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Sciarra R, Merli M, Cristinelli C, Lucioni M, Zibellini S, Riboni R, Furlan D, Uccella S, Zerbi C, Bianchi B, Gotti M, Ferretti VV, Varraso C, Fraticelli S, Lazic T, Defrancesco I, Mora B, Libera L, Mazzacane A, Carpi F, Berliner M, Neri G, Rizzo E, De Paoli F, Sessa F, Passamonti F, Paulli M, Arcaini L. Molecular characterization of diffuse large B-cell lymphomas associated with hepatitis C virus infection. Br J Haematol 2024; 204:2242-2253. [PMID: 38442902 DOI: 10.1111/bjh.19378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/18/2024] [Accepted: 02/21/2024] [Indexed: 03/07/2024]
Abstract
Hepatitis C virus (HCV)-associated diffuse large B-cell lymphoma (DLBCL) displays peculiar clinicopathological characteristics, but its molecular landscape is not fully elucidated. In this study, we investigated the clinicopathological and molecular features of 54 patients with HCV-associated DLBCL. The median age was 71 years. An underlying marginal zone lymphoma component was detected in 14.8% of cases. FISH analysis showed rearrangements involving BCL6 in 50.9% of cases, MYC in 11.3% and BCL2 in 3.7%. Lymph2Cx-based assay was successful in 38 cases, recognizing 16 cases (42.1%) as ABC and 16 cases as GCB subtypes, while six resulted unclassified. ABC cases exhibited a higher lymphoma-related mortality (LRM). Next-generation sequencing analysis showed mutations in 158/184 evaluated genes. The most frequently mutated genes were KMT2D (42.6%), SETD1B (33.3%), RERE (29.4%), FAS and PIM1 (27.8%) and TBL1XR1 (25.9%). A mutation in the NOTCH pathway was detected in 25.9% of cases and was associated with worst LRM. Cluster analysis by LymphGen classified 29/54 cases within definite groups, including BN2 in 14 (48.2%), ST2 in seven (24.2%) and MCD and EZB in four each (13.8%). Overall, these results indicate a preferential marginal zone origin for a consistent subgroup of HCV-associated DLBCL cases and suggest potential implications for molecularly targeted therapies.
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Affiliation(s)
- Roberta Sciarra
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Michele Merli
- Division of Hematology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Marco Lucioni
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- Anatomic Pathology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Silvia Zibellini
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Roberta Riboni
- Anatomic Pathology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Daniela Furlan
- Anatomic Pathology Unit, University of Insubria, Ospedale di Circolo, Varese, Italy
| | - Silvia Uccella
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Pathology Service, IRCCS, Humanitas Research Hospital, Milan, Italy
| | - Caterina Zerbi
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Benedetta Bianchi
- Division of Hematology, University Hospital Ospedale di Circolo e Fondazione Macchi-ASST Sette Laghi, Varese, Italy
| | - Manuel Gotti
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Chiara Varraso
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Sara Fraticelli
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- Anatomic Pathology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Tanja Lazic
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Irene Defrancesco
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Medical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Barbara Mora
- Division of Hematology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Laura Libera
- Anatomic Pathology Unit, University of Insubria, Ospedale di Circolo, Varese, Italy
| | | | - Federico Carpi
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Martha Berliner
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Giuseppe Neri
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | | | | | - Fausto Sessa
- Anatomic Pathology Unit, University of Insubria, Ospedale di Circolo, Varese, Italy
| | - Francesco Passamonti
- Division of Hematology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- University of Milan, Milan, Italy
| | - Marco Paulli
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- Anatomic Pathology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Luca Arcaini
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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2
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Wang SS. Epidemiology and etiology of diffuse large B-cell lymphoma. Semin Hematol 2023; 60:255-266. [PMID: 38242772 PMCID: PMC10962251 DOI: 10.1053/j.seminhematol.2023.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/15/2023] [Accepted: 11/21/2023] [Indexed: 01/21/2024]
Abstract
