Identification of EBV-DNA in tumour cells of AIDS-related lymphomas by in-situ hybridisation

Burkitt's lymphoma of the duodenum in a patient with AIDS

Non-Hodgkin's lymphoma of B-cell type is the second most common neoplasm after Kaposi's sarcoma, among patients with human immunodeficiency virus infection. Most non-Hodgkin's lymphoma cases that are associated with acquired immunodeficiency syndrome involve extranodal sites, especially the digestive tract and the central nervous system. We report a case of primary lymphoma of the duodenum in a patient with AIDS. Upper gastrointestinal endoscopy revealed pseudopolypoid masses found in the second portion of the duodenum. A complete diagnostic study including histological, immunohistochemical and virological analyses showed high-grade B-cell Burkitt's lymphoma. The Epstein-Barr virus genome was detected in biopsies by immunohistochemical and in situ hybridization.

AIDS malignancies

Among individuals with HIV-infection, coinfection with oncogenic viruses including EBV, HHV-8, and HPV cause significant cancer-related morbidity and mortality. It is clear that these viruses interact with HIV in unique ways that predispose HIV-infected individuals to malignant diseases. In general, treatment directed specifically against these viruses does not appear to change the natural history of the malignant disease, and once the malignancy develops, if their health permits, HIV-infected patients should be treated using similar treatment protocols to HIV-negative patients. However, for the less frequent HIV-related malignancies, such as PEL, or MCD, optimal treatments are still emerging. For certain AIDS-defining malignancies, it is clear that the widespread access to HAART has significantly decreased the incidence, and improved outcomes. However, for other cancers, such as the HPV-related tumors, the role of HAART is much less clear. Further research into prevention and treatment of these oncogenic virally mediated AIDS-related malignancies is necessary.

AIDS-related non-Hodgkin's lymphomas

This work reviews the current status of non-Hodgkin's lymphoma (NHL) in HIV infected patients. HIV infection remains at significantly increased risk for the development of NHL. The great majority of these lymphomas are high-grade monoclonal B-cell neoplasms often occurring in unusual sites. A number of genetic abnormalities have been found but additional studies are necessary to understand the etiology and pathogenesis of NHL in the setting of HIV infection. The cases in this paper have been seen on the Hematopathology service of the Tulane Health Sciences Center.

Current treatment strategies for patients with Hodgkin's lymphoma and HIV infection

Hodgkin's lymphoma is the most common non-AIDS-defining tumor diagnosed in HIV-infected patients. Although the introduction of highly active antiretroviral therapy (HAART) led to a decreased incidence of several malignancies among HIV-infected patients, the incidence of HIV-associated Hodgkin's lymphoma (HIV-HL) has been persistent in recent years. Its unusually aggressive tumor behavior includes a higher frequency of unfavorable histologic subtypes, high stage and extranodal involvement by the time of presentation and poor therapeutic outcome, in comparison with Hodgkin's lymphoma outside the HIV setting. Treatment of HIV-HL is challenging considering the underlying immunodeficiency caused by HIV itself and may increase the risk of opportunistic infections by inducing further immunosuppression. To address this delicate vulnerability of the HIV-infected host, tailored regimens, which are less aggressive than standard regimens for HIV-negative hosts, have been applied to achieve tumor control. The introduction of HAART has opened a new perspective in the treatment of HIV-associated malignancies. The improved control of HIV infection and the subsequently improved survival rates of HIV-infected patients has changed the goal from tumor control to cure and new treatment approaches with more potent regimens need to be evaluated to improve survival and quality of life in HIV-HL.

AIDS-related malignancies

Immunodeficiency alters the risk of cancer. Specific types of immune dysfunction are associated with different tumor risks, but most tumors are related to oncogenic viruses. In acquired immunodeficiency due to the human immunodeficiency virus (HIV), HIV itself rarely directly causes cancer; rather, it provides the immunologic background against which other viruses can escape immune control and induce tumors. The most common malignancies are Kaposi's sarcoma and non-Hodgkin's lymphoma. This chapter discusses the pathophysiologic background of these tumors, how they have been affected by the use of anti-HIV medications, and their clinical management.

Etiology and pathogenesis of AIDS-related non-Hodgkin's lymphoma

The incidence of NHL is greatly increased in HIV-infected individuals; malignant lymphoma is the second most common neoplasm that occurs in association with AIDS. The vast majority of neoplasms are clinically aggressive, monoclonal B-cell neoplasms that exhibit Burkitt's, immunoblastic, large cell, or transitional histopathology. Approximately 80% arise systemically (nodal or extranodal) and 20% arise as primary CNS lymphomas. A small proportion of neoplasms are body cavity-based, primary effusion lymphomas that are uniquely associated with KSHV infection. Recently, HIV-associated polymorphic lymphoproliferative disorders have been described as well. AIDS-related NHLs appear to exhibit distinctive clinical characteristics according to their histopathology and anatomic site of origin. Factors that contribute to lymphoma development include HIV-induced immunosuppression, impaired immune surveillance, cytokine release and deregulation, and chronic antigenic stimulation. This environment is associated with the development of oligoclonal B-cell expansions. The appearance of NHL is characterized by the presence of a monoclonal B-cell population that displays a variety of genetic lesions, including, for example, EBV infection, MYC gene rearrangement, BCL6 gene rearrangement, P53 mutations and deletions, and RAS gene mutations. The number and type of genetic lesions vary somewhat among AIDS-related NHLs according to their histopathologic category and anatomic site of origin. These findings suggest that more than one pathogenetic mechanism is operational in the development and progression of AIDS-related NHLs. Further work is necessary to develop a complete understanding of the etiology and pathogenesis of NHL in the setting of HIV infection. AIDS-related NHL is an important biologic model for investigating the development and progression of high-grade NHLs and NHLs that develop in immunedeficient hosts.

