Detection of Epstein-Barr virus in esophageal squamous cell carcinoma in Taiwan

Molecular characterization of plasma virome of hepatocellular carcinoma (HCC) patients

Hepatocellular carcinoma (HCC) stands as the most common cancer type, arising from various causes, and responsible for a substantial number of cancer-related fatalities. Recent advancements in viral metagenomics have empowered scientists to delve into the intricate diversity of the virosphere, viral evolution, interactions between viruses and their hosts, and the identification of viral causes behind disease outbreaks, the development of specific symptoms, and their potential role in altering the host's physiology. The present study had the objective of "Molecular Characterization of HBV, HCV, anelloviruses, CMV, SENV-D, SENV-H, HEV, and HPV viruses among individuals suffering from HCC." A total of 381 HCC patients contributed 10 cc of blood each for this study. The research encompassed the assessment of tumor markers, followed by molecular characterization of HBV, HCV, Anelloviruses (TTV, TTMV, and TTMDV), SENV-H and SENV-D viruses, HEV, CMV, and HPV, as well as histopathological examinations. The outcomes of this study revealed that majority of the HCC patients 72.4% (276/381) were male as compared to females. HCV infection, at 76.4% (291 out of 381), exhibited a significant association (p < 0.05) with HCC. Most patients displayed singular lesions in the liver, with Child Pugh Score Type B being the predominant finding in 45.2% of cases. Plasma virome analysis indicated the prevalence of TTMDV (75%), followed by TTMV (70%) and TTV (42.1%) among anelloviruses in HCC patients. Similarly, SENV-H (52%) was followed by SENV-D (20%), with co-infections at 15%. The presence of CMV and HEV among the HCC patients was recorded 5% each however 3.5% of the patients showed the presence of HPV. In conclusion, this study underscores that HCC patients serve as reservoirs for various pathogenic and non-pathogenic viruses, potentially contributing to the development, progression, and severity of the disease.

Oesophageal carcinoma: The prevalence of DNA tumour viruses and therapy

Oesophageal carcinoma ranks the sixth leading cause of cancer death and affected 544,000 - 604,000 people in 2020. Patients often presented with a poor cancer prognosis with a low survival rate of 15-25%. Depending upon the cell type, oesophageal carcinoma is categorised into oesophageal squamous cell carcinoma (ESCC) and oesophageal adenocarcinoma (EAC). ESCC is predominantly reported in developing countries, while EAC is more common in developed countries. Aside from the presence of exogenous co-factors, such as cigarette smoking, alcohol consumption, obesity, gastroesophageal reflux disease (GERD); infection with oncogenic viruses is suspected to be one of the major factors contributing to EC development. Oncogenic viruses, including human papillomavirus (HPV), Epstein Barr virus (EBV), Cytomegalovirus (CMV) and Herpes Simplex Virus (HSV) have been detected in various proportions of EC samples. Nonetheless, their aetiological roles in EC remain debatable. In this review, we garnered previous studies that focus on the association between oncogenic viruses and EC. Among these oncogenic viruses, HPV appears to have a stronger association with EC than the others. In addition, we also discuss the pros and cons of the treatment regimens to treat EC patients, including immunotherapy, chemo- and chemoradiotherapy, and their efficacy.

Viral Pathogens in Oesophageal and Gastric Cancer

Tumour virology was born with the discovery by Peyton Rous in 1911 of a filterable agent in chicken cellular extracts that caused neoplasia in healthy chickens. Universally, 20% of all human cancers have a viral aetiology. Viruses are involved at various stages of the carcinogenesis pathway, depending on the viral pathogen, and likely require co-factors. Multiple risk factors have been associated with oesophageal and gastric malignancy, including carcinogenic pathogens. These viruses and bacteria include human papillomavirus (HPV) [oesophageal cancer], Epstein-Barr virus (EBV) [proximal stomach cancer], and Helicobacter pylori (HP) [non-cardia stomach cancer]. Viruses such as EBV have been firmly established as causal for up to 10% of gastric cancers. HPV is associated with 13 to 35% of oesophageal adenocarcinoma but its role is unclear in oesophageal squamous cell carcinomas. The causal relationship between hepatitis B (HBV), cytomegalovirus (CMV), HPV, and John Cunningham (JCV) and gastric neoplasia remains indeterminate and warrants further study. The expression of viral antigens by human tumours offers preventive and therapeutic potential (including vaccination) and has already been harnessed with vaccines for HPV and HBV. Future goals include viral protein-based immunotherapy and monoclonal antibodies for the treatment of some of the subset of EBV and HPV-induced gastro-esophageal cancers.

Gastrointestinal tumors and infectious agents: A wide field to explore

Infection is currently one of the main contributors to carcinogenesis. In fact, the International Agency for Research on Cancer has categorized eleven biological agents as group I carcinogens. It is estimated that around 16% of the 12.7 million new cancers diagnosed in 2008 were attributable to infectious agents. Although underdeveloped regions carry the highest incidence rates, about 7.4% of infection-related cancer cases occur in developed areas. Physicians are increasingly aware of the potential carcinogenic role of common virus like the Human Papilloma virus in cervical cancer, or the hepatitis B and C viruses in hepatocarcinoma. However, the carcinogenic role of several other infectious agents is less recognized. Given that gastrointestinal malignancies carry an overall poor prognosis, a better understanding of the carcinogenic mechanisms triggered by infectious agents is key to decrease the rate of cancer related deaths. Preventive measures directed to such infections would ideally impact survival. In this paper we review the main pathogenic mechanisms related to the development of gastrointestinal malignancies induced by infectious microorganisms and other pathogens which are currently under investigation.

