrent infection. These were analyzed for presence of HPV, its surrogate marker p16, and EBV. HPV was studied using PapilloCheck (a PCR method), while p16 was identified in epithelial and lymphoid tissue with immunohistochemistry and EBV using EBER-ISH (Epstein-Barr encoding region-in situ hybridization). Results HPV was not detected, and p16 was present at low numbers in all epithelial samples as well as in 92.5% of the lymphoid tonsillar samples. At least one EBER-positive cell was seen in 65% of cases. Larger numbers of EBER-expressing cells were only seen in two cases. Conclusion These findings demonstrate that EBV and HPV infect tonsils independently, but further studies are warranted to confirm their infectious relationship. Level of Evidence Cross-sectional study.
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Affiliation(s)
- Anna Holm
- Division of Otorhinolaryngology, Department of Clinical Sciences Uppsala University Uppsala Sweden
| | - Alexandra Schindele
- Division of Otorhinolaryngology, Department of Clinical Sciences Uppsala University Uppsala Sweden.,Department of Ear, Nose and Throat Östersunds hospital, Jämtland/Härjedalen County Council, Uppsala University Uppsala Sweden
| | - Annika Allard
- Division of Clinical Virology, Department of Clinical Microbiology Uppsala University Uppsala Sweden
| | - Irene Eriksson
- Division of Clinical Virology, Department of Clinical Microbiology Uppsala University Uppsala Sweden
| | - Karl Sandström
- Division of Otorhinolaryngology, Department of Surgical Sciences Uppsala University Uppsala Sweden
| | - Göran Laurell
- Division of Otorhinolaryngology, Department of Surgical Sciences Uppsala University Uppsala Sweden
| | | | - Katarina Olofsson
- Division of Otorhinolaryngology, Department of Clinical Sciences Uppsala University Uppsala Sweden
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10
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Gao X, Li J, Wang Y, Liu S, Yue B. Clinical characteristics and prognostic significance of EBER positivity in diffuse large B-cell lymphoma: A meta-analysis. PLoS One 2018; 13:e0199398. [PMID: 29920566 PMCID: PMC6007832 DOI: 10.1371/journal.pone.0199398] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 06/06/2018] [Indexed: 12/15/2022] Open
Abstract
Recent studies show that Epstein-Barr virus (EBV) positivity might be related to adverse prognosis in patients with diffuse large B-cell lymphoma (DLBCL), but the results are still inconclusive. We conducted this meta-analysis to define the clinical value of EBV infection in DLBCL. All potential articles in PubMed, Web of Science, Medline, and Embase were retrieved. Using the random-effects or fixed-effect model, pooled hazard ratios (HRs) or relative risk (RR) with 95% confidence intervals (CIs) were used to calculate the correlation between EBER and prognosis and clinical features in DLBCL. A total of 13 qualified studies with 4111 patients were identified in our meta-analysis based on the inclusion and exclusion criteria. The overall estimates revealed that EBV-encoded small RNAs (EBER) positivity was significantly correlated with worse overall survival (HR = 2.43, 95% CI: 1.73–3.36) and progression-free survival (HR = 3.60, 95% CI: 2.07–6.26). In addition, EBER positivity was associated with age older than 60 years (RR = 1.51, 95% CI: 1.02–2.24), male sex (RR = 1.34, 95% CI: 1.05–1.71), more advanced stage (RR = 2.25, 95% CI: 1.72–2.96), high international prognostic index (RR = 2.20, 95% CI: 1.71–2.82), more than one extranodal involvement (RR = 1.69, 95% CI: 1.27–2.26), presence of B symptom (RR = 1.75, 95% CI: 1.30–2.35), non-germinal center B-cell subtype (RR = 1.35, 95% CI: 1.03–1.78), and elevated lactate dehydrogenase levels (RR = 1.30, 95% CI: 0.98–1.72). EBER positivity was correlated with worse outcomes, worse clinical course, and adverse clinicopathologic features among patients with DLBCL.
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MESH Headings
- Disease-Free Survival
- Herpesvirus 4, Human/genetics
- Herpesvirus 4, Human/isolation & purification
- Herpesvirus 4, Human/pathogenicity
- Humans
- Lymphoma, Large B-Cell, Diffuse/epidemiology
- Lymphoma, Large B-Cell, Diffuse/pathology
- Lymphoma, Large B-Cell, Diffuse/virology
- Prognosis
- RNA, Viral/genetics
- RNA, Viral/isolation & purification
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Affiliation(s)
- Xiaojuan Gao
- Department of Laboratory Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, P. R. China
- Faculty of Laboratory Medicine, Zhengzhou University, Zhengzhou, P. R. China
| | - Jia Li
- Department of Laboratory Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, P. R. China
- Faculty of Laboratory Medicine, Zhengzhou University, Zhengzhou, P. R. China
| | - Yaqi Wang
- Department of Laboratory Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, P. R. China
- Faculty of Laboratory Medicine, Zhengzhou University, Zhengzhou, P. R. China
| | - Shuai Liu
- Department of Laboratory Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, P. R. China
- Faculty of Laboratory Medicine, Zhengzhou University, Zhengzhou, P. R. China
- Key Laboratory Medicine of Henan Province, Faculty of Laboratory Medicine of Zhengzhou University, Zhengzhou, P. R. China
| | - Baohong Yue
- Department of Laboratory Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, P. R. China
- Faculty of Laboratory Medicine, Zhengzhou University, Zhengzhou, P. R. China
- Key Laboratory Medicine of Henan Province, Faculty of Laboratory Medicine of Zhengzhou University, Zhengzhou, P. R. China
- Open Laboratory, Henan Province Key Subject of Clinical Medicine, Zhengzhou, P. R. China
- * E-mail:
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11
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Tracy SI, Habermann TM, Feldman AL, Maurer MJ, Dogan A, Perepu US, Syrbu S, Ansell SM, Thompson CA, Weiner GJ, Nowakowski GS, Allmer C, Slager SL, Witzig TE, Cerhan JR, Link BK. Outcomes among North American patients with diffuse large B-cell lymphoma are independent of tumor Epstein-Barr virus positivity or immunosuppression. Haematologica 2017; 103:297-303. [PMID: 29170255 PMCID: PMC5792274 DOI: 10.3324/haematol.2017.176511] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 11/22/2017] [Indexed: 12/12/2022] Open
Abstract