Hodgkin's disease in HIV

The outcome of patients with HIV-HD has improved with better, combined antineoplastic and antiretroviral approaches. New and effective antiretroviral drugs (ie, protease inhibitors), in conjunction with nucleoside analogs, improve the control of the underlying HIV infection when used during treatment of HD with chemotherapy. In fact, the possibility of reducing viral load to undetectable levels and increasing the CD4+ cell count reduces the risk of OIs during antineoplastic treatment. The inclusion of hematopoietic growth factors in the treatment of patients with HIV-HD may allow for the administration of higher dose-intensity chemotherapy and the prolonged use of antiretroviral drugs, with the aim of improving the survival. Finally, more effective antineoplastic regimens--such as high-dose chemotherapy with autologous stem cell transplantation (which is required in the case of HIV-HD, due to its aggressiveness)--should be considered to improve the response rate and disease-free survival of these patients.

Maintenance and characterization of an Epstein Barr virus-infected CD56-negative T cell lymphoma

T cell lymphoma carrying Epstein Barr virus (EBV(+) TL) is very rare among Western countries while it is much more common among Japanese. Here we report an EBV(+) TL which has been maintained for years by the use of mice with severe combined immune deficiency (SCID) mice. Lymphoma was obtained from a 55-year-old male suffering from oculomotor nerve palsy and lymphadenopathy. A small piece of biopsied tumor was transplanted into SCID mice and the lymphoma has been maintained for over 3 years with passages every 2 - 3 weeks. The maintained lymphoma, termed as TMS24, and the original lymphoma cells showed identical phenotype and genotype, including diffuse medium-sized cell morphology lacking granules, suppressor / cytotoxic immunophenotype and identical T cell receptor beta-chain gene rearrangement mode. Further, both were shown to carry an identical EBV clone in terms of the number of terminal repeats and the latency II-type restricted gene expression profile. Cytogenetically, TMS24 retained two characteristic chromosomal translocations of t(1;18)(q32;q21) and t(6;12)(p21;q24). Since only one cell line with such characters has been reported previously, TMS24 should be useful for detailed analysis of EBV(+) TL.

Pathogenetic and histogenetic features of HIV-associated Hodgkin's disease

Compared with the cases in the general population, Hodgkin's disease (HD) arising in the HIV setting shows distinctive features in terms of epidemiology, aetiopathogenesis, histopathology and clinical behaviour. Although HD does not represent an AIDS-defining condition, recent evidence consistently indicates that HIV-infected individuals have a significantly increased risk of developing HD. HIV-related HD is characterised by the preponderance of aggressive histological subtypes, advanced stage at presentation, and highly malignant clinical course. Moreover, unlike HD in the general population, the large majority of HIV-related HD cases are pathogenetically linked to Epstein-Barr virus (EBV), with rates of EBV positivity ranging from 80 to 100%. Hodgkin and Reed-Sternberg cells of these cases invariably show a strong expression of the EBV-encoded latent membrane protein-1 (LMP-1), which functions as a constitutively activated tumour necrosis factor (TNF) receptor-like molecule. Usurpation of physiologically relevant pathways by LMP-1 may lead to the simultaneous or sequential activation of signalling pathways involved in the promotion of cell activation, growth, and survival, contributing thus to most of the features of HIV-related HD.

Non-Hodgkin's lymphoma of the sinonasal tract

OBJECTIVES

A review of the presenting features, management, and outcome of extranodal non-Hodgkin's lymphoma (NHL) of the sinonasal tract during a 10-year period in Nottingham, UK.

STUDY DESIGN

Twenty-four patients received a diagnosis of extranodal NHL of the nasal cavity, paranasal sinuses, or both, from 1987 to 1996. The patients' data were collected prospectively in the Nottinghamshire Lymphoma Registry.

METHODS

All patients' records and their histology were reviewed along with data entered into the Nottinghamshire Lymphoma Registry, noting the patient's age, sex, presenting symptoms and signs, staging, computed tomography findings, histology, treatment, complications, and outcome.

RESULTS

The 24 patients with extranodal NHL of the sinonasal tract represent 1.63% of the 1,457 patients with NHL seen in the 10-year period of this study in Nottinghamshire. The median age was 72 years (range, 42-96 y), with a male dominance (male-to-female ratio: 15:9). Most patients presented with nonspecific nasal symptoms such as nasal obstruction and epistaxis. Only one patient had a relapse involving the central nervous system after treatment. All the histology was reviewed and showed a predominance of large B-cell subtype (21 patients). The overall 5-year survival was 40% (95% CI, 19%-61%) and 33% for 10-year (95% CI, 12%-54%). The cause-specific survival at 5 years and 10 years was 62% (95% CI, 39%-86%).

CONCLUSIONS

A high degree of suspicion and appropriate use of computed tomography scans and surgical biopsy are the keys to the management of NHL.

Value of long-term administration of acyclovir and similar agents for protecting against AIDS-related lymphoma: case-control and historical cohort studies

Acyclovir or similar agents with activity against Epstein-Barr virus (EBV) theoretically may prevent non-Hodgkin's lymphoma (NHL) in AIDS. A case-control study of 29 patients with AIDS-related NHL and 58 matched control subjects assessed the frequency with which daily acyclovir (>/=800 mg/d) or similar agents were used for > or =1 year. In a historical cohort of 304 patients with AIDS for > or =2 years, the prevalence of NHL was assessed among 3 groups of patients: those who received long-term treatment with high-dose acyclovir (or similar agents) or low-dose or intermittent acyclovir; those treated with ganciclovir/foscarnet for <1 year; and those who had not previously been treated with acyclovir, ganciclovir, or foscarnet. In the case-control study, 22 patients (72.4%) with NHL never received acyclovir or similar drugs versus 19 control subjects (32.8%; P=. 002); 2 patients (6.9%) with NHL received acyclovir (> or =800 mg/d) for > or =1 year versus 27 (46.6%) of control subjects (P=.0001). In the cohort study, 6 (6.8%) of 88 patients who received acyclovir (> or =800 mg/d) for > or =1 year developed NHL versus 15 (15.5%) of 97 patients who received intermittent or lower-dose acyclovir and 30 (25.2%) of 119 patients who never received these agents (P=.002). Long-term administration (>1 year) of high-dose acyclovir or similar agents with anti-EBV activity may prevent NHL in patients with AIDS. A prospective, randomized study is warranted to confirm these results.