Association of Epstein–Barr Virus and Cytomegalovirus Infections with Esophageal Carcinoma

Background: Given the fact that viral infections play an important role, either directly or indirectly, in around 20 percent of human cancers, this study aimed at investigating the potential association of Epstein–Barr virus (EBV) and cytomegalovirus (CMV) infections in esophageal cancer that is the sixth most common cause of cancer-related deaths. Methods: In this case-control study, a total of 200 paraffin-embedded biopsies of cancerous and benign esophageal tissues were gathered from the biopsy bank of Imam Reza Hospital, Tabriz, Iran in 2017. All samples were first deparaffinized, and then subjected to commercial DNA extraction. The quality of extracted DNA was evaluated by amplification of the beta globulin gene. Identification of EBV and CMV DNA was performed using primers designed for the EBER region of EBV and the immediate early (IE) region of the CMV genome, respectively. Results: The mean age of the subjects in the test and control groups was 52.2 (17.1) and 59.9 (18.9), respectively. The distribution of gender (male/female) in patient and control groups was 54/46 and 53/47, respectively. Our results showed that the frequency of EBV (P < 0.001) and CMV (P < 0.001) in cancerous samples was statistically higher than control group. Moreover, in the cancerous group the rate of EBV was significantly higher in the esophageal adenocarcinomas (EAC) sample (12 out of 70) than esophageal squamous cell carcinomas (ESCC) (0 out of 30) (P = 0.016) but, in the ESCC group, 17 out of 30 subjects were positive for CMV which was significantly higher in comparison with EAC patients (1 out of 70) (P < 0.001). Conclusions: Findings indicated that EBV and CMV might be contributed to the pathogenesis of EAC and ESCC types of esophageal carcinoma, respectively, although further studies are warranted.

Risk factors for esophageal cancer in a high-incidence area of Malawi

PURPOSE

To explore associations of nutritional, infectious, and lifestyle factors with esophageal cancer (EC) occurrence in a high-risk area of Malawi.

METHODS

This case-control study was performed with 227 patients undergoing endoscopy for dysphagia or other upper gastrointestinal complaints. Data on clinicopathological characteristics and risk factors were collected using a questionnaire developed for this study specifically. Ninety-eight blood samples were collected and the prevalence of antibodies against human immunodeficiency virus, herpes simplex virus, cytomegalovirus, Epstein-Barr virus, varicella-zoster virus, and Helicobacter pylori were determined serologically.

RESULTS

The tumor and control groups comprised 157 (69.2%) and 70 (31.8%) patients, respectively. Patients with tumors were significantly older than controls (55.5 vs. 43.5 years, p < 0.001). The male/female ratio did not differ between groups (59% and 54% male, respectively; p = 0.469). EC was associated with smoking (p < 0.001), and alcohol consumption (p = 0.020), but 43% of patients with tumors did not smoke or drink. EC was associated with the consumption of hot food and tea (p = 0.003) and smoked fish (p = 0.011). EC was not associated with any serologically investigated infectious agents. In an age adjusted binary logistic regression analysis of all nutritive factors, only locally made alcohol was significant [odds ratio (OR), 9.252; 95% confidence interval (CI), 1.455-58.822; p = 0.018].

CONCLUSIONS

Apart from alcohol consumption and smoking, the consumption of hot food or tea and smoked fish are associated with EC. Locally distilled alcohol consumption increases the EC risk in Malawi.

Viruses and esophageal cancer

Esophageal adenocarcinoma (EAC) has had the fastest increasing incidence of any solid tumor in the United States in the last 30 years. Long standing gastroesophageal reflux disease is a well-established risk factor with strong associations with obesity, alcohol and tobacco. However, there are likely additional contributing factors. Viruses such as human papillomavirus, ebstein-barr virus and herpes simplex virus have been implicated in the pathogenesis of esophageal cancer. This review will discuss the known literature linking viruses to esophageal adenocarcinoma and consider future relationships such as identifying prognostic and predictive molecular biomarkers to guide therapies.

Viruses in Cancers of the Digestive System: Active Contributors or Idle Bystanders?

The human virome, which is a collection of all the viruses that are present in the human body, is increasingly being recognized as an essential part of the human microbiota. The human gastrointestinal tract and related organs (e.g., liver, pancreas, and gallbladder)-composing the gastrointestinal (or digestive) system-contain a huge number of viral particles which contribute to maintaining tissue homeostasis and keeping our body healthy. However, perturbations of the virome steady-state may, both directly and indirectly, ignite/sustain oncogenic mechanisms contributing to the initiation of a dysplastic process and/or cancer progression. In this review, we summarize and discuss the available evidence on the association and role of viruses in the development of cancers of the digestive system.

Blood-based Markers in the Prognostic Prediction of Esophagogastric Junction Cancer

Esophagogastric junction cancer poses a great threat to human beings both in western countries and East Asia, especially in China and Japan, and its incidence has increased during recent decades. The 5-year survival rate of esophagogastric junction cancer is quite poor compared with that of other gastric cancer sites. Until now, the traditional TNM staging system has been widely used in clinical practice for prognosis. However, the TNM system is based on pathology after surgical resection or radiology using CT and MRI, not on blood markers. Evidently, some research has been reported concentrated on the prognostic value of blood-based markers with the character of non-invasive and non-radioactive in EJA. Hematologic, biochemical and coagulation parameters could be obtained from clinical data and utilized to analyze their prognostic values. Tumor-associated antigens, microRNAs and circulating tumor cells have also been reported in EJC prognosis. In this article, we review research focused on blood-based markers to evaluate their prognostic value in esophagogastric junction cancer, especially its main subtype adenocarcinoma.