The prevalence, presenting clinical and pathological characteristics, and outcomes for patients with diffuse large B-cell lymphoma that is Epstein-Barr virus positive remain uncertain as does the impact of congenital or iatrogenic immunosuppression. Patients with newly diagnosed diffuse large B-cell lymphoma with available tissue arrays were identified from the University of Iowa/Mayo Clinic Molecular Epidemiology Resource. Patients infected with human immunodeficiency virus or who had undergone a prior organ transplant were excluded. Epstein-Barr virus-associated ribonucleic acid testing was performed on all tissue arrays. A history of significant congenital or iatrogenic immunosuppression was determined for all patients. At enrollment, 16 of the 362 (4.4%) biopsies were positive for Epstein-Barr virus. Thirty-nine (10.8%) patients had a significant history of immunosuppression. Patients with Epstein-Barr-positive diffuse large B-cell lymphoma had no unique clinical characteristics but on pathology exhibited a higher frequency of CD30 positivity (25.0% versus 8.1%, respectively; P<0.01), and non-germinal-center subtype (62.5% versus 34.1%, respectively; P<0.01). No baseline clinical characteristics were associated with a history of immunosuppression. With a median follow up of 59 months, and after adjustment for International Prognostic Index, there was no association of Epstein-Barr virus positivity or immunosuppression with event-free survival at 24 months (odds ratio=0.49; 95% confidence interval: 0.13–1.84 and odds ratio=0.81; 95% confidence interval: 0.37–1.77) or overall survival (hazard ratio=0.86; 95% confidence interval: 0.38–1.97 and hazard ratio=1.00; 95% confidence interval: 0.57–1.74). In contrast to non-Western populations, our North American population had a low prevalence of Epstein-Barr virus-positive diffuse large B-cell lymphoma that did not convey an adverse prognosis. A history of immunosuppression, while known to be a risk factor for the development of diffuse large B-cell lymphoma, did not affect subsequent prognosis.
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Affiliation(s)
| | | | | | | | - Ahmet Dogan
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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12
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Ohashi A, Kato S, Okamoto A, Inaguma Y, Satou A, Tsuzuki T, Emi N, Okamoto M, Nakamura S. Reappraisal of Epstein-Barr virus (EBV) in diffuse large B-cell lymphoma (DLBCL): comparative analysis between EBV-positive and EBV-negative DLBCL with EBV-positive bystander cells. Histopathology 2017; 71:89-97. [PMID: 28231401 DOI: 10.1111/his.13197] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 02/20/2017] [Indexed: 12/28/2022]
Abstract
AIMS Epstein-Barr virus (EBV)-positive diffuse large B-cell lymphoma (DLBCL) not otherwise specified is defined as monoclonal EBV+ B-cell proliferation affecting patients without any known immunosuppression. Non-neoplastic EBV+ cells proliferating in or adjacent to EBV- DLBCL were reported recently, but their clinical significance is unclear. Thus, the aim of this study was to investigate the prognostic impact of EBV+ cells in DLBCL. METHODS AND RESULTS We compared the clinicopathological characteristics of 30 EBV+ DLBCL patients and 29 and 604 EBV- DLBCL patients with and without EBV+ bystander cells (median age of onset 71, 67 and 62 years, respectively). Both EBV+ DLBCL patients and EBV- DLBCL patients with EBV+ bystander cells tended to have high and high-intermediate International Prognostic Index scores (60% and 59%, respectively), as compared with only 46% of EBV- DLBCL patients without EBV+ bystander cells. EBV- DLBCL patients with EBV+ bystander cells showed a significantly higher incidence of lung involvement than those without EBV+ bystander cells (10% versus 2%, P < 0.05). Furthermore, EBV+ DLBCL patients and EBV- DLBCL patients with EBV+ bystander cells had a poorer prognosis than patients without any detectable EBV+ cells [median overall survival (OS) of 100 months and 40 months versus not reached, P < 0.01]. Notably, EBV+ DLBCL patients and EBV- DLBCL patients with EBV+ bystander cells treated with rituximab showed overlapping survival curves (OS, P = 0.77; progression-free survival, P = 1.0). CONCLUSIONS EBV- DLBCL with bystander EBV+ cells has similar clinical characteristics to EBV+ DLBCL. DLBCL with EBV+ bystander cells may be related to both age-related and microenvironment-related immunological deterioration.
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Affiliation(s)
- Akiko Ohashi
- Department of Surgical Pathology, Aichi Medical University Hospital, Nagakute, Japan.,Department of Pathology and Laboratory Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Seiichi Kato
- Department of Pathology and Laboratory Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Akinao Okamoto
- Department of Haematology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yoko Inaguma
- Department of Haematology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Akira Satou
- Department of Surgical Pathology, Aichi Medical University Hospital, Nagakute, Japan.,Department of Pathology and Laboratory Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Toyonori Tsuzuki
- Department of Surgical Pathology, Aichi Medical University Hospital, Nagakute, Japan
| | - Nobuhiko Emi
- Department of Haematology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Masataka Okamoto
- Department of Haematology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Shigeo Nakamura
- Department of Pathology and Laboratory Medicine, Nagoya University Hospital, Nagoya, Japan
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13
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Stuhlmann-Laeisz C, Borchert A, Quintanilla-Martinez L, Hoeller S, Tzankov A, Oschlies I, Kreuz M, Trappe R, Klapper W. In Europe expression of EBNA2 is associated with poor survival in EBV-positive diffuse large B-cell lymphoma of the elderly. Leuk Lymphoma 2016; 57:39-44. [PMID: 25899404 DOI: 10.3109/10428194.2015.1040014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Epstein-Barr virus (EBV)-positive diffuse large B-cell lymphoma (DLBCL) of the elderly occurs by definition in patients above the age of 50 years without any known underlying immunodeficiency. We investigated the incidence and clinical relevance of this subtype in Europe with special attention to the EBV-latency type. Among the 598 DLBCL, 15 EBV-positive lymphomas fulfilling the criteria of EBV-positive DLBCL of the elderly were identified (2.5%). Patients with EBV-positive DLBCL expressing EBNA2 showed a significantly poorer overall survival than patients with EBNA2-negative EBV-positive DLBCL (p = 0.0156). The incidence of EBV-positive DLBCL of the elderly in Europe is much lower than in Asian countries (2.5% of all cases of DLBCL). Interestingly, the likelihood of EBV positivity did not increase with age in patient above 50 years. Among EBV-positive DLBCL of the elderly a subgroup with EBV-latency type III expressing EBNA2 can be identified, which shows a poor outcome.