As the most common non-Hodgkin lymphoma subtype, diffuse large B-cell lymphoma (DLBCL) incidence patterns generally parallel that for NHL overall. Globally, DLBCL accounts for a third of all NHLs, ranging between 20% and 50% by country. Based on United States (U.S.) cancer registry data, age-standardized incidence rate for DLBCL was 7.2 per 100,000. DLBCL incidence rises with age and is generally higher in males than females; in the U.S., incidence is highest among non-Hispanic whites (9.2/100,000). Like NHL incidence, DLBCL incidence rose in the first half of the 20th century but has largely plateaued. However, there is some evidence that incidence rates are rising in areas of historically low rates, such as Asia; there are also estimates for rising DLBCL incidence in the near future due to the changing demographics in developed countries whose aging population is growing. Established risk factors for DLBCL include those that result in severe immune deficiency such as HIV/AIDS, inherited immunodeficiency syndromes, and organ transplant recipients. Factors that lead to chronic immune dysregulations are also established risk factors, and include a number of autoimmune conditions (eg, Sjögren syndrome, systemic lupus erythematosus, rheumatoid arthritis), viral infections (eg, HIV, KSHV/HHV8, HCV, EBV), and obesity. Family history of NHL/DLBCL, personal history of cancer, and multiple genetic susceptibility loci are also well-established risk factors for DLBCL. There is strong evidence for multiple environmental exposures in DLBCL etiology, including exposure to trichloroethylene, benzene, and pesticides and herbicides, with recent associations noted with glyphosate. There is also strong evidence for associations with other viruses, such as HBV. Recent estimates suggest that obesity accounts for nearly a quarter of DLBCLs that develop, but despite recent gains in the understanding of DLBCL etiology, the majority of disease remain unexplained. An understanding of the host and environmental contributions to disease etiology, and concerted efforts to expand our understanding to multiple race/ethnic groups, will be essential for constructing clinically relevant risk prediction models and develop effective strategies for disease prevention.
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Affiliation(s)
- Sophia S Wang
- City of Hope Comprehensive Cancer Center, Duarte, CA.
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3
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Zhang M, Gao F, Peng L, Shen L, Zhao P, Ni B, Hou J, Huang H. Distinct clinical features and prognostic factors of hepatitis C virus-associated non-Hodgkin's lymphoma: a systematic review and meta-analysis. Cancer Cell Int 2021; 21:524. [PMID: 34627251 PMCID: PMC8502277 DOI: 10.1186/s12935-021-02230-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 09/27/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Increasing evidence suggests that hepatitis C virus (HCV) infection is associated with non-Hodgkin's lymphoma (NHL). However, no clear consensus has been reached about the clinical features and effective treatment of HCV-associated NHL patients. We therefore performed a systematic review and meta-analysis to explore the clinical characteristics and effectiveness of antiviral treatment or rituximab administration among NHL patients with HCV infection. METHODS Eight electronic databases, including PubMed, OVID, EMBASE, Cochrane Library, ClinicalTrials, WANFANG, CNKI, and VIP, were searched for eligible studies up to July 31, 2021. The hazard ratio (HR) or odds ratio (OR) corresponding to the 95% confidence interval (CI) was calculated to estimate the outcomes. Publication bias was assessed by Egger's and Begg's tests. Statistical analysis was performed with RevMan 5.4 software and Stata version 15. RESULTS There were 27 shortlisted articles out of a total of 13,368 NHL patients included in the current meta-analysis. Our results demonstrated that NHL patients with HCV infection had a significantly shorter overall survival (OS: HR 1.89; 95% CI 1.42-2.51, P < 0.0001) and progression-free survival (PFS: HR 1.58; 95% CI 1.26-1.98, P < 0.0001), a lower overall response rate (ORR: OR 0.58, 95% CI 0.46-0.73, P < 0.00001) and a higher incidence of hepatic dysfunction during chemotherapy (OR 5.96; 95% CI 2.61-13.62, P < 0.0001) than NHL patients without HCV infection. HCV-positive NHL patients exhibited an advanced disease stage, an elevated level of LDH, a high-intermediate and high IPI/FLIPI risk as well as a higher incidence of spleen and liver involvement. Moreover, antiviral treatment prolonged survival (OS: HR 0.38; 95% CI 0.24-0.60, P < 0.0001), reduced disease progression [PFS/DFS (disease-free survival): HR 0.63; 95% CI 0.46-0.86, P = 0.003] and reinforced the treatment response (ORR: OR 2.62; 95% CI 1.34-5.11, P = 0.005) among the HCV-infected NHL patients. Finally, rituximab administration was associated with a favourable OS, while liver cirrhosis and low levels of albumin predicted a poor OS for HCV-positive NHL patients. CONCLUSIONS The current study provided compelling evidence about an inferior prognosis and distinct clinical characteristics among HCV-associated NHL patients. Antiviral treatment and rituximab-containing regimens were shown to be efficacious in improving the clinical outcomes of NHL patients with HCV infection.
