Occurrence of human T cell lymphotropic virus (type I) antibodies in cutaneous T cell lymphoma

Epidemiology and Etiopathology of Human T-Lymphotropic Viruses: Diagnostic and Clinical Implications for Non-Endemic Areas

Human T-lymphotropic viruses (HTLV) type I and II were first described more than a decade ago. HTLV-I epidemiology and etiopathology are more defined than those of HTLV-II, but conflicting results have been obtained in seroepidemiologic surveys, mainly for difficulties in the discrimination between the two infections. The introduction of advanced serologic and molecular assays has recently provided sensitive and specific tools for diagnosis, and the epidemiologic and etiopathologic patterns linked to these retroviruses are being more precisely defined. Moreover, extensive nucleotide sequence analyses performed so far have mainly focused on HTLV-I isolates. The recent discovery of new HTLV-II endemic areas and the isolation of HTLV-II strains from intravenous drug users have finally provided the material for the molecular characterization of HTLV-II isolates, which is now a rapidly envolving field. We review the diagnostic strategies available and the etiologic associations reported so far for both viruses and also discuss the occurrence and significance of indeterminate serologic reactivities observed in both endemic and non-endemic areas.

The Diagnosis, Staging, and Treatment Options for Mycosis Fungoides

Background

Cutaneous T-cell lymphoma (CTCL) represents a spectrum of diseases composed of malignant T lymphocytes. The most common type is mycosis fungoides (MF). An accurate diagnosis of early MF may be difficult because of the varied clinical and histologic expressions of the disease.

Methods

The authors review the epidemiology, possible risk factors, clinical manifestations, diagnostic techniques, staging, prognosis, and treatment options for MF.

Results

The varied and often nonspecific clinical and bistologic presentations of MF may delay diagnosis and staging, thus necessitating further studies such as immunophenotyping and T-cell receptor gene rearrangement analysis.

Conclusions

A multidisciplinary approach to the diagnosis, staging, and treatment of MF assists in optimizing outcomes from management of patients with this disease.

The influence of STAT5 antisense oligodeoxynucleotides on the proliferation and apoptosis of selected human cutaneous T-cell lymphoma cell lines

STAT5 (signal transducers and activators of transcription) are suggested to play a role in the pathogenesis of leukaemia and lymphoma; however, their influence on the growth of cutaneous T-cell lymphoma cells is not clear enough. The aim of our study was to analyse the function of STAT5 proteins in the proliferation and apoptosis of selected cutaneous T-cell lymphoma cell lines (HUT 78; PB-1; HUT 102B), using antisense oligodeoxynucleotide (ODN) strategy. RT-PCR and Western blot were applied to analyse the expression of STAT5 after incubation with antisense ODN (AS ODN). The effect of ODN pretreatment on the cell clonogenecity was analysed in methylcellulose cultures. The process of apoptosis was estimated using two different flow cytometry (FACScan) methods: (1) combined Annexin V/propidium iodide staining, (2) the TUNEL method. Perturbation of STAT5 expression reduced the proliferation of the PB-1 cells after a 24-h exposure to antisense ODNs. Prolonged exposure (72 h) decreased the growth of each examined cell line, especially after antisense STAT5A (AS STAT5A) treatment. Incubation with AS STAT5 induced apoptosis in the population of HUT 78 and PB-1 cells. STAT5s may play a significant role in the growth and the process of apoptosis of selected human cutaneous T-cell lymphoma cells.

Primary cutaneous CD30-positive lymphoproliferative disorders

Primary cutaneous CD30-positive (anaplastic) large T-cell lymphoma and lymphomatoid papulosis have many overlapping clinical, histologic, and immunophenotypic features. These entities are currently considered as parts of a spectrum of primary cutaneous CD30-positive lymphoproliferative disorders. We provide the clinician with practical guidelines for the diagnosis, management, and treatment of patients within this spectrum of primary cutaneous CD30-positive lymphoproliferative disorders. Most patients within this spectrum of disease have an excellent prognosis. Multi-agent chemotherapy should be reserved for patients who have extracutaneous disease.