Epstein-Barr virus early ribonucleic acids as a diagnostic adjunct for relapsed metastatic tumors in patients with cured primary undifferentiated nasopharyngeal carcinoma

PURPOSE

Epstein-Barr virus (EBV) has been consistently shown to be associated with undifferentiated nasopharyngeal carcinoma (NPC). In this article, the authors attempt to detect Epstein-Barr virus in distant relapsed metastatic sites in undifferentiated NPC patients with cured primary cancer.

MATERIALS AND METHODS

In situ hybridization (ISH) technique is a reliable method to detect EBV early RNAs (EBERs) within NPC cells. We used a nonisotopical ISH technique to examine the presence of EBERs in paraffin-embedded tissues obtained from 1 paired specimen of primary NPC and its metastatic counterpart at liver and 2 metastatic specimens of retroperitoneal lymph nodes and bone.

RESULTS

All the primary lesions and the metastatic tumors of NPC with undifferentiated histology contained EBERs that could be clearly detected in the nuclei of cancer cells.

CONCLUSIONS

This article shows that EBERs can be successfully detected in cells of the distant relapsed metastatic sites. These results suggest that this nonisotopical ISH method of EBERs can be potentially used to diagnose NPC patients developing distant relapsed metastatic lesions with cured primary cancer early. It can offer quick information as to institute suitable salvage chemotherapy for these patients.

Non-Hodgkin's lymphoma of the maxillary sinus in a patient with acquired immunodeficiency syndrome

Non-Hodgkin's lymphoma (NHL) is one of the most common malignancies in patients infected with human immunodeficiency virus (HIV): it occurs 25-60 times more frequently in HIV-infected patients than in the general population. This neoplasm in acquired immunodeficiency syndrome (AIDS) patients is a highly aggressive tumour with a poor prognosis and tends to develop in extranodal sites, such as the central nervous system, digestive tract and bone marrow. NHL involving the paranasal sinuses is rare in HIV-infected patients, and is likely to be confused clinically and radiographically with sinusitis; moreover, its optimal treatment is currently uncertain. We present a case of NHL involving the left maxillary sinus in a patient with AIDS. The patient was treated with systemic chemotherapy (low dose-CHOP), but the malignancy did not respond. Subsequently, he was treated with local maxillary sinus irradiation which resulted in partial regression of the neoplasm and in decrease of local symptoms.

EBV-associated anorectal lymphomas in patients with acquired immune deficiency syndrome

Primary lymphomas of the gastrointestinal tract represent 9% of all non-Hodgkin lymphomas, and of these only 3% arise in the rectum or anus. In contrast to their rare occurrence in the general population, the incidence of anorectal lymphomas in patients with acquired immune deficiency syndrome (AIDS), particularly homosexual patients, may be as high as 26% as reported in our own series of AIDS-associated lymphomas. To determine the characteristics of this entity, we studied 15 cases of primary anorectal lymphoma in AIDS patients and compared them with four cases of anorectal lymphoma unrelated to AIDS. The cases in our study were also compared with the reports of rectal lymphoma in the medical literature over the past 30 years. In the present series, the AIDS patients were all male with a median age of 34 years, human immunodeficiency virus (HIV)-positive, with homosexuality as the main risk factor. The four non-AIDS patients included a woman and had a median age of 66.5 years. Histologically, the anorectal lymphomas in AIDS patients were all high grade, predominantly immunoblastic, and polymorphous. In the non-AIDS patients, only two of four lymphomas were high grade, including one Burkitt type. All tumors were of B-cell phenotype. In the AIDS-associated anorectal lymphomas, the presence of Epstein-Barr virus (EBV) in a latent form was demonstrated by an abundance of Epstein-Barr-encoded RNA (EBER) in 14 of 15 cases and latent membrane protein (LMP) in four cases. All anorectal lymphomas unrelated to AIDS were negative for EBV. The unusual anorectal location of AIDS-associated lymphomas is explainable by the high incidence of preceding traumatic lesions and chronic infections in the area. As a result, EBV-carrying B cells may be attracted to the field providing the cell population that, under the conditions of immune deficiency, is able to give rise to high-grade lymphomas.

Preventive effect of IgG from EBV-seropositive donors on the development of human lympho-proliferative disease in SCID mice

The effect of weekly treatments with various gammaglobulin preparations on the development of human B-cell tumors was studied in severe combined immunodeficient (SCID) mice. SCID mice were injected i.p. with human peripheral blood mononuclear cells (PBMCs) from an Epstein-Barr virus (EBV)-seropositive healthy blood donor. Repopulated SCID mice were divided into 7 treatment groups receiving either PBS, 2 commercial gammaglobulin preparations, purified IgG prepared from pooled plasma from EBV-seronegative or -seropositive blood donors, a rabbit anti-serum against EBV envelope glycoprotein gp340 or interferon (IFN)-alpha. All treatments started 1 day after injection of PBMC and continued for 8 weeks. In the PBS-treated control group, 85% of mice developed tumors in the abdominal cavity, mostly with liver metastasis within 150 days. Tumor formation was prevented by treatment with the 2 commercial gammaglobulin preparations as well as by purified IgG from EBV-seropositive donors. In contrast, purified IgG from EBV-seronegative donors, rabbit anti-gp340 anti-serum or IFN-alpha had no effect. Our results indicate that the effect of gammaglobulin is due to the presence of specific antibodies against EBV antigens. Further experiments showed that both the time of onset and the duration of treatment, as well as the dose of Ig, are important factors for prevention of tumor formation. Studies aiming at identification of target antigens for antibodies which prevent lymphoma development may be clinically relevant for prevention and possibly treatment of lympho-proliferative disease in severely immuno-compromised patients.