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Affiliation(s)
- Minyue Zhang
- Division of Hematology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, China.,Division of Chinese Medicine, M.D. Prefectural People's Hospital, Chuxiong Yi Autonomous Prefecture, 675500, China
| | - Fei Gao
- State Key Laboratory of Southwestern Chinese Medicine Resources, Pharmacy School, Chengdu University of Traditional Chinese Medicine, Chengdu, 611730, China
| | - Ling Peng
- Division of Chinese Medicine, M.D. Prefectural People's Hospital, Chuxiong Yi Autonomous Prefecture, 675500, China
| | - Lijing Shen
- Division of Hematology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, China
| | - Peng Zhao
- State Key Laboratory of Southwestern Chinese Medicine Resources, Pharmacy School, Chengdu University of Traditional Chinese Medicine, Chengdu, 611730, China
| | - Beiwen Ni
- Division of Hematology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, China
| | - Jian Hou
- Division of Hematology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, China.
| | - Honghui Huang
- Division of Hematology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, China.
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Alkrekshi A, Kassem A, Park C, Tse W. Risk of Non-Hodgkin's Lymphoma in HCV Patients in the United States Between 2013 and 2020: A Population-Based Study. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:e832-e838. [PMID: 34330674 DOI: 10.1016/j.clml.2021.06.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/09/2021] [Accepted: 06/19/2021] [Indexed: 12/11/2022]
Abstract
Hepatitis C virus (HCV) is a significant healthcare problem affecting ~1% of the United States population. Meta-analyses of epidemiological studies reported a strong association between non-Hodgkin's lymphoma (NHL) and HCV. Direct oncogenic properties of HCV proteins and chronic antigenic stimulation are possible etiologies. We explored if NHL's prevalence has changed since older HCV therapy based on interferon that shared antiviral and anti-lymphoma properties was replaced with interferon-free direct-acting antivirals (DAA). We reviewed data from a nationwide database (Explorys, IBM) that aggregates records from 26 health-care-systems. We identified patients with chronic hepatitis C infection between June 2013 and June 2020. The control group was gender, race, and age-matched HCV-negative population. Statistical analysis used the odds ratio (OR) with P value <.001 for significance. There were 940 cases of NHL of 129,970 patients in the HCV group versus 107,480 cases of NHL of 37,961,970 in the control cohort [OR 2.6, 95% confidence interval (CI) 2.4-2.7]. A positive association was present for chronic lymphocytic leukemia, follicular lymphoma, marginal zone lymphoma, lymphoplasmacytic lymphoma, diffuse large B-cell lymphoma, Burkitt's lymphoma, non-Hodgkin T-cell lymphoma, and primary cutaneous T-cell lymphoma. There were no differences in Mantle cell lymphoma. The increased risk of HCV-associated lymphoma was persistent across genders, Caucasians and African-Americans, and age groups. While the risk of NHL in the HCV-negative population was higher in Caucasians than African-Americans (OR 1.8, 95% CI 1.7-1.8), the risk of HCV-associated NHL was not different. Further prospective studies examining the risk of HCV-associated lymphoma following DAA are warranted.
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Affiliation(s)
- Akram Alkrekshi
- Department of Hematology and Oncology, The MetroHealth System campus of Case Western Reserve University, Cleveland, OH.
| | - Ahmad Kassem
- Department of Hematology and Oncology, The MetroHealth System campus of Case Western Reserve University, Cleveland, OH
| | - Changsu Park
- Department of Hematology and Oncology, The MetroHealth System campus of Case Western Reserve University, Cleveland, OH
| | - William Tse
- Department of Hematology and Oncology, The MetroHealth System campus of Case Western Reserve University, Cleveland, OH
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5
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de Carvalho PS, Leal FE, Soares MA. Clinical and Molecular Properties of Human Immunodeficiency Virus-Related Diffuse Large B-Cell Lymphoma. Front Oncol 2021; 11:675353. [PMID: 33996608 PMCID: PMC8117347 DOI: 10.3389/fonc.2021.675353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 04/14/2021] [Indexed: 12/15/2022] Open
Abstract
Non-Hodgkin lymphoma is the most common malignancy affecting people living with HIV (PLWH). Among its several subtypes, diffuse large B-cell lymphoma (DLBCL) is an important manifestation within the HIV-infected compartment of the population. Since HIV is able to modulate B cells and promote lymphomagenesis through direct and indirect mechanisms, HIV-related DLBCL has specific characteristics. In this review, we address the clinical and molecular properties of DLBCL disease in the context of HIV infection, as well as the mechanisms by which HIV is able to modulate B lymphocytes and induce their transformation into lymphoma.