Sensitive detection of EBV microRNAs across cancer spectrum reveals association with decreased survival in adult acute myelocytic leukemia

Epstein Barr virus (EBV) is the etiologic agent involved in numerous human cancers. After infecting the host, EBV establishes a latent infection, with low levels of messenger RNA (mRNA) and protein expression, evolved to evade immune recognition. Conversely, EBV microRNAs (miRNA) are expressed ubiquitously and abundantly within infected cells. Their role in tumor biology and clinical outcomes across the spectrum of cancer is not fully explained. Here, we applied our bioinformatics pipeline for quantitative EBV miRNA detection to examine sequencing data of 8,955 individual tumor samples across 27 tumor types representing the breadth of cancer. We uncover an association of intermediate levels of viral miRNA with decreased survival in adult acute myeloid leukemia (AML) patients (P = 0.00013). Prognostic modeling of this association suggests that increased EBV miRNA levels represent an independent risk factor for poor patient outcomes. Furthermore, we explore differences in expression between elevated and absent viral miRNA loads in adult AML tumors finding that EBV positivity was associated with proinflammatory signals. Together, given no associations were found for pediatric AML, our analyses suggests EBV positivity has the potential for being a prognostic biomarker and might represent a surrogate measure related to immune impairment in adult patients.

Epstein-Barr virus and mismatch repair deficiency status differ between oesophageal and gastric cancer: A large multi-centre study

BACKGROUND

Oesophageal (OeC) and gastric (GC) cancer patients are treated with similar multimodal therapy and have poor survival. There remains an urgent clinical need to identify biomarkers to individualise patient management and improve outcomes. Therapy with immune checkpoint inhibitors has shown promising results in other cancers. Proposed biomarkers to predict potential response to immune checkpoint inhibitors include DNA mismatch repair (MMR) and/or Epstein-Barr virus (EBV) status. The aim of this study was to establish and compare EBV status and MMR status in large multi-centre series of OeC and GC.

METHODS

EBV was assessed by EBV-encoded RNA (EBER) in situ hybridisation and MMR protein expression by immunohistochemistry (IHC) in 988 OeC and 1213 GC from multiple centres. In a subset of OeC, microsatellite instability (MSI) was tested in parallel with MMR IHC.

RESULTS

Frequency of MMR deficiency (MMRdef) and MSI was low in OeC (0.8% and 0.6%, respectively) compared with GC (10.3%). None of the OeCs were EBER positive in contrast to 4.8% EBER positive GC. EBV positive GC patients were younger (p = 0.01), more often male (p = 0.001) and had a better overall survival (p = 0.012). MMRdef GC patients were older (p = 0.001) and showed more often intestinal-type histology (p = 0.022).

CONCLUSIONS

This is the largest study to date indicating that EBV and MMRdef do not play a role in OeC carcinogenesis in contrast to GC. The potential clinical usefulness of determining MMRdef/EBV status to screen patients for eligibility for immune-targeting therapy differs between OeC and GC patients.

A viral map of gastrointestinal cancers

Cancers of the gastrointestinal tract (GIT) are expected to account for approximately 20% of all cancers in 2017. Apart from their high incidence, GIT cancers show high mortality rates, placing these malignancies among the most prominent public health issues of our time. Cancers of the GIT are the result of a complex interplay between host genetic factors and environmental factors and frequently arise in the context of a continued active inflammatory response. Several tumor viruses are able to elicit such chronic inflammatory responses. In fact, several viruses have an impact on GIT tumor initiation and progression, as well as on patients' response to therapy and prognosis, through direct and indirect mechanisms. In this review, we have gathered information on different viruses' rates of infection, viral-driven specific carcinogenesis mechanisms and viral-related impact on the prognosis of cancers of the GIT (specifically in organs that have an interface with the environment - esophagus, stomach, intestines and anus). Overall, while some viral infections show a strong causal relation with specific gastrointestinal cancers, these represent a relatively small fraction of GIT malignancies. Other types of cancer, like Esophageal Squamous Cell Carcinoma, require further studies to confirm the carcinogenic role of some viral agents.

Evaluation of the Prevalence of Human Papillomavirus and Epstein-Barr Virus in Esophageal Squamous Cell Carcinomas

The aim of this study was to determine the possible involvement of human papillomavirus and Epstein-Barr virus in esophageal squamous cell cancer (ESCC) carcinogenesis in the Greek population. DNA was extracted from 30 ESCC and 27 normal esophageal specimens and screened for HPV type-specific or EBV infection by PCR-based assay. Seventeen out of 30 ESCC specimens (56%) were found positive for HPV DNA, of which 15 (88%) were typed as HPV-18 infected, one (5.9%) as HPV-16 infected, and one (5.9%) as infected by an HPV type different from the studied HPV-6, 11, 16, 18 and 33 subtypes. Six of the 27 normal esophageal specimens (22.2%) were positive for HPV infection, five typed as HPV-18 (83.3%) and one as HPV-16 (16.7%). All samples were negative for EBV genome detection as assessed by the PCR assay. No statistically significant correlation was found between the HPV status of the tumor samples and clinical parameters including sex, age of the patients, tobacco or alcohol use, differentiation grade of the lesions and stage of the disease. In conclusion, our findings indicate a statistically significant (p<0.001) overall association between ESCC and HPV infection, mostly related to the HPV-18 subtype, in the Greek population.