Pulmonary disease

This article has presented the reader with an overview of the pulmonary disorders that develop during the course of HIV disease with special emphasis on the more commonly encountered entities. This information is intended to prepare the clinician to recognize the hallmark characteristics of the various diseases as well as atypical features. Despite the advances in basic understanding of the clinicopathologic consequences of infection with HIV, a cure has not been realized. There has, however, been success in controlling some of the major pulmonary problems that adversely affect both the quality and the length of life for persons with AIDS. For most complications of HIV infection, prognosis ultimately depends not only on treatment of the specific problem, but also controlling the relentless process of progressive immunosuppression. Continued research into treatment or prevention of HIV infection itself is needed, but at present prevention, rapid diagnosis, and treatment of recognized problems remain an intermediary goal.

Etiology and pathogenesis of AIDS-related non--Hodgkin's lymphoma

The incidence of NHL is greatly increased in HIV-infected individuals. The vast majority are clinically aggressive B cell-derived neoplasms exhibiting BL, IBL, or LCL histology. Approximately 80% arise systemically (nodal and/or extranodal), and the remaining 20% arise as primary CNS lymphomas. A small proportion are body cavity-based lymphomas associated with KSHV infection. Possible factors contributing to lymphoma development include HIV-induced immunosuppression, chronic antigenic stimulation, and cytokine overproduction. These alterations are associated with the development of oligoclonal B-cell expansions. The appearance of NHL is characterized by the presence of a monoclonal B-cell population displaying a variety of genetic lesions, including EBV infection, c-myc gene rearrangement, bcl-6 gene rearrangement, ras gene mutations, and p53 mutations/deletions. The number and type of genetic lesions varies according to the anatomic site and histopathology. In the case of BL, virtually 100% exhibit c-myc gene rearrangements, two thirds display p53 gene mutations, one third contain EBV, and none exhibit bcl-6 gene rearrangements. In contrast, in the case of IBL, virtually 100% contain EBV, 25% display c-myc gene rearrangements, 20% display bcl-6 gene rearrangements, and very few exhibit p53 gene mutations. These findings suggest that more than one pathogenetic mechanism is operational in the development and progression of AIDS-related NHLs. Further work will be necessary to develop a complete understanding of the etiology and pathogenesis of NHL in the setting of HIV infection. AIDS-related NHL remains an important biologic model for investigating the development and progression of high-grade NHLs as well as NHLs that develop in immune-deficient hosts.

Reversible AIDS-related sclerosing cholangitis

Although hepatobiliary involvement is common in the acquired immunodeficiency syndrome, it infrequently leads to biliary tract abnormalities. We describe a 39-year-old man with human immunodeficiency virus infection and no previous acquired immunodeficiency syndrome-defining illnesses, who presented with malaise, right upper quadrant pain, lymphadenopathy and cholestasis. An endoscopic retrograde cholangiopancreatography demonstrated sclerosing cholangitis due to disseminated B-cell nonHodgkin's lymphoma. Following chemotherapy, his symptoms and signs rapidly improved, so that 1 month later his endoscopic retrograde cholangiopancreatography had returned entirely to normal.

Correlation between cytopathological results and in situ hybridisation on needle aspiration biopsies of suspected African Burkitt's lymphomas

Burkitt's lymphoma (BL) is a very high-incidence malignancy in sub-Saharan Africa, where it targets mainly young children. This lymphoma is closely associated with Epstein-Barr virus (EBV). Diagnosis of BL relies on clinical presentation as well as histological results obtained from biopsies. In this report, 66 new patients from Malawi (one of the southernmost African countries with high-incidence BL), suspected on clinical grounds to present with BL, had fine needle aspiration biopsies taken, smeared on slides and used for May-Grünwald Giemsa staining. Duplicate slides were independently assessed for EBV presence and expression by DNA-DNA and/or RNA-RNA in situ hybridisation (ISH), using respectively the repetitive viral BamHIW DNA fragment in a biotinylated probe and the small EBV-encoded RNA EBER I in a digoxigenin-labelled riboprobe. There was very good correlation between the various techniques in the diagnosis of the lymphomas, showing 67% of clinically suspect cases to be BL. Our report, presenting data on BL in Malawi, illustrates the usefulness of a simple aspiration biopsy in the diagnosis of this malignancy by Giemsa staining and also in both types of ISH.

Gastrointestinal disease in the immunocompromised patient

Gastrointestinal (GI) disease is frequent in all types of immunocompromised patients but occurs with greatest frequency in patients with acquired immunodeficiency syndrome (AIDS). Thus, much of this review deals with human immunodeficiency virus (HIV)-related GI diseases. Gastrointestinal diseases in other immunocompromised patients are compared with those in patients with AIDS. Conditions unique to transplant recipients, such as graft-versus-host disease (GVHD) and posttransplant lymphoproliferative disorders (PTLDs), are discussed separately. We have divided these GI diseases into four main categories: (1) HIV-related inflammatory conditions other than opportunistic infections (HIV-related enteropathy, proctocolitis, and CD8 lymphocytosis); (2) inflammatory conditions unrelated to HIV or opportunistic infections (neutropenic enterocolitis, regional enteritislike enteropathy, and GVHD); (3) opportunistic infections (illnesses caused by herpesvirus, cytomegalovirus, and miscellaneous other viruses; Mycobacterium, Candida, Histoplasma, Cryptococcus, Cryptosporidium, Microsporida, Isospora, Leishmania, Toxoplasma and Strongyloides organisms as well as Pneumocystitis carinii; and (4) neoplasias (Kaposi's sarcoma [KS], AIDS-related non-Hodgkin's lymphoma [NHL], HIV-related Hodgkin's disease [HD], PTLDs, and miscellaneous neoplasms). The prevalence, pathogenesis, clinical manifestations, gross pathological findings, and microscopic features of each disease entity are discussed.