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Affiliation(s)
| | - Alisa Borchert
- a Department of Pathology , Hematopathology Section and Lymph Node Registry, University of Kiel , Germany
| | | | - Sylvia Hoeller
- c Department of Pathology , University of Basel , Switzerland
| | | | - Ilske Oschlies
- a Department of Pathology , Hematopathology Section and Lymph Node Registry, University of Kiel , Germany
| | | | - Ralf Trappe
- e Second Department of Medicine , University of Kiel , Germany and 5 DIAKO Bremen , Bremen Germany
| | - Wolfram Klapper
- a Department of Pathology , Hematopathology Section and Lymph Node Registry, University of Kiel , Germany
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14
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Ikeda JI, Wada N, Nojima S, Tahara S, Tsuruta Y, Oya K, Morii E. ID1 upregulation and FoxO3a downregulation by Epstein-Barr virus-encoded LMP1 in Hodgkin's lymphoma. Mol Clin Oncol 2016; 5:562-566. [PMID: 27900085 DOI: 10.3892/mco.2016.1012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 07/25/2016] [Indexed: 11/06/2022] Open
Abstract
Cancer-initiating cells (CICs) are specialized cells that have the ability to self-renew and are multipotent. We recently demonstrated that Forkhead box O3a (FoxO3a)-expressing cells exhibited a CIC-like potential in Hodgkin's lymphoma (HL). A proportion of HL patients are infected with Epstein-Barr virus (EBV). EBV-encoded latent membrane protein (LMP) 1 downregulates FoxO3a, suggesting that FoxO3a expression may be abolished in EBV-positive HL. Inhibitors of DNA-binding (ID) proteins are highly conserved transcription factors mediating stem cell functions. To the best of our knowledge, no study has investigated possible associations among ID1, FoxO3a and LMP1 expression in HL to date. We immunohistochemically evaluated the expression of the three abovementioned factors in HL patients. The ID1 expression level was inversely correlated with that of FoxO3a (P=0.00035). LMP1-positive HL cells abundantly expressed ID1 (P=0.029), but not FoxO3a (P=0.00085). Thus, our previous observation that FoxO3a may serve as a marker of CICs may not be applicable in EBV-positive HL patients, but rather ID1 may be a candidate CIC marker in this type of HL.
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Affiliation(s)
- Jun-Ichiro Ikeda
- Department of Pathology, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Naoki Wada
- Department of Pathology, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Satoshi Nojima
- Department of Pathology, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Shinichiro Tahara
- Department of Pathology, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Yoko Tsuruta
- Department of Pathology, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Kaori Oya
- Department of Pathology, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Eiichi Morii
- Department of Pathology, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
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15
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Jöhrens K, Trappe RU, Lenze D, Pfreundschuh M, Ziepert M, Hummel M, Anagnostopoulos I. Age and cellular composition influence overall survival in a collective of non-immunocompromised patients with EBV-positive diffuse large B-cell lymphoma from a German lymphoma center. Leuk Lymphoma 2016; 57:2791-2803. [PMID: 27122390 DOI: 10.3109/10428194.2016.1169406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We investigated 41 diffuse large B-cell lymphomas (DLBCL) diagnosed at one center harboring ≥50% of latently Epstein-Barr virus (EBV)-infected neoplastic cells occurring in 34 patients aged ≥50 years and in 7 patients younger than 50 years in the absence of any known immunodeficiency for the expression patterns of EBV latent and immediate-early proteins, for the differentiation stage of the neoplastic cells, the presence of cytogenetic alterations and a possible co-infection with the human herpes virus (HHV)-8. Here, we show that EBV-positive DLBCLs rarely arise from naïve and more frequently from post-germinal center B-cells that often contain crippling immunoglobulin gene mutations. Most of the lymphomas did not exhibit breaks in the BCL2, BCL6, and MYC genes and none of the cases investigated contained HHV-8 sequences. Patients aged <50 years performed better than older ones while in patients aged ≥50 years only the cellular composition had an impact on overall survival.
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Affiliation(s)
- Korinna Jöhrens
- a Institute of Pathology, Charité - Medical University Berlin , Berlin , Germany
| | | | - Dido Lenze
- a Institute of Pathology, Charité - Medical University Berlin , Berlin , Germany
| | - Michael Pfreundschuh
- c Department of Medicine I , Saarland University Medical School , Homburg , Germany
| | - Marita Ziepert
- d Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig , Leipzig , Germany
| | - Michael Hummel
- a Institute of Pathology, Charité - Medical University Berlin , Berlin , Germany
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16
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Abstract
Epstein-Barr virus (EBV) infection is a common feature of B cell lymphoproliferative disorders (LPDs), including diffuse large B cell lymphoma. Approximately 10 % of DLBCLs are EBV-positive, with the highest incidence in immunocompromised and elderly patients. Here, we review the clinical, genetic, and pathologic characteristics of DLBCL and discuss the molecular role of EBV in lymphoma tumorigenesis. Using EBV-positive DLBCL of the elderly as a model, we describe the key features of EBV-positive DLBCL. Studies of EBV-positive DLBCL of the elderly demonstrate that EBV-positive DLBCL has a distinct biology, related to both viral and host factors. The pathogenic mechanisms noted in EBV-positive DLBCL of the elderly, including enhanced NFκB activity, are likely to be a generalizable feature of EBV-positive DLBCL. Therefore, we review how this information might be used to target the EBV or its host response for the development of novel treatment strategies.