Viruses, Other Pathogenic Microorganisms and Esophageal Cancer

BACKGROUND

Esophageal cancer (EC) is the eighth most prevalent malignant tumor and the sixth leading cause of cancer mortality throughout the world. Despite the technical developments in diagnosis and treatment, the 5-year survival rate is still low. The etiology of EC remains poorly understood; multiple risk factors may be involved and account for the great variation in EC incidence in different geographic regions.

SUMMARY

Infection with carcinogenetic pathogens has been proposed as a risk factor for EC. This review explores the recent studies on the association of human papillomavirus (HPV), Epstein-Barr virus (EBV), Helicobacter pylori and esophageal bacterial biota with EC.

KEY MESSAGE

Among the above-mentioned pathogens, HPV most likely contributes to esophageal squamous cell carcinoma (ESCC) in high-risk populations. New techniques are being applied to studies on the role of infection in EC, which will inevitably bring novel ideas to the field in the near future.

PRACTICAL IMPLICATIONS

Multiple meta-analyses support the finding of a higher HPV detection rate in regions associated with high risk for ESCC compared to low-risk areas. A potential role of HPV in the rise of esophageal adenocarcinoma (EAC) was proposed recently. However, further studies are required before a firm conclusion can be drawn. Less work has been done in studying the association between EBV and ESCC, and the results are quite controversial. H. pylori infection is found to be inversely related to EC, which is probably due to the reduced incidence of gastroesophageal reflux disease. Analysis of the esophageal bacterial biota revealed distinct clusters of bacteria in normal and diseased esophagi. A type II microbiome rich in Gram-negative bacteria potentially contributes to EAC by inducing chronic inflammation. Novel findings from such studies as these may benefit public health by justifying anti-infection measures to prevent EC.

Infection and esophageal cancer

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on infection and cancer, and includes commentaries on the influence of bacterial infections on mucin expression and cancer risk; the role of esophageal bacterial biota in the incidence of esophageal disease; the association between human papilloma virus (HPV) and esophageal squamous cell carcinoma; the role of HPV in esophageal adenocarcinoma; the role of Helicobacter pylori in cardiac carcinoma; and the role of Epstein-Barr virus infection in esophageal cancer.

Role of human papillomaviruses in esophageal squamous cell carcinoma

Esophageal cancer (EC) is responsible for almost half a million deaths worldwide annually and has a multifactorial etiology, which may account for its geographical variation in incidence. In the last 30 years the potential of human papillomaviruses (HPV) as oncogenes or co-factors in the tumorigenic process of esophageal squamous cell carcinoma (ESCC) has been widely studied. While the etiology of HPV in cervical and certain other anogenital and aerodigestive cancers has been established, results regarding its role in EC have been largely inconclusive. A causal association can be evaluated only with a case-control study, where normal controls are compared to ESCC cases for the presence of HPV. We reviewed all studies investigating ESCC tissue for HPV DNA and identified 139 that met our inclusion criteria, of which only 22 were case-control studies. Our results support previous findings of higher levels of HPV detection in high-risk ESCC regions than in areas of low risk. In addition, we confirm that the role of HPV in ESCC remains unclear, despite an accumulation of studies on the subject. The variations in investigative technique, study design and sample types tested may account for the lack of consistency in results. There is a need for a meta-analysis of all case-control studies to date, and for large, well-designed case-control studies with adequate power to investigate the association. The potential benefits of prophylactic HPV vaccines could be evaluated if HPV is identified as an etiological factor in EC, highlighting the need for further research in this area.

Geographic origin is a significant determinant of human papillomavirus prevalence in oesophageal squamous cell carcinoma: systematic review and meta-analysis

BACKGROUND

Since the first reports in 1982 suggesting an aetiological role for human papillomavirus (HPV) in a subset of oesophageal squamous cell carcinomas (ESCC), the literature reporting HPV detection in ESCC has expanded rapidly. However no formal meta-analysis of this literature has been published yet. The objective of this study was to perform a systematic review and formal meta-analysis of the literature reporting HPV detection in ESCC.

METHODS

MEDLINE and Current Contents were searched through March 2012. The effect size was calculated as event rates and their 95% confidence interval (95% CI), with homogeneity testing using Cochran's Q and I² statistics. Meta-regression was used to test the impact of study-level covariates (HPV detection method, geographic origin of study) on effect size, and potential publication bias was estimated using funnel plot symmetry (Begg and Mazumdar rank correlation, Egger's regression, and Duval and Tweedie's trim and fill method).

RESULTS

Of the 1177 abstracts found, 152 studies were determined to be eligible for this meta-analysis. These 152 studies covered a total of 10,234 ESCC cases, analysed by different HPV detection methods in different geographic regions. Of these 10,234 cases, 3135 (30.6%) tested HPV-positive, translating to an effect size of 0.372 (95% CI 0.360-0.384; fixed effects model) and 0.290 (95% CI 0.251-0.31; random effects model). When stratified by HPV detection technique, there was a significant heterogeneity between the studies, but importantly, the between-strata summary comparison was not significant (random effects model; p = 0.440). In contrast, there was significant heterogeneity between the studies from the different geographic regions. In the maximum likelihood meta-regression, HPV detection method was not a significant study-level covariate, in contrast to the geographic origin of the study, which had a significant impact (p = 0.00005) on the summary effect size estimates. No evidence for significant publication bias was found in funnel plot symmetry testing. In the sensitivity analysis, all meta-analytic results appeared robust to all (n = 151) one-by-one study removals.