Monoclonal Epstein-Barr virus genomes but lack of EBV-related protein expression in different types of gastric carcinoma

Thirty-nine resection specimens of gastric carcinomas have been investigated for the presence of EBV RNA sequences using a highly sensitive non-radioactive in situ hybridization technique. Transcribed EBER sequences were found in seven (18%), including four cases of undifferentiated carcinoma with prominent lymphoid infiltration and three gastric adenocarcinomas. In the positive tumours all, or nearly all, tumour nuclei were distinctly labelled. No positive signals could be detected in the non-dysplastic epithelial cells or the reactive inflammatory infiltrate. Clonality analysis using specific probes to the variable tandem repeat region of the EBV yielded single episomal bands in all four cases tested, two of which were undifferentiated carcinomas and two adenocarcinomas. By means of immunohistology, no expression of the EBV-related proteins LMP or EBNA-2 was present in tumour cells of positive cases in in situ or blotting attempts. Our results suggest that infection of gastric carcinomas by the EB virus occurs early in tumourigenesis but, in contrast to nasopharyngeal carcinomas, does not result in the expression of EBV-specific proteins.

Characteristic clinicopathologic features of Epstein-Barr virus-associated peripheral T-cell lymphoma

BACKGROUND

The authors previously reported the existence of a unique subtype of peripheral T-cell lymphoma (PTCL) characterized by a clonotypical proliferation of Epstein-Barr virus (EBV) in the tumor cells (Blood 1991; 77:799). Detailed clinicopathologic features of this newly recognized entity remain to be clarified.

METHODS

A retrospective study was done in 23 patients receiving consecutive diagnoses at National Taiwan University Hospital by methods previously described.

RESULTS

There were 13 male and 10 female patients, with a median age of 40 years. Seventeen patients had Stage III/IV disease, and 15 patients had fever as a presenting B symptom. Initial extranodal involvement occurred in skin (10 patients), lung (4 patients), bone marrow (4 patients), brain (3 patients), and nasal cavity (1 patient) and was evidenced by hepatosplenomegaly (6 patients). Sixteen patients had specific histopathologic features including characteristics similar to angioimmunoblastic lymphadenopathy with dysproteinemia (3 patients), angioinvasive-type features (6 patients), Hodgkin disease-like features (2 patients), hepatosinusoidal-type features (2 patients), Lennert lymphoma (2 patients), and malignant histiocytosis-like features (1 patient). Six (37.5%) of the 16 patients who received a standard regimen with cyclophosphamide, doxorubicin, vincristine, and prednisone or an equivalent regimen as induction chemotherapy achieved complete remission. The median survival time was only 8 months. Six (42.8%) of the 14 patients who have died at this report ended up with a terminal hemophagocytosis syndrome. All five relapsed tumors were found to have a strong expression of P-glycoprotein (P-gp).

CONCLUSIONS

The authors suggest that EBV-associated PTCL should be regarded as a separate entity of non-Hodgkin lymphoma showing characteristic histopathologic features, frequent expression of P-gp in relapsed tumor, a terminal hemophagocytosis syndrome, and a generally ominous outcome.

Cutaneous anaplastic T-cell lymphoma in a patient with human immunodeficiency virus infection: detection of Epstein-Barr virus DNA

The Epstein-Barr virus (EBV) genome exists in tumour cells of T-cell lymphomas in non-immunosuppressed patients. We identified EBV-DNA by in situ hybridization in a case of anaplastic T-cell lymphoma associated with acquired immunodeficiency syndrome (AIDS). EBV-DNA has been reported in AIDS-related Hodgkin's disease or B-cell lymphoma, but never in T-cell lymphoma. Although our results suggest that EBV could play a role in the development of these anaplastic T-cell lymphomas, the mechanism of EBV penetration into T-cells remains uncertain.

The pathogenesis of AIDS lymphomas: a foundation for addressing the challenges of therapy and prevention

The association between AIDS and a spectrum of malignancies relates to chronic, profound defects in both cellular and humoral mechanisms of immune surveillance. Ironically, as AIDS patients live longer in response to increasingly effective antiretroviral therapies, the incidence of AIDS-related malignancies will continue to rise. The emergence of non-Hodgkin's lymphomas (NHL) as a major sequela of HIV infection bears a striking relationship to depletion of CD4 lymphocytes, particularly below 50/mm3. The ability to interfere early in the course of active HIV infection with additional mechanisms that may promulgate transformed cell hyperproliferation and clonal expansion--growth factors, HIV itself or other viruses (Epstein-Barr, in particular), aberrant oncogene or tumor suppressor genes expression, factors that induce genetic instability or DNA damage or alter host or viral genome repair--might decrease the occurrence or prolong the time to development of AIDS-related malignancies. The development of antiretroviral strategies that confer long-term suppression of HIV activity and relative preservation of immune function are essential to the ultimate prevention of malignancies that arise as a consequence of HIV-induced immunosuppression.

Lack of evidence of Epstein-Barr virus in hairy cell leukemia and monocytoid B-cell lymphoma

An association between the Epstein-Barr virus (EBV) and hairy cell leukemia (HCL) has been reported. Due to the similarities between HCL and monocytoid B-cell lymphoma (MBCL), an association between EBV and MBCL has been postulated. To address these issues we studied 27 spleens from cases with HCL and 13 tissue specimens from cases with MBCL from various sites for evidence of EBV DNA and RNA by in situ hybridization. Using a genomic EBV internal repeat probe and an oligonucleotide probe directed against the EBER1 gene, we were unable to identify EBV DNA or RNA, respectively, in the tumor cells of any of the cases. The results of our study suggest that EBV may not be strongly linked with either HCL or MBCL.