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Affiliation(s)
- Pedro S de Carvalho
- Programa de Oncovirologia, Instituto Nacional do Câncer, Rio de Janeiro, Brazil
| | - Fabio E Leal
- Programa de Oncovirologia, Instituto Nacional do Câncer, Rio de Janeiro, Brazil
| | - Marcelo A Soares
- Programa de Oncovirologia, Instituto Nacional do Câncer, Rio de Janeiro, Brazil.,Departamento de Genética, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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6
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Ciancio A. Impact of Direct Antiviral Agents (DAAs) on B-cell Non Hodgkin's Lymphoma in patients with chronic hepatitis C. Minerva Gastroenterol (Torino) 2021; 67:227-233. [PMID: 33856146 DOI: 10.23736/s2724-5985.21.02834-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The relationship between HCV infection and extrahepatic manifestations has been demonstrated by epidemiological, clinical, immunological and pathological studies. Patients with HCV infection have an increased risk of morbidity and mortality related to these non-liver diseases. For these reasons, HCV chronic infection should be considered a systemic disease in which extrahepatic manifestations increase the severity of the disease. HCV-extrahepatic manifestations may severely affect the overall prognosis, while viral eradication significantly reduces non-liver related deaths. Over the past 5 years, treatment of chronic HCV infection in patients with hematologic malignancies has evolved rapidly and effective and safe direct-acting antivirals (DAAs) have become the standardof-care treatment. The choice of regimens with DAAs should be individualized after thorough assessment for potential hematologic toxic effects and drug-drug interactions. Elimination of HCV from infected cancer patients confers virologic, hepatic, and oncologic benefits.
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Affiliation(s)
- Alessia Ciancio
- Dipartimento di Scienze Mediche, Scuola di Medicina, Università degli Studi di Torino, Turin, Italy -
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7
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Sun XH, Wang LN, Ma HZ, Li ZJ, Xi YM. Complete regression of an HCV-associated diffuse large B cell lymphoma achieved by chemoimmuno-free antiviral therapy. Ann Hematol 2021; 100:1891-1894. [PMID: 33409624 DOI: 10.1007/s00277-020-04367-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 11/30/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Xiao-Hong Sun
- Division of Hematology, The First Hospital of Lanzhou University, Lanzhou, 730000, Gansu, China
| | - Li-Na Wang
- Division of Hematology, The First Hospital of Lanzhou University, Lanzhou, 730000, Gansu, China
| | - Hai-Zhen Ma
- Division of Hematology, The First Hospital of Lanzhou University, Lanzhou, 730000, Gansu, China
| | - Zi-Jian Li
- Division of Hematology, The First Hospital of Lanzhou University, Lanzhou, 730000, Gansu, China.
| | - Ya-Ming Xi
- Division of Hematology, The First Hospital of Lanzhou University, Lanzhou, 730000, Gansu, China.
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8
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Abstract
OBJECTIVE Chronic hepatitis C virus (HCV) and hepatitis B virus (HBV) infections are associated with increased risks of lymphomas in the non-HIV setting. Their impacts on HIV-associated lymphomas deserved further studies in the modern combined antiretroviral therapy (cART) era. DESIGN We evaluated the associations between HCV, HBV and HIV-related lymphomas in the Lymphovir-ANRS-CO16 cohort. METHODS Prevalence of HCV seropositivity and chronic HBV infections were compared with those observed in the French Hospital Database on HIV (FHDH-ANRS-CO4). RESULTS Between 2008 and 2015, 179 patients with HIV-related lymphomas from 32 French hospitals were enrolled, 69 had Hodgkin's lymphoma (39%), and 110 non-Hodgkin's lymphoma (NHL) (61%). The prevalence of HCV infection was higher in patients with NHL than in the FHDH-ANRS-CO4 [26 versus 14%, odd ratio (OR): 2.15; 95% confidence interval (1.35-3.32)] whereas there was no association between Hodgkin's lymphoma and chronic HCV infection. Chronic HBV infection was not associated with NHL in our cohort with a prevalence of 5 versus 7% in FHDH-ANRS-CO4 but tended to be associated with Hodgkin's lymphoma [prevalence of 14%, OR: 2.16 (0.98-4.27)]. Chronic HCV infection tended to pejoratively impact 2-year overall survival in patients with NHL: 72% [57%, 91%] versus 82% [74%, 91%], hazard ratio: 2.14 [0.95-4.84]. In contrast, chronic HBV infection did not correlate with outcome. CONCLUSION In the modern cART era, chronic HCV infection is associated with an increased risk of NHL in PLWHIV and tends to pejoratively impact overall survival. HBV infection is not associated with the risk of NHL but with a borderline increase of Hodgkin's lymphoma risk.