CONCLUSIONS

These meta-analysis results indicate that the reported wide variability in HPV detection rates in ESCC is not due to the HPV detection techniques, but is explained by the geographic origin of the study. These data substantiate the recently elaborated concept that ESCC might have a different aetiology in low-incidence and high-incidence geographic regions, HPV playing an important role only in the latter.

The incidence and risk of developing a second primary esophageal cancer in patients with oral and pharyngeal carcinoma: a population-based study in Taiwan over a 25 year period

BACKGROUND

The incidence of oral and pharyngeal (including oral cavity, oropharynx and hypopharynx) carcinoma increases rapidly in Asia and South Pacific because of betel quid chewing. Thus far, large-scale epidemiological studies are not available yet to stratify these patients by their risks of developing a second primary cancer in the digestive tract including esophagus, stomach, colon, and rectum.

METHODS

A population-based study was conducted using the database from the Taiwan National Cancer Registry for the period 1979-2003. We quantified standardized incidence ratios (SIRs) and cumulative incidence of second primary cancers among 33,787 patients with initial diagnoses of oral and pharyngeal carcinoma.

RESULTS

Among these four digestive tract organs, the esophagus was the only site of second cancer with excess risk in patients with oral and pharyngeal carcinoma. The incidence and risk of developing a second primary esophageal cancer differed by the site of the primary index tumor, most frequently seen in hypopharyngeal cancer (71/4,218 = 1.68%, SIR = 22.76, 95% CI 17.77-28.70), followed by oropharyngeal cancer (30/3,403 = 0.88%, SIR = 14.29, 95% CI 9.64-20.39) and the least in oral cavity cancer (99/26,166 = 0.38%, SIR = 5.57, 95% CI 4.53-6.78). In addition, the risk was extraordinarily high for patients with a follow-up interval

CONCLUSION

The present study represents the first population-based study in Asia attempting to stratify the patients of oral and pharyngeal carcinoma by their risk of developing a second esophageal cancer. It helps identify patients at high risk and tailor the application of intense follow-up surveillance to the estimated risk in each individual case.

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MESH Headings

• Adult
• Aged
• Aged, 80 and over
• Carcinoma, Squamous Cell/epidemiology
• Esophageal Neoplasms/epidemiology
• Female
• Follow-Up Studies
• Humans
• Incidence
• Male
• Middle Aged
• Mouth Neoplasms/epidemiology
• Neoplasms, Second Primary/epidemiology
• Pharyngeal Neoplasms/epidemiology
• Population Groups/statistics & numerical data
• Registries/statistics & numerical data
• Risk Factors
• Taiwan/epidemiology
• Young Adult

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Affiliation(s)

Kuan-Der Lee Department of Hematology and Oncology, Chang Gung Memorial Hospital at Chiayi, Taiwan, Republic of China Department of Medicine and Graduate Institute of Clinical Medical Sciences, Chang Gung University, Tao-Yuan Chang Gung Institute of Technology, Chia-yi Campus, Chiayi, Taiwan, Republic of China
Chang-Hsien Lu Department of Hematology and Oncology, Chang Gung Memorial Hospital at Chiayi, Taiwan, Republic of China Department of Medicine and Graduate Institute of Clinical Medical Sciences, Chang Gung University, Tao-Yuan Chang Gung Institute of Technology, Chia-yi Campus, Chiayi, Taiwan, Republic of China
Ping-Tsung Chen Department of Hematology and Oncology, Chang Gung Memorial Hospital at Chiayi, Taiwan, Republic of China Department of Medicine and Graduate Institute of Clinical Medical Sciences, Chang Gung University, Tao-Yuan Chang Gung Institute of Technology, Chia-yi Campus, Chiayi, Taiwan, Republic of China
Chunghuang Hubert Chan Department of Hematology and Oncology, Chang Gung Memorial Hospital at Chiayi, Taiwan, Republic of China Department of Medicine and Graduate Institute of Clinical Medical Sciences, Chang Gung University, Tao-Yuan Chang Gung Institute of Technology, Chia-yi Campus, Chiayi, Taiwan, Republic of China
Jen-Tsun Lin Department of Hematology and Oncology, Chang Gung Memorial Hospital at Chiayi, Taiwan, Republic of China Department of Medicine and Graduate Institute of Clinical Medical Sciences, Chang Gung University, Tao-Yuan Chang Gung Institute of Technology, Chia-yi Campus, Chiayi, Taiwan, Republic of China
Cih-En Huang Department of Hematology and Oncology, Chang Gung Memorial Hospital at Chiayi, Taiwan, Republic of China
Chih-Cheng Chen Department of Hematology and Oncology, Chang Gung Memorial Hospital at Chiayi, Taiwan, Republic of China Department of Medicine and Graduate Institute of Clinical Medical Sciences, Chang Gung University, Tao-Yuan Chang Gung Institute of Technology, Chia-yi Campus, Chiayi, Taiwan, Republic of China
Min-Chi Chen Department of Public Health and Biostatistics Consulting Center, School of Medicine, Chang Gung University, Tao-Yuan, Taiwan, Republic of China

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Absence of Epstein-Barr virus in esophageal squamous cell carcinoma

It is strongly suspected that the Epstein-Barr virus (EBV) plays a role in the genesis of nasopharyngeal and gastric carcinoma. The aim of this study was to search for such a connection between esophageal squamous cell carcinoma (ESCC) and EBV. We investigated 104 surgically resected esophageal cancers using in situ hybridization (ISH) for EBV-encoded RNA (EBER). We found no EBER-positive cancer cells in any tests, although there were five samples in which EBER-positive tumor-infiltrating lymphocytes (TILs) were found. We conclude from this study that EBV is not associated with ESCC.