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17
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Battle-Lopez A, Gonzalez de Villambrosia S, Nuñez J, Cagigal ML, Montes-Moreno S, Conde E, Piris MA. Epstein-Barr virus-associated diffuse large B-cell lymphoma: diagnosis, difficulties and therapeutic options. Expert Rev Anticancer Ther 2016; 16:411-21. [PMID: 26838128 DOI: 10.1586/14737140.2016.1149065] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Epstein Barr Virus (EBV)-positive diffuse large B cell lymphoma (DLBCL) most frequently affects elderly patients, without previous immunosuppression, with frequent extra-nodal involvement and whose disease runs an aggressive clinical course with high International Prognostic Index (IPI) scores. Various EBV-related transforming mechanisms, much favored by immunosenescence, have been described, including activation of the NFKB transcriptional program. Elderly patients show poor survival after treatment with conventional CHOP regimens, even after addition of Rituximab. Younger patients, however, have a better outcome with a similar prognosis to EBV-negative DLBCL cases. New therapeutic strategies, including treatments targeting EBV, new drugs directed against specific pathways constitutively activated in these lymphomas, and new specific conjugate antibodies against molecules usually expressed in the tumor cells, such as CD30, are described.
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Affiliation(s)
- Ana Battle-Lopez
- a Services of Haematology and Pathology , Hospital Universitario Marques de Valdecilla , Santander , Spain
| | | | - Javier Nuñez
- a Services of Haematology and Pathology , Hospital Universitario Marques de Valdecilla , Santander , Spain
| | - Maria-Luisa Cagigal
- a Services of Haematology and Pathology , Hospital Universitario Marques de Valdecilla , Santander , Spain
| | - Santiago Montes-Moreno
- a Services of Haematology and Pathology , Hospital Universitario Marques de Valdecilla , Santander , Spain
| | - Eulogio Conde
- a Services of Haematology and Pathology , Hospital Universitario Marques de Valdecilla , Santander , Spain
| | - Miguel A Piris
- a Services of Haematology and Pathology , Hospital Universitario Marques de Valdecilla , Santander , Spain
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18
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Andrade TAD, Evangelista AF, Campos AHF, Poles WA, Borges NM, Camillo CMC, Soares FA, Vassallo J, Paes RP, Zerbini MC, Scapulatempo C, Alves AC, Young KH, Colleoni GWB. A microRNA signature profile in EBV+ diffuse large B-cell lymphoma of the elderly. Oncotarget 2015; 5:11813-26. [PMID: 25544772 PMCID: PMC4322989 DOI: 10.18632/oncotarget.2952] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 12/09/2014] [Indexed: 12/27/2022] Open
Abstract
Currently, there is no characteristic microRNA (miRNA) expression pattern in Epstein-Barr virus+ diffuse large B-cell lymphoma of the elderly (EBV+DLBCLe). This study aims to characterize a signature profile and identify miRNAs that can be used as biomarkers and alternative therapeutic targets for EBV+DLBCLe. Seventy-one DLBCL patients aged 50 years and older were included and four EBV+ and four EBV– samples were analyzed in two miRNA array platforms (pilot study). A larger multicenter cohort (29 EBV+DLBCLe and 65 EBV–DLBCL patients) was used to validate the results by real-time polymerase chain reaction. In the pilot study, 9% of DLBCL were EBV+DLBCLe by in situ hybridization. In multicenter study, EBV+DLBCLe group showed a predominance of non-germinal center B-cell origin. Overall survival duration of EBV+DLBCLe was significantly inferior to that of EBV–DLBCL patients. We found 10 deregulated miRNAs in the two groups, but only seven were statistically different. We confirmed overexpression of hsa-miR-126, hsa-miR-146a, hsa-miR-146b, hsa-miR-150, and hsa-miR-222 and underexpression of hsa-miR-151 in EBV+DLBCLe cases compared to EBV–DLBCL cases. Hsa-miR-146b and hsa-miR-222 showed high specificity for identifying EBV+DLBCLe. The present study proposed a miRNA signature for EBV+DLBCLe and our findings suggest that hsa-miR-146b and hsa-miR-222 could be biomarkers and therapeutic targets.
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Affiliation(s)
| | | | | | | | | | | | | | - Jose Vassallo
- A.C. Camargo Cancer Center, Sao Paulo, Brazil. Universidade de Campinas, Campinas, Brazil
| | | | | | | | | | - Ken H Young
- Department of Hematopathology, MD Anderson Cancer Center, Houston, Texas, USA
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19
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20
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Abstract
Epstein-Barr virus (EBV) positive diffuse large B-cell lymphoma (DLBCL) of the elderly is defined as patients older than 50 years alone. However, recent studies showed young patients with sound immune status could also be affected. In this study, we investigated the clinical features and outcomes of patients with EBV positive DLBCL in the different age groups using different EBER cut-off values. The prevalence of EBV positive DLBCL was 14.0% (35/250) and 10.4% (26/250) for EBER cut-off of 20% and 50%, respectively. With both EBER cut-off values, patients with EBV DLBCL shared many unfavorable prognostic characteristics, regardless of age. EBV positive patients, both in the elderly and young groups, showed significantly worse overall survival and progression-free survival than negative cases. Moreover, no significant differences of outcomes were identified between different age groups with EBV positive DLBCL. In conclusion, EBV positive DLBCL patients, regardless of age, shared similar poor prognostic features and showed worse outcome than negative cases. We suggest that the age criterion of EBV positive DLBCL of the elderly, and possibly the name itself, be modified in future.