Absence of Human T-Lymphotropic Virus Type I in Japanese Patients With Cutaneous T-Cell Lymphoma

Cutaneous T-cell lymphoma (CTCL) is a disease entity characterized by a primary sporadic T-cell proliferation in the skin. Human T-lymphotropic virus type 1 (HTLV-1) is a retrovirus that causes adult T-cell leukemia/lymphoma. Recently, several authors have detected the HTLV-1 genome in genomic DNA from patients with CTCL and proposed a causal relation of HTLV-1 to CTCL. However, it remains controversial because these studies contain some problems in materials used to detect HTLV-1. We investigated both fresh and cultured T lymphocytes (128 specimens) derived from 50 Japanese patients with CTCL, where HTLV-1 is endemic, by using polymerase chain reaction with four sets of primers including gag,pol,env, and pX regions of HTLV-1 to elucidate the relationship between HTLV-1 and CTCL in Japan. However, none of the 128 DNA specimens revealed positive for HTLV-1 in contrast to the previous studies. We conclude that CTCL, which does not include HTLV-1, is present although the pathogenesis of CTCL may be different by areas or races. © 1997 by The American Society of Hematology.

Absence of Human T-Lymphotropic Virus Type I in Japanese Patients With Cutaneous T-Cell Lymphoma

Cutaneous T-cell lymphoma (CTCL) is a disease entity characterized by a primary sporadic T-cell proliferation in the skin. Human T-lymphotropic virus type 1 (HTLV-1) is a retrovirus that causes adult T-cell leukemia/lymphoma. Recently, several authors have detected the HTLV-1 genome in genomic DNA from patients with CTCL and proposed a causal relation of HTLV-1 to CTCL. However, it remains controversial because these studies contain some problems in materials used to detect HTLV-1. We investigated both fresh and cultured T lymphocytes (128 specimens) derived from 50 Japanese patients with CTCL, where HTLV-1 is endemic, by using polymerase chain reaction with four sets of primers including gag,pol,env, and pX regions of HTLV-1 to elucidate the relationship between HTLV-1 and CTCL in Japan. However, none of the 128 DNA specimens revealed positive for HTLV-1 in contrast to the previous studies. We conclude that CTCL, which does not include HTLV-1, is present although the pathogenesis of CTCL may be different by areas or races. © 1997 by The American Society of Hematology.

The difficulty of detecting HTLV-1 proviral sequences in patients with mycosis fungoides

Although most patients with cutaneous T cell lymphomas, including mycosis fungoides (MF) and its leukemic variant, the Sézary syndrome, are seronegative for antibodies to the human T cell lymphotropic viruses (HTLV-I/II), it has recently been shown that > 95% of such patients harbor proviral DNA sequences related to the region of the HTLV genome that encodes the transregulatory/transforming gene, tax. However, the demonstration of HTLV sequences, even after amplification by polymerase chain reaction (PCR), has not been universally successful, and some investigators continue to question this observation. In an effort to resolve this controversy, we have compared published methodologies that have been less successful with techniques currently used in this laboratory. Major differences were found in (a) the nature of the cells used [freshly isolated versus cultured peripheral blood mononuclear cells (PBMC)] and (b) the methods used to prepare samples for PCR (whole cell lysates versus DNA extracts). PBMC from 10 different MF patients and the healthy daughter of 1 of the patients were subjected to comparative analyses. While all of the PBMC lysates were positive, the DNA extract from only one of these individuals revealed HTLV tax sequences. Studies were also conducted comparing cell lysates and DNA extracts of cultured cells derived from tax sequence-positive PBMC from seven different MF patients. The cells from four of the seven were shown to have retained tax sequences after varying times in culture, when whole-cell lysates were used as targets for PCR amplification and Southern analysis, whereas none of the DNA extracts were positive. It appears that the use of whole-cell lysates instead of DNA extracts and the use of fresh instead of cultured cells greatly enhance the ability to detect HTLV-1 tax sequences in specimens from MF patients.