Presence of Epstein-Barr virus in esophageal cancer is restricted to tumor infiltrating lymphocytes

As representatives of low and high incidence countries respectively, 72 esophageal squamous cell carcinomas and 40 adenocarcinomas from Germany, and 43 esophageal squamous cell carcinomas from Russia were tested for the presence of Epstein-Barr virus (EBV) DNA by PCR and in situ hybridization. Thirty-four percent of the squamous cell carcinomas (SCC) and 26% of the adenocarcinomas (AC) contained EBV DNA as detected by nested PCR. Quantitative analysis using real time PCR revealed one copy of the EBV genome per every 27-200,000 cells. EBER RNA in situ hybridization showed no EBV-specific transcripts in the nuclei of the tumor cells. However, EBER transcripts were expressed in the nuclei of tumor infiltrating lymphocytes in 7 SCC and 1 AC of 24 EBV DNA positive cases. The present data provide no evidence for the persistence of EBV in the tumor cells of esophageal cancer. In contrast to a previous report from Taiwan, EBV is unlikely to play a role in esophageal carcinogenesis.

Detection of HSV and EBV in esophageal carcinomas from a high-incidence area in Shantou China

An association between viral infection, particularly the human papillomavirus, and the development of esophageal carcinoma (EC) has been reported. However, reports concerning the relationship between herpes simplex virus (HSV) and Epstein-Barr virus (EBV) with EC are few. There are geographic variations in infection rates. This study was aimed to determine the co-incidence of infection of the two viruses' with esophageal carcinoma and the differentiation of cancer tissues and lymphocytes infiltration in the tumor stroma of the high-incidence area of Shantou China. To determine the association between viral infection (HSV and EBV) and EC, we applied in situ hybridization (ISH) and immunohistochemistry (IHC) in 164 esophageal carcinoma surgical specimens from the high-incidence area of Shantou China. HSV DNA and HSVI, II protein expression were found in 52 (31.7%) of the 164 tumors; EBV EBER and LMP-1 proteins were identified in only 10 (6.1%) carcinoma specimens by in situ hybridization and immunohistochemistry. In histopathology analysis, the positive cases of HSV appeared to be more predominant in well and moderately differentiated squamous cell carcinomas, and the positive cases of EBV were found in poorly differentiated squamous cell carcinomas or undifferentiated carcinomas with intense lymphoid infiltration. Our results confirm the involvement of HSV and EBV in esophageal carcinomas and the relationship between HSV and EBV infection and esophageal carcinoma cell differentiation with lymphocyte infiltration in the tumor stroma. However, the two herpes viruses, HSV and EBV, particularly the human HSV may be one of the etiological factors in development of this malignancy among the high-incidence population of Shantou China.

Epstein-Barr virus in hepatocellular carcinogenesis

AIM: In recent years, studies have suggested that Epstein-Barr virus (EBV) is associated with HCC. The present study was to determine the prevalence of EBV in HCC patients, and whether EBV acted synergistically with hepatitis viruses in HCC carcinogenesis.

METHODS: Liver tissue 115 HCC patients and 26 non-carcinoma patients were studied. Polymerase chain reaction (PCR) was performed to detect EBV BamHI W DNA, EBV LMP1 DNA, HBV X DNA, and HBV S DNA. Reverse transcription PCR (RT-PCR) was performed to detect HCV RNA and HDV RNA. Immunohistochemistry was performed to detect LMP1, HBsAg, HBcAg and HCV. The positive ratios were compared between HCC group and control group by χ² test.

RESULTS: Totally, 78 HCC samples whose β -globulin DNA was positively detected by amplified PCR were selected. PCR was performed in all cases for EBV DNA and HBV DNA. RT-PCR was performed in 18 cases for HCV RNA and HDV RNA. EBV BamHI W and EBV LMP1 were positive in 18 and 6 cases, respectively. HBV X gene and HBV S gene were positive in 42 and 27 cases respectively. HCV was positive in one of the 18 cases, and none was positive for HDV. The positive rates were 28.2% (22 of 78) for EBV DNA (BamHI W and/or LMP1) and 56.4% (44 of 78) for HBV DNA (X gene and/or S gene) respectively. In addition, 12 cases were positive for both EBV DNA and HBV DNA. Among the 26 cases in the control group, 2 cases were positive for EBV BamHI W, 4 positive for HBV X gene and 3 positive for HBV S gene. The positive rates were 8.0% (2 of 26) and 23.1% (6 of 26), respectively, for EBV DNA and HBV DNA. The result of DNA sequencing of BamHI W was 100% homologous with the corresponding sequence of B95-8. There was significant difference in EBV infection rate between HCC patients and controls (χ² = 4.622, P < 0.05). The difference in HBV infection rate was also significant (χ² = 8.681, P < 0.05). However, there was no obvious correlation between HBV and EBV in HCC patients (χ² = 0.835, P > 0.05). LMP1, HBV (HBsAg, HBcAg) and HCV were detected positively in 25, 45 and 6 of 78 cases of HCC tissues respectively. In the 26 control cases, the corresponding positive cases were 2, 4 and 0. The difference in EBV infection rate between HCC patients and control cases was statistically significant (χ² = 6.02, P < 0.05). The difference in HBV infection rate was also statistically significant (χ² = 10.03, P < 0.05). In the 25 cases with positive LMP1 expression, 6 were in the nuclei of tumor cells, 9 in the cytoplasm of tumor cells and 10 in mesenchymal lymphocyte cytoplasm.