Head and neck malignancies associated with HIV infection

Immunosuppressed persons are at greater risk of developing malignancies. In human immunodeficiency virus (HIV) immunosuppression the most common oral cancers are Kaposi's sarcoma and non-Hodgkin's lymphoma. Squamous cell carcinoma has also been reported to be associated with HIV disease. Kaposi's sarcoma is the most frequent neoplastic disease in acquired immunodeficiency syndrome and is by far the most common in the head and neck area. This article reviews the prevalence, clinical features, and management of these diseases in HIV infection.

Demonstration of Epstein-Barr viral DNA in paraffin-embedded specimens of lymphoproliferative syndrome. Evidence for a productive infection comparable to lymphoblastoid cell lines

B-cell lymphoproliferative syndromes (LPS) occurring in immunodeficient subjects are frequently associated with EBV infections. Histology as well as EBV-related serology are not diagnostic, but demonstration of EBV DNA in LPS suspected lesions might be useful for diagnosis. We studied four autopsied cases of LPS that developed in the setting of bone marrow transplantation, with proliferations ranging from poly- to monoclonal. Our protocol of DNA extraction allowed detection of EBV DNA in formalin-fixed, paraffin-embedded tissue specimens of all four cases. In dot blot hybridization the sensitivity in these specimens was 10% as compared to fresh frozen material, but still sufficient for a biotinylated probe. Southern blotting with the former DNA was not successful due to extensive degradation. In situ hybridization resulted in positive signals in all cases, using either 35S or 3H labeled probes. The labeling pattern suggested virus replication in B cells of LPS. By this, LPS resembles productively infected lymphoblastoid cell lines rather than latently EBV-infected Burkitt's lymphoma (BL). These findings strengthen the concept of LPS as a distinct clinicopathologic entity, differing from monoclonal, latently EBV-infected BL, as well as from polyclonal infectious mononucleosis, and the more common EBV-negative Non-Hodgkin lymphomas of the immunocompetent host.

Fatal B-cell lymphoproliferative syndrome in allogeneic marrow graft recipients. A clinical, immunobiological and pathological study

We have studied four cases of fatal B-cell lymphoproliferative syndrome (LPS) developing among 333 patients (incidence 1.2%) treated with allogeneic bone marrow transplantation (BMT). All four patients had received a T-cell depleted graft. Onset of the first clinical symptoms (palpable lymph node enlargement in three and IgA-lambda paraproteinemia in two patients) occurred between 41 and 188 days post-BMT (median 76 days). The course of the LPS was rapidly progressive in all cases, leading to death in 2-5 weeks. The peripheral blood showed progressive pancytopenia with disproportionally high numbers of activated NK cells, apparently compensating for the T-cell deficiency. Post-mortem histological studies disclosed polymorphic B-cell proliferations, most pronounced in the lymph nodes, spleen, liver, lungs and kidneys. Lymphohemopoietic cells were of donor origin in three patients. In the fourth patient, graft failure suggested a host origin for the proliferating cells. Immunophenotyping and gene rearrangement analysis revealed polyclonal proliferation in one patient, monoclonal proliferation in another patient, and an oligoclonal pattern in the other two patients. The clinical behavior of the LPS was independent of clonality. Immunohistologically, the proliferating cells showed characteristics of relatively mature B-cells in three cases, and pre-B-cell features in one case. Epstein Barr virus (EBV) serology indicated seroconversion (primary infection) in one child, and chronic active EBV infection in both adults. EBV DNA as well as EBV nuclear antigen (EBNA) were detected in infiltrated tissues of all four patients. The labeling pattern on in situ hybridization suggested a replicative EBV infection comparable to that in lymphoblastoid cell lines. We conclude that EBV-associated LPS developing as a result of post-transplant immunodeficiency is a distinct clinicopathologic entity, differing from non-Hodgkin's lymphoma (including Burkitt's lymphoma) and infectious mononucleosis of the immunocompetent host.

Non-Hodgkin's lymphomas in patients with human immunodeficiency virus infection. Presence of Epstein-Barr virus by in situ hybridization, clinical presentation, and follow-up

The authors studied all patients with serologic evidence of human immunodeficiency virus (HIV) infection and malignant non-Hodgkin's lymphoma (NHL) that presented at a single hospital from 1982 to 1989. Sixteen patients were identified, all white homosexual men with a mean age of 38.2 years. Lymphoma was the initial presentation of HIV infection in 37.5%. Sixty-two percent of the cases had a high-grade NHL, 31% had intermediate-grade, and 6% (one patient) had a low-grade lymphoplasmacytoid lymphoma. Extranodal involvement was present in 43.7%, with the gastrointestinal tract and liver being the most common sites. Actuarial survival was increased by treatment with methotrexate, doxorubicin, cyclophosphamide, vincristine, prednisone, and bleomycin (MACOP-B). Colorimetric in situ hybridization identified Epstein-Barr virus (EBV) in nine of the 14 cases hybridized. A statistically significant association of EBV with diffuse small noncleaved type (i.e., Burkitt's-like) (six of six) compared with other morphologic types (three of eight) was found (P = 0.025).

Expression of Epstein-Barr virus replicative proteins in AIDS-related non-Hodgkin's lymphoma cells

Epstein-Barr virus (EBV) infection in lymphoproliferative lesions has been assumed to be strictly latent. In order to investigate the possible occurrence of EBV replication in AIDS-related lymphoma (ARL) cells, we studied 13 cases by immunohistology using monoclonal antibodies to the EBV-encoded switch-protein BZLF1, early antigens (EAs), late replicative proteins [virus capsid antigens (VCAs) and membrane antigens (MAs)], and to the latent proteins EB nuclear antigen 2 (EBNA 2) and latent membrane protein (LMP). EBV genomes were detected by in situ hybridization. EBV genomes and/or gene products were demonstrated in ten cases, including all immunoblast-rich lymphomas, two Burkitts lymphomas, and a T-cell anaplastic large-cell lymphoma. The BZLF1 protein, which disrupts latency in B cells, was identified in six (60 per cent), and EAs in four (40 per cent) of the EBV-positive ARL. Only one lymphoma (10 per cent) expressed VCAs and MAs. EBNA 2 and LMP were detected in three (30 per cent) and eight (80 per cent) of EBV-positive cases, respectively. EBV DNA was detected in lymphoma cells in 7 of 12 (58 per cent) cases. The most important finding of this study was frequent spontaneous activation of latent EBV in ARL. Production of complete virus, however, was either aborted, or tumour cells expressing late productive cycle proteins (VCA, MA) were rapidly cleared from tissues. It is suggested that host factors that normally inhibit replication of EBV are deficient in AIDS patients.