Failure to detect human T-lymphotropic virus type-I proviral DNA in cell lines and tissues from patients with cutaneous T-cell lymphoma

Previous molecular studies investigating the presence of HTLV-I proviral DNA in cell lines and tissue samples of patients with cutaneous T-cell lymphoma (CTCL) have reported a detection rate ranging from 0-92%. Despite the lack of epidemiologic data linking HTLV-I infection with CTCL, the molecular data still invite speculation regarding the precise role of HTLV-I in the pathogenesis of CTCL. To determine the detection rate of HTLV-I proviral DNA among CTCL patients referred to our medical center, we analyzed Epstein-Barr virus-transformed cell lines established from peripheral blood of seven CTCL patients and 43 tissue samples from 22 patients with different stages of disease. Genomic DNA was polymerase chain reaction-amplified with primers within the HTLV-I tax gene region. Amplification products were probed with nested oligonucleotide probes by Southern blot analysis. No HTLV-I proviral sequences were detected in the samples (0/50). Using HTLV-I/II pol primers, no HTLV-I pol gene sequences were detected. In tissues from one patient, HTLV-II pol and tax gene sequences were detected; however, HTLV-II proviral integration was not detected by Southern blot analysis of the genomic DNA. Our data suggest: (i) HTLV-I does not appear to be a primary etiologic agent in CTCL; and (ii) HTLV-II pol and tax gene sequences can be detected in a minority of CTCL patients, but this does not necessarily imply an etiologic role.

The cutaneous T cell lymphoma, mycosis fungoides, is a human T cell lymphotropic virus-associated disease. A study of 50 patients

For nearly two decades it has been suspected that the cutaneous T cell lymphoma, mycosis fungoides (MF), and its leukemic variant, the Sézary syndrome, are caused by the human T lymphotropic virus (HTLV-I/II). Arguments against this concept included the finding that only a small number of MF patients have antibodies to HTLV-I/II and that attempts to detect proviral sequences by mere Southern hybridization of extracted DNA usually met with failure. However, we have reported repeatedly that HTLV-like particles emerge in blood mononuclear cell (PBMC) cultures of practically all patients with this disease. In several instances, the particles were identified as HTLV by immunoelectron microscopy as well as biomolecular analysis. With the assumptions that the virus in MF patients may have become detection by Southern hybridization alone, the extracts of freshly isolated PBMC of 50 consecutive patients were subjected to combined PCR/Southern analysis. Here we report the presence of HTLV pol and/or tax proviral sequences in 46 out of 50 (92%) of the patients tested. In addition, five of the patients, who lacked antibodies to HTLV-I/II structural proteins, were found to be seropositive for tax. It thus seems reasonable to conclude that MF/Sézary syndrome is an HTLV-associated disease and that lack of an immune response does not preclude infection with this type of virus.

Detection of Epstein-Barr virus genome in primary cutaneous T and B cell lymphomas and pseudolymphomas

The Epstein-Barr virus (EBV) genome has recently been identified in Hodgkin's disease (HD) and nodal non-Hodgkin's lymphomas (NHL). In order to elucidate the possible aetiopathogenetic role of EBV in benign and malignant lymphoproliferative disorders we investigated skin specimens from 24 patients with a primary cutaneous lymphoproliferative disorders (10 T-cell lymphomas 6 B-cell lymphomas and 8 pseudolymphomas) and from 22 normal individuals for the presence of EBV DNA using the polymerase chain reaction (PCR) technique and in situ hybridization (ISH) on formalin-fixed paraffin-embedded tissue sections. EBV DNA was identified by PCR in one of two cases of mycosis fungoides, in one of seven cases of pleomorphic T-cell lymphomas, in one case of centroblastic (CB) lymphoma of six B-cell lymphomas, and in three of eight pseudolymphomas. The EBV genome was also found in 2 of 22 specimens of normal skin. The small EBV-encoded nuclear RNAs, EBERs, were not detected in any PCR-positive sample by ISH. Based on our PCR and ISH findings, EBV does not seem to play a significant role in the development of cutaneous lymphomas.

Examination of cutaneous T-cell lymphoma for human herpesviruses by using the polymerase chain reaction

The etiology of cutaneous T-cell lymphoma remains unknown, although an association with viral infection, in particular certain retroviruses and human herpesviruses, has been suggested. The purpose of this study was to examine skin biopsies of cutaneous T-cell lymphoma for the presence of Epstein-Barr virus, herpes simplex virus type 1 and type 2, and human herpesvirus-6 by using the polymerase chain reaction. Lesional skin biopsies from 30 patients with cutaneous T-cell lymphoma were studied. Control specimens included biopsies from 9 patients with lymphomatoid papulosis and 10 patients with pityriasis lichenoides et varioliformis acuta. DNA extracted from each specimen, as well as from a known positive control for each virus, was examined by using the polymerase chain reaction with viral-specific primers. Each DNA specimen was also amplified with control primers for human beta globin. The specificity of the amplified products was confirmed by Southern analysis. Neither Epstein-Barr virus nor herpes simplex virus was detected in any of the patient specimens examined. Human herpesvirus-6 was detected in one specimen of cutaneous T-cell lymphoma and one specimen of lymphomatoid papulosis. These results do not support a role for any of these herpesviruses in the pathogenesis of cutaneous T-cell lymphoma.