CONCLUSION: The existence of EBV infection in HCC tissues suggests that EBV may be involved in the hepatocellular carcinogenesis in China. HBV infection may be a major cause of HCC. There is no correlation between EBV and HBV in the development of HCC. The prevalence of HCV infection is low in our area, and HDV appears not to play a direct role in hepatocellular carcinogenesis.

Photodynamic therapy and endoscopic metal stent placement for esophageal papillomatosis associated with squamous cell carcinoma

Esophageal squamous papillomatosis is a rare condition associated with human papilloma virus infection and has been complicated by the development of squamous cell carcinoma. Photodynamic therapy using porfimer sodium has been used for the treatment of esophageal cancer but has not been utilized in the treatment of esophageal squamous papillomatosis. We report here the first case of papillomatosis and obstructing squamous cell carcinoma of the esophagus palliated with porfimer sodium photodynamic therapy indicating successful photosensitizer uptake in papilloma-laden tissue. Extensive debulking of papilloma and tumor allowed esophageal recanalization and placement of a self-expanding metal stent for long-term dysphagia palliation. This unique case highlights the combined use of endoscopic techniques for optimal treatment results.

Epstein-Barr virus association is rare in esophageal squamous cell carcinoma

BACKGROUND

A critical role of Epstein-Barr virus (EBV) in carcinogenesis of nasopharyngeal squamous cell carcinoma and gastric adenocarcinoma is strongly suspected. We analyzed the possible EBV association for Japanese squamous cell carcinoma (SCC)-dominant esophageal cancer cases.

METHODS

We retrospectively screened 36 surgically resected esophageal cancer lesions from 36 patients mainly with SCC using in situ hybridization (ISH) for EBV-encoded small RNA1 (EBER-1). EBV DNA analysis using real-time quantitative polymerase chain reaction (Q-PCR) was performed for three recent cases.

RESULTS

We found no EBER-1-positive cancer cell in any tested esophageal cancer lesion. There were many EBER-1-positive tumor-infiltrating lymphocytes in the basaloid SCC lesion and a small number of positive lymphocytes in the other five advanced SCC lesions (14.7% of SCC). One SCC lesion with a highcopy number of EBV DNA had EBER-1-positive lymphocytes.

CONCLUSIONS

EBV is rarely associated with esophageal SCC, and may appear through tumorinfiltrating lymphocytes in some advanced lesions.

Esophageal cancer in Germany is associated with Epstein-Barr-virus but not with papillomaviruses

Esophageal squamous cell carcinomas ( n=23) and adenocarcinomas ( n=14) from German patients were tested for the presence of human papillomavirus (HPV) and Epstein-Barr-Virus (EBV) DNA. No DNA for either genital HPV or epidermodysplasia verruciformis-associated HPV was detected in any tumor. In contrast, 35% of squamous cell carcinomas and 36% of adenocarcinomas were shown to contain EBV DNA by nested polymerase chain reaction.

Chronic immune activation and inflammation in the pathogenesis of AIDS and cancer

Infection with the human immunodeficiency virus (HIV) invariably leads to the development of acquired immunodeficiency syndrome (AIDS) in most infected humans, yet does so rarely, if at all, in HIV-infected chimpanzees. The differences between the two species are not due to differences in cellular receptors or an inability of the chimpanzee to be infected, but rather to the lack of pan-immune activation in the infected primate. This results in reduced apoptotic death in CD4+ T-helper lymphocytes and a lower viral load. In humans the degree of chronic immune activation correlates with virus load and clinical outcome with high immune activation leading to high viral loads and the more rapid progression to AIDS and death. The type of immune perturbation seen in HIV-associated AIDS is similar to that of chronic graft-versus-host disease (GVHD) where reduced cell-mediated immune (CMI) responses occur early in the course of the disease and where humoral responses (HI) predominate. A reduced CMI response occurs in a number of chronic infectious diseases, including tuberculosis and leishmaniasis. More recently, it has become increasingly apparent that the CMI response is suppressed in virtually all malignant diseases, including melanoma and colorectal and prostate cancer. This raises the possibility that, as the malignant process develops, the cancer cells evolve to subvert the CMI response. Moreover, the reduced CMI response seen in colorectal cancer (CRC) patients is completely reversed following curative surgery strongly supporting the hypothesis that CRC can suppress the systemic immune response. Wound healing, ovulation, embryo implantation, and fetal growth are all associated with suppressed CMI and neovascularization (the formation of new blood vessels) or angiogenesis (the formation of new blood vessels from an existing vasculature). If unresolved, wound healing results in chronic inflammation, which can give rise to the phenomenon of "scar cancers." Indeed all the chronic inflammatory conditions known to be associated with the subsequent development of malignant disease, including chronic obstructive airway disease (COPD), ulcerative colitis (UC), and asbestosis, give rise to similar proangiogenic, suppressed CMI, and HI-predominant environments. In keeping with this CMI-associated cytokines such as interleukin (IL)-2 and interferon (IFN)-gamma tend to be antiangiogenic, whereas HI cytokines such as IL-6 tend to be proangiogenic. Furthermore, chronic immune activation leads to the synthesis and release of factors such as macrophage inflammatory protein (MIP)-1 that inhibit apoptosis through suppression of p53 activity. The "Golden Triangle" of suppressed CMI, angiogenesis, and reduced apoptosis would provide the ideal environment for the serial mutations to occur that are required for the development of malignant disease. If the observed association is relevant to carcinogenesis, then treatments aimed at reducing the components of these inflammatory conditions may be useful both in the setting of chemoprevention and the therapeutic management of established disease.