Nodular cutaneous B-cell lymphoma of the scalp in the acquired immunodeficiency syndrome

Aggressive B-cell non-Hodgkin's lymphoma frequently complicates human immunodeficiency virus type 1 infection. Although extranodal disease is an important feature of this condition, the incidence of cutaneous involvement has not been determined. A review of 754 published cases of B-cell non-Hodgkin's lymphoma associated with human immunodeficiency virus type 1 revealed an incidence of cutaneous extranodal involvement of 8.2%, approximately equal to that seen in non-Hodgkin's lymphoma not associated with human immunodeficiency virus. Lymphoma was the initial manifestation of acquired immunodeficiency syndrome in two thirds of these cases. In particular, although the head and neck are commonly involved in non-Hodgkin's lymphoma not associated with human immunodeficiency virus, scalp involvement is uncommon in human immunodeficiency virus-associated B-cell non-Hodgkin's lymphoma, and we report the second case. The natural history and proposed pathogenesis of human immunodeficiency virus-associated non-Hodgkin's lymphoma are discussed.

Detection of Epstein-Barr virus genomes in Hodgkin's disease: relation to age

An investigation as to whether any particular subgroup of patients with Hodgkin's disease was particularly likely to be Epstein-Barr virus (EBV) genome positive was made on samples from 95 patients. These were grouped according to age and Hodgkin's disease subtype, and analysed using Southern blot analysis. Most samples from children or adults aged 50 years or over contained detectable EBV genomes; samples from young adults were only rarely positive. The differences in EBV positivity by age were highly significant, but there was no significant association between EBV and histological subtype after allowing for the effect of age. The results support the hypothesis that Hodgkin's disease in different age groups may have different aetiologies, and suggest that EBV does have a pathogenetic role in Hodgkin's disease in children and older age groups.

Immunologic observations in close relatives of two sisters with mammary Burkitt's lymphoma. Mammary Burkitt's lymphoma in sisters

In a sibship of four sisters, two had Burkitt's lymphoma localized to the breast. Their pretreatment Epstein-Barr virus (EBV) serology were not examined. No EBV genome was demonstrated in the tumors using an in situ hybridization technique. The mother showed an abnormal antibody response to EBV infection consisting of elevated IgA and IgG antibody titers to viral capsid antigen (VCA) and high IgG antibody titer to early antigen. Furthermore, one of the two healthy sisters showed elevated IgG antibody titer to VCA. The EBV serology is mimicking the findings in female carriers of the X-linked lymphoproliferative syndrome.

Non-Hodgkin's lymphoma after prolonged remission of Hodgkin's disease in an HIV-infected patient

Hodgkin's disease was diagnosed in a 22-year-old HIV-seropositive man in 1986. Alternate MOPP/ABVD chemotherapy induced a clinical remission. He was asymptomatic until 3 years later when fever and peripheral and mediastinal lymphadenopathy appeared. Lymph node biopsy showed a large-cell anaplastic lymphoma and EBV genome was identified in the malignant cells, suggesting that transformation might had been induced by EBV. The present case affirms that in patients with HIV-related lymphomas who present enlarging lymphadenopathy after stable remission, the development of lymphomas of higher malignancy needs to be ruled out.

Detection of Epstein-Barr virus genomes in AIDS related lymphomas: sensitivity and specificity of in situ hybridisation compared with Southern blotting

Eighteen cases of AIDS related, non-Hodgkin's lymphomas were examined for the presence of Epstein-Barr virus (EBV) genomes using in situ hybridisation with a 35S-labelled probe. The results were compared with those obtained independently by Southern blot analysis with a 32P-labelled probe of frozen tissue from the same tumours. Technically satisfactory results were obtained with both methods in 15 lymphomas. EBV DNA was detected in seven of 15 (47%) cases by in situ hybridisation and in eight of 15 (53%) cases by Southern blotting (including all the cases positive by in situ hybridisation). The results of EBV DNA detection by the two techniques were identical in 14 of 15 (93%) cases. In situ hybridisation gave no false positive results. This study shows that the sensitivity and specificity of in situ hybridisation for the detection of EBV genomes in AIDS related lymphomas approaches that of Southern blotting, even when using routinely processed archival, paraffin wax embedded material.

Acquired immunodeficiency syndrome-associated lymphomas: clinical, pathologic, immunologic, and viral characteristics of 111 cases