Absence of Epstein-Barr viral RNA in lymphomatoid papulosis

Epstein-Barr virus (EBV) recently has been implicated in the pathogenesis of Hodgkin's disease (HD). Lymphomatoid papulosis (LyP) is a premalignant cutaneous lymphoproliferative disorder which shares several characteristics with HD. The hypothesis has been made that EBV may be associated with the pathogenesis of LyP. We therefore examined 17 skin biopsy specimens and two lymph nodes from nine patients with LyP for EBV RNA using the highly sensitive and specific EBER method. In all specimens, the large atypical cells were negative for EBV while poly T studies confirmed the presence of adequate RNA for detection of EBER. The negative EBER results were confirmed in seven LyP patients whose biopsies were also stained for latent membrane protein (LMP-1). Interestingly, one patient with clonally related LyP and HD had no EBV RNA detected in any specimen. We conclude that EBV is unlikely to be an important aetiological agent in LyP. If confirmed in other patients, HD associated with LyP may have a different aetiology from HD arising de novo.

Tumor viruses in CD30-positive anaplastic large cell lymphomas

CD30+ anaplastic large cell lymphoma (ALCL) represents a novel lymphoma entity at the borderline between Hodgkin's disease and non-Hodgkin's lymphomas. Phenotypic, genotypic, and karyotypic analyses have shown that ALCL are heterogeneous in cellular origin, and may be conceived as malignancies derived from activated, mainly T- or B-lymphoid cells, in some instances with an immature genotype. Epstein-Barr virus genomes and gene products, most notably the transformation-associated latent membrane protein (LMP), have been detected in a proportion of cases, and some cutaneous ALCL proved to harbor complete or incomplete HTLV-1 proviruses. These findings suggest that both EBV and HTLV-I, which are powerful inducers of CD30 expression in lymphoid cells in vitro, may contribute to the pathoetiology of ALCL.

Epidemiology of lymphomatoid papulosis

BACKGROUND

Lymphomatoid papulosis is a rare skin disease with malignant potential. Its epidemiology is largely unknown.

METHODS

A case-control study of lymphomatoid papulosis was done to characterize the patient population and investigate the risk factors for its development. Fifty-seven patients with biopsy-proven lymphomatoid papulosis and 67 individually matched control subjects who were recruited among relatives and acquaintances of the patients answered a standard questionnaire over the telephone.

RESULTS

Among patients with lymphomatoid papulosis, 3 had a history of Hodgkin disease, 3 had non-Hodgkin lymphoma, and 10 had mycosis fungoides; none of the control subjects reported such histories. No significant differences were observed between patients and control subjects in regard to residence or travel history or exposures to various physical, chemical, and biologic agents. A higher, although not statistically significant, percentage of patients than control subjects reported a history of radiation therapy and nonlymphoid malignant lesions. No differences were found between patients and control subjects in regard to other medical conditions or family medical history.

CONCLUSIONS

Patients with lymphomatoid papulosis have a significantly increased frequency of prior or coexisting lymphoproliferative disorders, an increased frequency of nonlymphoid malignant lesions, and exposure to radiation therapy.

No detection of HTLV-I DNA in punch skin biopsies from patients with cutaneous T-cell lymphoma by the polymerase chain reaction

In this study we have tried to take advantage of the high genetic homology between conserved regions of human T-cell lymphotropic virus (HTLV) types I and II, hoping that a possible retrovirus in patients with cutaneous T-cell lymphoma (CTCL) would have regions with homology to types I/II. DNA was extracted from punch skin biopsies from 21 patients and subjected to the polymerase chain reaction (PCR), using primer sets designed to match conserved regions in the HTLV-I/II genome. The PCR products were subjected to agarose gel electrophoresis with subsequent Southern blotting and hybridization to an HTLV-I probe. No bands of exogenous origin were seen on the agarose gel or by hybridization. If a retrovirus is present in the skin in CTCL patients, it is either not related to HTLV-I/II, present at a copy number below the PCR detection limit, or has been cleared from the skin before the clinical symptoms appear.