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21
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Ziarkiewicz M, Wołosz D, Dzieciątkowski T, Wilczek E, Dwilewicz-Trojaczek J, Jędrzejczak WW, Gierej B, Ziarkiewicz-Wróblewska B. Epstein-Barr Virus-Positive Diffuse Large B cell Lymphoma in the Experience of a Tertiary Medical Center in Poland. Arch Immunol Ther Exp (Warsz) 2015; 64:159-69. [PMID: 26084760 PMCID: PMC4805698 DOI: 10.1007/s00005-015-0341-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 05/15/2015] [Indexed: 03/09/2023]
Abstract
The role of Epstein–Barr virus (EBV) in the biology and clinical characteristics of diffuse large B cell lymphoma (DLBCL) is still poorly defined. A new provisional entity EBV-positive DLBCL of the elderly has been described in Asian population. Its incidence and prognosis remains unknown in middle European patients. Clinical data and tissue samples were collected from 74 Caucasian patients with DLBCL, aged between 23 and 86 years, treated at a single institution. Lymphoma morphology was reassessed, laboratory procedures included in situ hybridization specific for EBV-encoded small RNAs (EBER), immunohistochemical staining for latent membrane protein and serological testing for EBV-specific antibodies. EBER staining revealed 12.2 % of EBV-positive cases, whereas 9.5 % were diagnosed as EBV-positive DLBCL of the elderly. Serologic EBV markers did not correlate with the presence of EBV in tissue samples (P > 0.10). Elderly EBV-positive cases had lower BCL-6 (P = 0.038) and higher CD30 (P = 0.049) expression and were characterized by higher progression risk (median time-to-progression 12.5 months vs not reached; P = 0.029) and a trend towards worse overall survival (median overall survival 24.5 months vs not reached; P = 0.059). EBV-positive DLBCL of the elderly occurs relatively frequently in Polish population and may be associated with inferior prognosis in comparison with DLBCL, not otherwise specified.
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Affiliation(s)
- Mateusz Ziarkiewicz
- Department of Hematology, Oncology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland.
| | - Dominika Wołosz
- Department of Pathology, Center for Biostructure Research, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Dzieciątkowski
- Department of Microbiology, Central Clinical Hospital, Warsaw, Poland.,Chair and Department of Medical Microbiology, Medical University of Warsaw, Warsaw, Poland
| | - Ewa Wilczek
- Department of Pathology, Center for Biostructure Research, Medical University of Warsaw, Warsaw, Poland
| | | | | | - Beata Gierej
- Department of Pathology, Center for Biostructure Research, Medical University of Warsaw, Warsaw, Poland
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22
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When to use in situ hybridization for the detection of Epstein-Barr virus: a review of Epstein-Barr virus-associated lymphomas. J Hematop 2015. [DOI: 10.1007/s12308-014-0230-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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23
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EBV-positive large B-cell lymphomas in young patients: a nodal lymphoma with evidence for a tolerogenic immune environment. Blood 2015; 126:863-72. [PMID: 25999451 DOI: 10.1182/blood-2015-02-630632] [Citation(s) in RCA: 190] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 05/15/2015] [Indexed: 12/22/2022] Open
Abstract
Few studies have reported Epstein-Barr virus-positive (EBV(+)) large B-cell lymphomas (LBCLs) in young patients without immunodeficiency. We identified 46 such cases in patients ≤45 years of age and analyzed the clinical and pathological characteristics. EBV(+) LBCLs affected predominantly males (male:female = 3.6:1), with a median age of 23 years (range, 4-45 years). All patients presented with lymphadenopathy and 11% also had extranodal disease. Morphologically, 3 patterns were identified: T-cell/histiocyte-rich large B-cell lymphoma-like (n = 36), gray zone lymphoma (n = 7), and diffuse LBCL-not otherwise specified (n = 3). Tumor cells (EBV(+) in >90% of cells) expressed B-cell antigens, were often CD30 and PD-L1 positive, and showed a nongerminal center immunophenotype. A total of 93% expressed EBV latency type II and 7% latency type III. Indoleamine 2,3-dioxygenase was expressed on background accessory cells. The most common treatment regimen was rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (58%), with local radiation therapy added in 21%. With a median follow-up of 22 months, 82% of patients are in clinical remission and only 8% died of disease. Younger patients achieved a significantly higher overall survival than prior series of EBV(+) LBCLs reported in the elderly (P < .0001). In conclusion, EBV(+) LBCLs are not restricted to the elderly. Young patients present with nodal disease and have a good prognosis.
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24
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Liang JH, Lu TX, Tian T, Wang L, Fan L, Xu J, Zhang R, Gong QX, Zhang ZH, Li JY, Xu W. Epstein-Barr virus (EBV) DNA in whole blood as a superior prognostic and monitoring factor than EBV-encoded small RNA in situ hybridization in diffuse large B-cell lymphoma. Clin Microbiol Infect 2015; 21:596-602. [PMID: 25743579 DOI: 10.1016/j.cmi.2015.02.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 02/17/2015] [Accepted: 02/19/2015] [Indexed: 12/12/2022]
Abstract
Epstein-Barr virus (EBV) status was retrospectively analysed by the use of EBV-encoded small RNA (EBER) in situ hybridization (ISH) and EBV DNA analysis in whole blood with diffuse large B-cell lymphoma, to assess the clinical significance for diagnosis, prognostication, and monitoring of tumour burden. Three hundred and twenty-nine patients were retrospectively enrolled, with 232 patients being available for EBER ISH analysis, 189 patients for EBV DNA analysis, and 138 patients for both analyses. EBER was positive in 24 (10.3%) patients, and EBV DNA was positive in 18 (9.5%) patients; the two analyses had 92.8% concordance. Patients with pretreatment EBER positivity had worse overall survival (OS) than those without EBER positivity (p 0.03); the same pattern was observed for EBV DNA (p < 0.01). A significant p-value was also observed for OS when EBER and EBV DNA were combined (p < 0.01). On multivariate analysis, both EBV DNA (hazard ratio 3.71, 95% CI 1.78-7.74, p < 0.01) and EBER (hazard ratio 2.03, 95% CI 1.03-4.00, p 0.04) remained independent predictive factors for OS. Regarding the dynamic changes in copy number of elevated EBV DNA, the transformation from positive to negative after cycle 3 with chemotherapy may have the most capacity to distinguish a superior from an inferior outcome. These findings suggest that EBV DNA in whole blood has good concordance with EBER ISH, and that it may be a better prognostic and monitoring biomarker than EBER.
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Affiliation(s)
| | - T-X Lu
- Department of Haematology, China
| | - T Tian
- Department of Haematology, China
| | - L Wang
- Department of Haematology, China
| | - L Fan
- Department of Haematology, China
| | - J Xu
- Department of Haematology, China
| | - R Zhang
- Department of Haematology, China
| | - Q-X Gong
- Department of Pathology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Z-H Zhang
- Department of Pathology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - J-Y Li
- Department of Haematology, China
| | - W Xu
- Department of Haematology, China.