Chronic immune activation and inflammation as the cause of malignancy

Several chronic infections known to be associated with malignancy have established oncogenic properties. However the existence of chronic inflammatory conditions that do not have an established infective cause and are associated with the development of tumours strongly suggests that the inflammatory process itself provides the prerequisite environment for the development of malignancy. This environment includes upregulation of mediators of the inflammatory response such as cyclo-oxygenase (COX)-2 leading to the production of inflammatory cytokines and prostaglandins which themselves may suppress cell mediated immune responses and promote angiogenesis. These factors may also impact on cell growth and survival signalling pathways resulting in induction of cell proliferation and inhibition of apoptosis. Furthermore, chronic inflammation may lead to the production of reactive oxygen species and metabolites such as malondialdehyde within the affected cells that may in turn induce DNA damage and mutations and, as a result, be carcinogenic. Here it is proposed that the conditions provided by a chronic inflammatory environment are so essential for the progression of the neoplastic process that therapeutic intervention aimed at inhibiting inflammation, reducing angiogenesis and stimulating cell mediated immune responses may have a major role in reducing the incidence of common cancers.

Epstein-Barr virus involvement is mainly restricted to lymphoepithelial type of gastric carcinoma among various epithelial neoplasms

To demonstrate the association of Epstein-Barr virus (EBV) with primary epithelial neoplasms in the south part of Kyushu, Japan, 761 carcinomas consisting of 75 lung, 61 breast, 107 esophagus, 102 colon, 58 pancreas, 45 thyroid, and 313 gastric cancers were examined by EBER-1 in situ hybridization. EBER-1 was detected in 23 cases (7.3%) out of 313 gastric carcinomas, while none of the other carcinomas was positive for EBER-1. Twenty-eight (9.4%) out of 313 gastric carcinomas were differentiated poorly to moderately carcinomas with prominent lymphoid cell infiltration, similar to so-called lymphoepithelioma-like carcinoma, and 19 cases (67.9%) were positive for EBER-1. Although two (2.6%) and 11(10.3%) out of 75 lung and 107 esophagus carcinomas were so-called lymphoepithelioma-like carcinomas, respectively, but EBER-1 was not detected in other epithelial neoplasms that originated from the lung, esophagus, breast, colon, pancreas, and thyroid in the south of Kyushu, Japan. As a result, EBV was associated with only some gastric carcinomas but not with other epithelial neoplasms originating from the lung, esophagus, breast, colon, pancreas, and thyroid in southern Japan.

Epstein-Barr virus load monitoring: its role in the prevention and management of post-transplant lymphoproliferative disease

The Epstein-Barr virus load in the peripheral blood at the time of diagnosis of post-transplant lymphoproliferative disease (PTLD) is elevated 1000- to 10,000-fold compared to the level detected in normal latency. With the use of quantitative polymerase chain reaction (PCR), changes in the viral load over time can be measured with a two- to fourfold accuracy. This has allowed early detection of first-time infections and reactivations that may lead to PTLD and has provided an opportunity to intervene before symptomatic disease has occurred. Viral load monitoring has also been used to follow patients with PTLD and, along with other parameters, provided an assessment of the effectiveness of therapeutic protocols. Viral load monitoring has led to the discovery that at least two-thirds of transplant recipients become persistent viral load carriers. While the persistent load appears to be largely carried in latently infected memory B cells, more work is needed to clearly define this type of persistent infection and determine the risks associated with it. New diagnostic tests need to be developed to distinguish the persistent latent viral loads from viral loads that are likely to become symptomatic PTLD.

In situ hybridization of Epstein-Barr virus in tumor cells and tumor-infiltrating lymphocytes of the gastrointestinal tract

Unlike gastric carcinoma, associations of the Epstein-Barr virus (EBV) with carcinomas of other sites in the gastrointestinal tract have not yet been clarified. To elucidate these associations, we investigated the presence of EBV in 142 cases of esophageal carcinoma, 107 cases of ampulla of Vater carcinoma, and 274 cases of colorectal carcinoma in Korean patients using EBV-encoded small RNAs (EBER)-in situ hybridization (ISH). In all cases, none of the tumor cells showed a positive signal, indicating that EBV is not generally related to the carcinogenesis of these cancers. Some EBV-positive tumor-infiltrating lymphocytes (TILs) were found in 8 of 142 cases (5.6%) of esophageal carcinoma, 8 of 107 cases (7.5%) of ampulla of Vater cancer, and 35 of 274 cases (12.8%) of colorectal carcinoma. For comparison, EBER-ISH was performed in consecutive gastric carcinomas; the EBER signal on tumor cells was observed in 17 of 306 cases (5.6%), and EBV-positive TILs were seen in 31 of the 289 cases (10.7%). There was no statistically significant difference in the frequencies of cases with EBV-positive TILs among the gastrointestinal tract cancers. We suggest that the reservoir lymphocytes carrying EBV, like other inflammatory cells, are able to reach anywhere, and that the chance for an epithelial cell to be exposed to EBV is similar at different sites of the gastrointestinal tract, regardless of its carcinogenic effect on the epithelial cell. HUM PATHOL 32:297-301.