A registry-based case-control study of mycosis fungoides

The etiology of mycosis fungoides is unknown. Two possible causes (an unknown retrovirus with increased prevalence among never-married men, and prior malignancies) were investigated to determine whether they are associated with the incidence of mycosis fungoides. During 1973 to 1986, 953 case patients with mycosis fungoides or Sézary syndrome were registered by the Surveillance, Epidemiology, and End Results program. Each was matched by 5-year age group, sex, ethnicity, and geographic area to four control subjects, one each with cancer of the pancreas, brain, and stomach, and non-Hodgkin's lymphoma. For never-versus ever-married men, none of the relative risks differed significantly from those for women (odd ratios, .8-1.0). For any prior malignancy, the relative risks (and 95% confidence intervals) were 1.3 (.9-2.0), 1.2 (.8-1.8), 1.0 (.7-1.5), and 1.1 (.7-1.6). These data reject the previous relative risk estimate of 3.3 with greater than 99% power, and are consistent with only a small risk, if any, attributable to prior malignancy.

Deleted HTLV-I provirus in blood and cutaneous lesions of patients with mycosis fungoides

Mycosis fungoides, a rare form of cutaneous T cell leukemia/lymphoma, is suspected of having a viral etiology on the basis of certain similarities to adult T cell leukemia, which is associated with human T cell leukemia/lymphoma virus type I (HTLV-I) infection. Cell lines were established from peripheral blood mononuclear cells (PBMC) of an HTLV-I-seronegative patient with mycosis fungoides. DNA hybridization analysis revealed the presence of HTLV-I-related sequences with unusual restriction endonuclease sites. Sequence analysis of subcloned fragments demonstrated the presence of a monoclonally integrated provirus with a 5.5-kilobase deletion involving large regions of gag and env and all of pol. Additional evidence for the presence of deleted proviruses was found by polymerase chain reaction (PCR) amplification of DNA from cutaneous lesions of five other HTLV-I-seronegative patients. The findings suggest that HTLV-I infection may be involved in the etiology of at least certain cases of mycosis fungoides.

Antibodies against retroviral core proteins in relation to disease outcome in patients with mycosis fungoides

We have studied the relationship of antibodies reacting with human retroviral core proteins to the disease outcome in Finnish mycosis fungoides (MF) patients in a prospective manner. Antibodies recognizing human T-cell leukaemia/lymphoma virus I (HTLV-I) or human immunodeficiency virus type 1 (HIV-1) core proteins were found in 12 of 14 MF patients as shown by the Western blot method. The antibody reactivities showed three patterns: three patients had antibodies cross-reacting with the gag-encoded core proteins of both HTLV-I and HIV-1; seven patients showed antibodies reacting with HTLV-I core proteins only; and the sera of two patients reacted with HIV p24 core protein only. When following the clinical course of these patients, we found that the three patients with antibodies cross-reacting with both viruses had the most fulminant clinical course, and the overall duration of MF was, on average, 4 years less than in the rest of the patients. None of the patients, however, became leukaemic, or showed any other features suggestive of acute T-cell leukaemia/lymphoma (ATL). Two patients, who did not show anti-retroviral antibodies during the follow-up, had a stable disease with plaque-type skin lesions. Histological or immunohistological typing of the skin infiltrates did not correlate with the disease outcome or the above antibody patterns. Our results thus raise the possibility that an unknown retrovirus, immunologically related to the known human retroviruses, may be aetiologically linked to MF.

Epidermal Langerhans' cell densities influence survival in mycosis fungoides and Sézary syndrome

Because Langerhans' cells (LC) (CD1a-positive epidermal cells) have been discussed to be involved in the pathogenesis of mycosis fungoides and Sézary syndrome, the authors examined the influence of densities of Langerhans' cells and, concurrently, of other phenotypes retrospectively on survival of 35 patients. Cell densities were assessed on cryostat sections (alkaline phosphatase antialkaline phosphatase-technique) of the respective diagnostic biopsy specimens. Additionally, two clinical parameters (age, stage of disease) were evaluated. CD1a-positive epidermal cells were demonstrated to be the only cell population being significantly associated (P = 0.011) with survival. Death resulting from mycosis fungoides and Sézary syndrome was significantly (P = 0.003) less frequent in patients with epidermal CD1a-positive cell densities higher than 90 cells/mm2 (optimal break point) as compared with patients with lower numbers. These results suggest that Langerhans' cells have a significant impact on prognosis of patients with mycosis fungoides and Sézary syndrome. They play an important role in the host defense mechanisms against these lymphomas rather than to favor their progression as proposed recently.