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25
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Cohen M, Narbaitz M, Metrebian F, De Matteo E, Preciado MV, Chabay PA. Epstein-Barr virus-positive diffuse large B-cell lymphoma association is not only restricted to elderly patients. Int J Cancer 2014; 135:2816-24. [PMID: 24789501 DOI: 10.1002/ijc.28942] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 04/17/2014] [Indexed: 01/20/2023]
Abstract
Diffuse large B-cell lymphoma (DLBCL), the most common group of malignant lymphomas, account for 30% of adult non-Hodgkin lymphomas. The 2008 World Health Organization (WHO) classification included a new entity, Epstein-Barr virus (EBV)+ DLBCL of the elderly, affecting patients aged 50 years or older. However, some reports of younger EBV+ DLBCL cases, without evidence of underlying immunosuppression, can be found. The role of EBV in tumor microenvironment composition in DLBCL is still not well understood. Our aim was to assess EBV presence and latency pattern as well as tumor T-cell population in an adult DLBCL series of Argentina. The study was conducted on biopsies from 75 DLBCL patients. EBERs expression was performed by in situ hybridization, while EBV gene expression was analyzed using real-time polymerase chain reaction. LMP1, LMP2A, EBNA2, EBNA3A, CD4, CD8 and Foxp3 expression was assessed by immunohistochemistry. Nine percent of cases showed EBV expression, with similar frequency among patients younger than 50 years and 50 years or older (13% and 8%, respectively). T-cell subsets were not altered by EBV presence. Latency type II was the most frequently observed, together with lytic gene expression in EBV+ DLBCL, with ≥20% of EBERs+ cells. These findings suggest that EBV+ DLBCL in our series was similar to the previously described in Asia and Latin-America, displaying latency II or III expression profile and no age-specific characteristics. Finally, EBV+ DLBCL may be an entity that is not only restricted to patients who are older than 50 years of age, in consequence the age cutoff revision may be a current goal.
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Affiliation(s)
- M Cohen
- Molecular Biology Laboratory, Pathology Division, Ricardo Gutiérrez Children's Hospital, Buenos Aires, Argentina
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26
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Lu CH, Lee KF, Chen CC, Chen YY, Huang CE, Tsai PS, Tsou HY, Chou HJ, Chen MF, Chen PT, Lee KD, Lung J. Clinical characteristics and treatment outcome in a Taiwanese population of patients with Epstein-Barr virus-positive diffuse large B-cell lymphoma. Jpn J Clin Oncol 2014; 44:1164-71. [PMID: 25320341 DOI: 10.1093/jjco/hyu155] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE Epstein-Barr virus-positive diffuse large B-cell lymphoma is a provisional entity in the 2008 World Health Organization classification of tumors of hematopoietic and lymphoid tissues. Reports on the characteristics and clinical outcome of this disease in different geographic regions showed great disparities. METHODS To define the clinical characteristics as well as the prognostic impact of Epstein-Barr virus infection on diffuse large B-cell lymphoma in Taiwan, we retrospectively investigated the Epstein-Barr virus status of 89 patients with newly diagnosed diffuse large B-cell lymphoma in our institute. RESULTS Using a cutoff point of positive nuclear staining of Epstein-Barr virus-encoded RNA-1-in situ hybridization in ≥20% of the examined cells, we identified 15 cases (16.9%) of the entire study cohort as Epstein-Barr virus-positive diffuse large B-cell lymphoma. The clinical and laboratory features were not different between Epstein-Barr virus-positive and -negative diffuse large B-cell lymphoma patients. Univariate analysis showed patients with diffuse large B-cell lymphoma that were either Epstein-Barr virus-positive or had activated B-cell-like features had an inferior overall survival. Older age, advanced stage and lymphoma with activated B-cell-like features or Epstein-Barr virus-encoded RNA positivity were independent prognostic factors affecting overall survival on multivariate analysis. Patients with two or three of these adverse-risk factors were considered high risk and fared far worse than patients with no or only one adverse factor. CONCLUSIONS Taken together, we demonstrated that a higher frequency of Epstein-Barr virus association was detected in a Taiwanese cohort of diffuse large B-cell lymphoma patients, and Epstein-Barr virus-encoded RNA positivity was shown to add important prognostic value in these patients.
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Affiliation(s)
- Chang-Hsien Lu
- Division of Hematology and Oncology, Department of Medicine, Chang Gung Memorial Hospital, Chiayi Graduate Institute of Clinical Medical Sciences, Chang Gung University, Tao-Yuan
| | - Kam-Fai Lee
- Department of Pathology, Chang Gung Memorial Hospital, Chiayi
| | - Chih-Cheng Chen
- Division of Hematology and Oncology, Department of Medicine, Chang Gung Memorial Hospital, Chiayi College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Yi-Yang Chen
- Division of Hematology and Oncology, Department of Medicine, Chang Gung Memorial Hospital, Chiayi
| | - Cih-En Huang
- Division of Hematology and Oncology, Department of Medicine, Chang Gung Memorial Hospital, Chiayi
| | - Pei-Shan Tsai
- Division of Hematology and Oncology, Department of Medicine, Chang Gung Memorial Hospital, Chiayi
| | - Hsing-Yi Tsou
- Division of Hematology and Oncology, Department of Medicine, Chang Gung Memorial Hospital, Chiayi
| | - Hui-Ju Chou
- Division of Hematology and Oncology, Department of Medicine, Chang Gung Memorial Hospital, Chiayi
| | - Miao-Fen Chen
- Department of Radiation Oncology, Chang Gung Memorial Hospital, Chiayi College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Pin-Tsung Chen