The incidence of lymphomas in individuals infected with the human immunodeficiency virus has increased progressively since the beginning of the acquired immunodeficiency syndrome (AIDS) epidemic. The present series includes 111 patients, all diagnosed and studied at one hospital in New York City. There were 108 men and three women; the average age was 39 years and male homosexuality was the predominant risk factor. The materials examined originated from 138 surgical specimens and 24 autopsies. There were 11 cases of Hodgkin's lymphoma and 100 cases of non-Hodgkin's lymphomas (NHL), a proportion strongly skewed in favor of the latter. Hodgkin's lymphoma in AIDS patients was characterized by advanced clinical stage, high histologic grade, and frequent bone marrow involvement. Non-Hodgkin's lymphoma in AIDS patients, in contrast to the general population, originated predominantly in extranodal locations (61 cases) versus locations in which the lymph nodes were the site of the primary tumors (39 cases). In the digestive tract, the unusual oral and anal primary locations were often noted and were possibly related to specific risk factors. There were 15 cases of NHL of the central nervous system, an incidence 14 times greater than that recorded in the general population. The majority of NHLs were of high histologic grade, Burkitt's and large cell immunoblastic, representing most of the cerebral and gastrointestinal tumors. All NHLs were of B-cell immunophenotype. Lymphadenopathies with the histologic features of human immunodeficiency virus infection, particularly of the late stage (type C), often preceded NHL. Probing for Epstein-Barr virus genome was more frequently positive in Hodgkin's lymphoma than in NHL. Immunologic evaluations showed severely depressed T cell counts and CD4 to CD8 cell ratios as well as markedly increased levels of antilymphocyte antibodies. Reflecting the background of profound immune deficiency, the AIDS-associated lymphomas were characterized by high aggressiveness, early tendency to generalization, frequent post-treatment relapse, and short periods of survival.

Detection of single copies of Epstein-Barr virus in paraffin wax sections by non-radioactive in situ hybridisation

A highly sensitive non-isotopic in situ hybridisation technique was developed for the localisation of Epstein-Barr virus (EBV) in paraffin wax embedded tissue sections. The method uses a repeated sequence of the EBV genome as a probe, labelled with the novel reporter molecule, digoxigenin. The method can identify individual copies of EBV by detection of both EBV DNA and highly localised RNA transcripts. A combination of careful proteolytic digestion of tissue sections, high temperature denaturation of probe and target DNA, and sensitive immunocytochemical detection are used to attain single copy sensitivity. The technique is quicker and simpler to perform than some other methods used for the identification of EBV, and provides simultaneous morphological information which cannot be obtained by methods using tissue extracts. This method permits the investigation of the role of EBV in neoplastic conditions of lymphoid and epithelial cells, and may prove valuable in determining the sites of latent virus in healthy subjects.

Hodgkin's disease in association with human immunodeficiency virus infection. Pathologic and immunologic features

Six patients with Hodgkin's disease (HD) and demonstrable serum antibodies to human immunodeficiency virus (HIV) and two additional patients with HD belonging to HIV-associated high-risk groups but with negative HIV serology were studied. All patients were men and ranged in age from 21 to 45 years. The HIV risk factors included homosexuality (6), intravenous drug abuse (2), and hemophilia A (1). All patients had high pathologically determined stage (one Stage III and seven Stage IV), and bone marrow involvement was observed in five patients with the initial diagnosis of HD based on marrow biopsy in two cases. Four cases were histologically subclassified as mixed cellularity (MC) and three as nodular sclerosis (NS); one patient underwent only bone marrow biopsy and was not subclassified. Histologically all cases were characterized by numerous Reed-Sternberg cells and variants, and with the exception of one case, all had a distinctive decrease in the proportion of reactive background lymphocytes compared with what is usually expected in MC or NS Hodgkin's disease (relative lymphocyte depletion). Flow-cytometric immunophenotypic studies done on cell suspensions from diagnostic lymph node biopsies in four cases showed decreased CD4:CD8 ratios (mean = 1.4) compared with expected values of 4 to 6. The relative lymphocyte depletion observed histologically is probably a reflection of the decreased tissue CD4:CD8 ratios, and this impairment of host immune response may be related to the observed high stage in all eight cases. Patients with high stage HD and the described histologic and immunologic features should be evaluated for the presence of HIV infection.

What's new in primary central nervous system lymphomas?

Primary central nervous system lymphomas (CNSL) are uncommon neoplasms accounting for about 1% of primary brain tumors. Patients with congenital or acquired immunodeficiencies including AIDS patients and transplant recipients represent the main high-risk population for CNSL occurrence. An important point emerging from the literature is that CNSL incidence has dramatically increased during the last years not only in HIV infected patients by virtue of the AIDS epidemic spread, but also for unclear reasons in immunologically normal persons. Although c-myc oncogene activation and Epstein-Barr virus infection are considered to play a role in CNSL development, the peculiar tendency of these lymphomas to occur and remain inside the CNS is not well understood and may involve putative CNS binding molecules carried by lymphocytes. The clinical presentation is characterized by a great variety of neurological disorders. Radiological features consist of hyperdense homogeneous deposits within the subcortical white matter with a pattern of marked enhancement after injection of contrast material. The tumor masses are usually ill-defined and multicentric. Although all cytological types can be observed, the most common types belong to the high-grade category of non-Hodgkin's lymphoma. Monoclonal antibodies reactive with formalin-fixed, paraffin-embedded sections can be used in conjunction with stereotactic needle biopsy to provide accurate immunological characterization of CNSL. The large majority of CNSL is of B-cell origin but T-cell lymphomas seem at the present time less exceptional than previously thought. Although radiotherapy and chemotherapy can increase length of survival, the prognosis of CNS remains dramatically poor, the shortest survival being observed in AIDS patients.

High frequency of Epstein-Barr virus genome detection in Hodgkin's disease of HIV-positive patients

Lymph nodes obtained from 7 HIV-positive and 20 HIV-negative patients with Hodgkin's disease were examined for the presence of Epstein-Barr virus antigens and genome. EBV antigens were observed in only 2 out of 20 HIV-negative patients, whereas lymph nodes of HIV-positive patients did not reveal evidence of EBV antigens. By in situ hybridization and Southern blot analysis, EBV genome was found in 5 out of 7 HIV-positive patients; the EBV genome was detected in the nucleus of Reed-Sternberg and Hodgkin's cells. EBV DNA was observed by in situ hybridization and Southern blot analysis in only 3 out of 20 HIV-negative patients with Hodgkin's disease. In both groups, Reed-Sternberg and Hodgkin's cells were negative for C3d EBV receptor. Our results show a statistically significant increased expression of EBV DNA in HIV-positive patients with Hodgkin's disease, as compared with HIV-negative patients with HD.