Sézary syndrome: diagnosis, prognosis, and critical review of treatment options

Sézary syndrome is a form of leukemia-lymphoma characterized clinically by erythroderma, pruritus, adenopathy, and circulating atypical cells with cerebriform nuclei. Histologically, atypical lymphocytes in the dermis and Pautrier's microabscesses are often present in skin biopsy specimens. Immunologic findings that support a diagnosis of Sézary syndrome include a predominance of CD4+ lymphocytes in both skin biopsy specimens and peripheral blood. Cytogenetic studies that demonstrate aneuploidy and DNA probe analysis that shows gene rearrangement for the beta-subunit of the T cell receptor are the latest, most sensitive, and specific methods for identifying the clonal nature of the disease. Various staging systems are used. We review the various treatments for Sézary syndrome, including the newer, biologically based investigational therapies, (e.g., antithymocyte globulin, monoclonal antibodies and other immunostimulants, retinoids, cyclosporine, interferon, and extracorporeal photopheresis). Extracorporeal photopheresis and some chemotherapeutic agents appear to produce the best results in terms of response and remission duration with minimal toxicity. However, more multicenter controlled clinical trials are needed to determine the most effective single or combined therapeutic regimen.

Fatal cutaneous T cell lymphoma in a child with atopic dermatitis

The development of a fatal cutaneous T cell lymphoma in a child with atopic disease is presented. From very early childhood the patient had classic atopic dermatitis, and at age 13 developed lymphoma-like skin tumors. The diagnosis--based on immunohistologic criteria--was initially difficult to establish, but cytogenetic and DNA studies of the dermal infiltrate supported the clinical suspicion of malignancy. In addition, the T cell receptor beta chain gene showed a clonal rearrangement pattern both in skin and in lymph node, suggesting malignancy. Whether the malignant evolution in our patient took place primarily in the skin or in the lymph nodes is difficult to decide. Further examination of the association between atopic dermatitis and cutaneous T cell lymphoma may lead to insights into both disorders.

HTLV-1 in Switzerland: low prevalence of specific antibodies in HIV risk groups, high prevalence of cross-reactive antibodies in normal blood donors

Sera from various Swiss population groups were tested for antibodies against the human T-cell leukemia virus type I (HTLV-I). Particle agglutination and ELISA were performed for screening; Western blot was done for confirmation. True-positive sera were found at a prevalence of 0.12% in a cohort of 846 individuals at risk for AIDS tested in 1984-1985. Prevalences of 0.35% were found among 575 HIV-I positives tested in 1987, and of 1.3% among 292 HIV-I positives of a different group tested in 1988. The 6 positives found in our study represent the first cases of HTLV-I infection, or HIV-I/HTLV-I double infection, diagnosed in Switzerland. In addition, high proportions of sera, regardless of whether they were from normal blood donors, HIV-positives, or individuals at risk for AIDS, had antibodies that reacted weakly with one or several proteins of the size of viral gag proteins. The prevalence of such antibodies in normal donors was in the range of 10 to 40%, depending on the strictness of interpretation. Competition Western blots performed with some of these sera showed that these antibodies reacted with HTLV-I, but not with HIV-I or cellular antigens, and had a lower affinity to HTLV-I proteins than the antibodies of human or goat antisera. The results indicate that these antibodies may be induced by agents immunologically related to, but different from, HTLV-I, which are highly prevalent in the Swiss population. Oligopeptide stretches with sequence homology to HTLV-I are known to exist in various normal body proteins, several infectious agents including common viruses and protozoa, but the results might also indicate the existence of additional human retroviruses. Screening of blood donors with sensitive tests for antibodies to HTLV-I might produce an unacceptably high rate of false-positive results, if stringent rules of interpretation analogous to those common in HIV screening are not used.