- Division of Hematology and Oncology, Department of Medicine, Chang Gung Memorial Hospital, Chiayi Graduate Institute of Clinical Medical Sciences, Chang Gung University, Tao-Yuan
| | - Kuan-Der Lee
- Division of Hematology and Oncology, Department of Medicine, Chang Gung Memorial Hospital, Chiayi Graduate Institute of Clinical Medical Sciences, Chang Gung University, Tao-Yuan College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Jrhau Lung
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Chang Gung Memorial Hospital, Chiayi
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27
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Ok CY, Li L, Xu-Monette ZY, Visco C, Tzankov A, Manyam GC, Montes-Moreno S, Dybkaer K, Dybaer K, Chiu A, Orazi A, Zu Y, Bhagat G, Chen J, Richards KL, Hsi ED, Choi WWL, van Krieken JH, Huh J, Ai W, Ponzoni M, Ferreri AJM, Farnen JP, Møller MB, Bueso-Ramos CE, Miranda RN, Winter JN, Piris MA, Medeiros LJ, Young KH. Prevalence and clinical implications of epstein-barr virus infection in de novo diffuse large B-cell lymphoma in Western countries. Clin Cancer Res 2014; 20:2338-49. [PMID: 24583797 DOI: 10.1158/1078-0432.ccr-13-3157] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Epstein-Barr virus-positive (EBV(+)) diffuse large B-cell lymphoma (DLBCL) of the elderly is a variant of DLBCL with worse outcome that occurs most often in East-Asian countries and is uncommon in the Western hemisphere. We studied the largest cohort of EBV(+) DLBCL, independent of age, treated with rituximab combined with CHOP (R-CHOP) in developed Western countries. EXPERIMENTAL DESIGN A large cohort (n = 732) of patients with DLBCL treated with R-CHOP chemotherapy is included from the multicenter consortium. This study group has been studied for expression of different biomarkers by immunohistochemistry, genetic abnormalities by FISH and mutation analysis, genomic information by gene expression profiling (GEP), and gene set enrichment analysis (GSEA). RESULTS Twenty-eight patients (4.0%) were positive for EBV with a median age of 60.5 years. No clinical characteristics distinguished patients with EBV(+) DLBCL from patients with EBV-negative (EBV(-)) DLBCL. Genetic aberrations were rarely seen. NF-κB p50, phosphorylated STAT-3, and CD30 were more commonly expressed in EBV(+) DLBCLs (P < 0.05). Significant differences in survival were not observed in patients with EBV(+) DLBCL versus EBV(-) DLBCL. However, CD30 expression combined with EBV conferred an inferior outcome. GEP showed a unique expression signature in EBV(+) DLBCL. GSEA revealed enhanced activity of the NF-κB and JAK/STAT pathways independent of molecular subtype. CONCLUSIONS The clinical characteristics of patients with EBV(+) versus EBV(-) DLBCL are similar and EBV infection does not predict a worse outcome. EBV(+) DLBCL, however, has a unique genetic signature. CD30 expression is more common in EBV(+) DLBCL and, consistent CD30 and EBV is associated with an adverse outcome. Clin Cancer Res; 20(9); 2338-49. ©2014 AACR.
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Affiliation(s)
- Chi Young Ok
- Authors' Affiliations: Departments of Hematopathology and Biostatistics and Bioinformatics, The University of Texas MD Anderson Cancer Center; The Methodist Hospital, Houston, Texas; Memorial Sloan-Kettering Cancer Center; Weill Medical College of Cornell University; Columbia University Medical Center and New York Presbyterian Hospital, New York, New York; University of North Carolina School of Medicine, Chapel Hill, North Carolina; Cleveland Clinic, Cleveland, Ohio; University of California San Francisco School of Medicine, San Francisco, California; Gundersen Lutheran Health System, La Crosse, Wisconsin; Feinberg School of Medicine, Northwestern University, Chicago, Illinois; San Bartolo Hospital, Vicenza; San Raffaele H. Scientific Institute, Milan, Italy; University Hospital, Basel, Switzerland; Hospital Universitario Marques de Valdecilla, Santander, Spain; Aalborg University Hospital, Aalborg; Odense University Hospital, Odense, Denmark; Medical School of Taizhou University, Taizhou, Zhejiang; University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, China; Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands; and Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea
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Chang ST, Lu YH, Lu CL, Weng SF, Lin SH, Kuo SY, Chuang YT, Takeuchi K, Ohshima K, Chuang SS. Epstein–Barr virus is rarely associated with diffuse large B cell lymphoma in Taiwan and carries a trend for a shorter median survival time. J Clin Pathol 2013; 67:326-32. [DOI: 10.1136/jclinpath-2013-201905] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Abstract
Epstein-Barr virus (EBV) positive diffuse large B-cell lymphoma (DLBCL) of the elderly, initially described in 2003, is a provisional entity in the 2008 World Health Organization classification system and is defined as an EBV-positive monoclonal large B-cell proliferation that occurs in patients >50 years of age and in whom there is no known immunodeficiency or history of lymphoma. These tumors are more common in Asia but also occur in North America and Europe at a low frequency. These neoplasms exhibit a morphologic continuum, from polymorphous to monomorphous, but morphologic features do not correlate with prognosis as all patients have a clinically aggressive course. Most EBV-positive DLBCL of the elderly patients have an activated B-cell immunophenotype and are characterized by prominent nuclear factor-κB activation. Cytogenetic complexity is usually low. In this review, we comprehensively delineate the data emerging from analyses of EBV latency program, microRNA-mediated EBV viral oncogenesis, functional genomics of EBV and its biology, and differential diagnosis challenge for EBV-positive DLBCL of the elderly. It is hoped that the improved understanding of these tumors will lead to the development of novel therapeutic approaches, enhance the effectiveness of clinical trials, and improve prognosis.
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Yanagisawa K, Tanuma J, Hagiwara S, Gatanaga H, Kikuchi Y, Oka S. Epstein-Barr viral load in cerebrospinal fluid as a diagnostic marker of central nervous system involvement of AIDS-related lymphoma. Intern Med 2013; 52:955-9. [PMID: 23648713 DOI: 10.2169/internalmedicine.52.9088] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE AIDS-related lymphoma (ARL) often involves the central nervous system (CNS). Although the diagnostic value of Epstein-Barr virus (EBV)-DNA in cerebrospinal fluid (CSF) in detecting HIV-positive primary CNS lymphoma (PCNSL) has been established, its usefulness for identifying CNS involvement of systemic ARL remains elusive. In this study, we evaluated the utility of the EBV-DNA load in CSF in identifying CNS involvement in patients with systemic ARL. METHODS We retrospectively reviewed the clinical and pathological data of consecutive ARL patients managed at our clinic between January 1998 and June 2012. Sixty-two patients with ARL, including eight PCNSL patients and 52 systemic ARL patients, and 63 controls underwent CSF EBV-DNA load evaluations before receiving chemotherapy. ARL-related CNS involvement was defined as any lesion diagnosed histologically or radiologically as a lymphoma in the brain, meninges, spine, cranial nerves or oculus. RESULTS A cut off value of 200 copies/mL predicted the presence of CNS lesions with a sensitivity of 70% and a specificity of 85% in both the PCNSL and systemic ARL patients, while a sensitivity of 75% and a specificity of 93% were obtained for systemic ARL. A cut off value of 2,000 (3.30 log) copies/mL provided the best specificity (100%), with a sensitivity of 50%. CONCLUSION Our results support the clinical utility of evaluating the quantitative EBV-DNA load in the CSF for the diagnosis of CNS involvement of systemic ARL as well as PCNSL.
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Affiliation(s)
- Kunio Yanagisawa
- Department of Medicine and Clinical Science, Graduate School of Medicine, Gunma University, Japan
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Pan Y, Meng B, Zhang H, Cao W, Wang H, Bi C, Liu F, Sun B, Hao X, Ai WZ, Fu K. Low incidence of Epstein-Barr virus-positive diffuse large B-cell lymphoma of the elderly in Tianjin, northern China. Leuk Lymphoma 2012; 54:298-303. [PMID: 22830615 DOI: 10.3109/10428194.2012.715347] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The purpose of this study was to examine the incidence of Epstein-Barr virus (EBV)-positive diffuse large B-cell lymphoma of the elderly in a representative northern Chinese population. Overall, 212 cases of primary diffuse large B-cell lymphoma were analyzed for EBV-positive status by detection of EBV-encoded RNA using in situ hybridization. Immunophenotypic identity was verified by a streptavidin-biotin peroxidase detection system using the markers CD20, CD3, CD10, BCL6 and MUM1. The prevalence of EBV-positive diffuse large B-cell lymphoma in elderly northern Chinese patients was 3.8% (eight of 212). All eight cases were negative for CD10 and BCL6 immunostaining. The incidence is less frequent than that of southern China and other East-Asian countries. Patients tend to be older, present with a non-germinal center B-cell-like immunophenotype and have a poor outcome.
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Affiliation(s)
- Yi Pan
- Tianjin Medical University Cancer Institute and Hospital and Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
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Wada N, Zaki MAA, Kohara M, Ogawa H, Sugiyama H, Nomura S, Matsumura I, Hino M, Kanakura Y, Inagaki H, Morii E, Aozasa K. Diffuse large B cell lymphoma with an interfollicular pattern of proliferation shows a favourable prognosis: a study of the Osaka Lymphoma Study Group. Histopathology 2012; 60:924-32. [PMID: 22321065 DOI: 10.1111/j.1365-2559.2011.04161.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIMS Diffuse large B cell lymphoma (DLBCL) occasionally shows an interfollicular pattern of proliferation (DLBCL-IF) preserving lymphoid follicles. In this study, clinicopathological findings in 31 cases of DLBCL-IF were analysed. METHODS AND RESULTS The study group comprised 20 males and 11 females, with ages ranging from 41 to 87 (median 69) years. The primary site was lymph node in 25 cases, and unknown in six due to advanced stage at diagnosis. Eight cases were clinical Stage I, 10 were Stage II, four Stage III, and nine Stage IV. A polymorphous pattern of proliferation containing large B cells and inflammatory cells was found in about 60% of cases. The overall survival rate of the DLBCL-IF patients was better than that of a DLBCL control group (log-rank test; P < 0.05). Multivariate analysis revealed that an interfollicular pattern of proliferation showed marginal significance for favourable prognosis (P = 0.069). Immunohistochemical double staining with antibodies for HLA-DR/CD68 (markers for M1-tumour-associated macrophage [M1-TAM]) or CD163/CD68 (M2-TAM) revealed that all DLBCL-IF patients with a low M2 count were alive at the end of observation. CONCLUSIONS These findings suggest that DLBCL-IF is a clinicopathological entity distinct from ordinary DLBCL. The possible origin of tumour cells in DLBCL-IF from marginal zone B cells is discussed.
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Affiliation(s)
- Naoki Wada
- Department of Pathology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Rojas-Feria M, Eslam M, Castro-Fernández M, Guerrero P, Larraona-Moreno JL, Romero-Gómez M. Cutaneous lymphoma in a patient with ulcerative colitis after immunosuppressive therapy. J Crohns Colitis 2011; 5:608-11. [PMID: 22115382 DOI: 10.1016/j.crohns.2011.04.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2011] [Revised: 04/12/2011] [Accepted: 04/20/2011] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Biologics are generally safe and well tolerated. However, the risk of haematopoietic cancer in patients with inflammatory bowel disease receiving infliximab has been a growing concern. CASE PRESENTATION We report the first case of cutaneous lymphoma after short use of infliximab in 75-year old Caucasian man with a 7-year history of ulcerative colitis. CONCLUSION Our current knowledge is not sufficient to rule out an increased risk of lymphoma associated with biologics, or allow definitive conclusions to be drawn about the association of infliximab and lymphoma. However, this case and others direct the attention to that both higher index of suspicion and closer follow up are required if patients are maintained on long-term infliximab together with other immunosuppressive therapy.
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Affiliation(s)
- Maria Rojas-Feria
- Unit for The Clinical Management of Digestive Diseases and CIBERehd, Hospital Universitario de Valme, Ctra de Cadiz s/n, Sevilla 41014, Spain.
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Beltran BE, Morales D, Quiñones P, Medeiros LJ, Miranda RN, Castillo JJ. EBV-Positive Diffuse Large B-Cell Lymphoma in Young Immunocompetent Individuals. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2011; 11:512-6. [DOI: 10.1016/j.clml.2011.07.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Revised: 07/08/2011] [Accepted: 07/15/2011] [Indexed: 01/30/2023]
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New developments in the pathology of malignant lymphoma: a review of the literature published from November 2010–January 2011. J Hematop 2011. [DOI: 10.1007/s12308-011-0086-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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