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9
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Defrancesco I, Zerbi C, Rattotti S, Merli M, Bruno R, Paulli M, Arcaini L. HCV infection and non-Hodgkin lymphomas: an evolving story. Clin Exp Med 2020; 20:321-328. [PMID: 32052244 DOI: 10.1007/s10238-020-00615-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 02/07/2020] [Indexed: 12/11/2022]
Abstract
Hepatitis C virus infection represents a global health problem with 3% of population infected worldwide. Several epidemiological studies have shown an increased risk of B cell non-Hodgkin lymphomas in HCV-infected subjects with a wide geographic variability. The observation that HCV eradication by antiviral treatment is associated with successful lymphoma response provided the most convincing evidence for the causal role of HCV in lymphoma's development. According to the most accepted model, HCV-driven chronic antigenic stimulation may represent the major stimulus for lymphoma growth. Several evidences have led to recommend antiviral therapy (in the past interferon-based, now the new direct-acting antiviral agents) in the setting of asymptomatic indolent B cell lymphomas not requiring an immediate systemic treatment. The favourable profile of direct-acting antiviral agents supports the HCV eradication also in the setting of HCV-positive diffuse large B cell lymphoma; however, further studies are needed to assess the appropriate timing of these drugs in the treatment of aggressive lymphomas. Multidisciplinary management involving expert hepatologists is highly warranted.
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Affiliation(s)
| | - Caterina Zerbi
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Sara Rattotti
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100, Pavia, Italy
| | - Michele Merli
- Division of Hematology, University Hospital Ospedale di Circolo e Fondazione Macchi-Azienda Socio-Sanitaria Territoriale Sette Laghi, University of Insubria, Varese, Italy
| | - Raffaele Bruno
- Division of Infectious Diseases Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Medical, Surgical, Diagnostic and Paediatric Science, University of Pavia, Pavia, Italy
| | - Marco Paulli
- Department of Molecular Medicine, University of Pavia, Pavia, Italy.,Anatomic Pathology Section, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Luca Arcaini
- Department of Molecular Medicine, University of Pavia, Pavia, Italy. .,Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100, Pavia, Italy.
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10
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Quality Initiative in Clinical Practice: A Single-Institution Appraisal of Quality Metrics in the Management of Newly Diagnosed Diffuse Large B-Cell Lymphoma. Mayo Clin Proc Innov Qual Outcomes 2020; 3:485-494. [PMID: 31993568 PMCID: PMC6978588 DOI: 10.1016/j.mayocpiqo.2019.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 05/30/2019] [Accepted: 08/23/2019] [Indexed: 11/22/2022] Open
Abstract
Objective To assess our adherence to treatment guidelines for diffuse large B-cell lymphoma (DLBCL) established by the American Society of Hematology in 2014 through implementation of a quality improvement initiative (QII) at our institution in 2015. Patients and Methods Patients with newly diagnosed DLBCL treated from January 1, 2006, through December 31, 2017, were identified. Electronic medical records were reviewed for documentation of American Society of Hematology Practice Improvement Module quality measures (eg, key pathologic features of DLBCL, lymphoma staging, and screening for hepatitis B virus [HBV] infection in patients receiving rituximab-based chemotherapy). We also reviewed assessment of prognosis by revised International Prognostic Index score, testing for hepatitis C virus, HBV, and HIV, chemotherapy education, and the addition of rituximab in the treatment regimen of CD20+ DLBCL. Results Following QII implementation, we saw improvements in most metrics, including reporting of key molecular features (fluorescence in situ hybridization for c-MYC, BCL2, and BCL6, from 45.5% [75 of 165 patients] before QII to 91.7% [22 of 24 patients] after QII; P<.001), screening for HBV (41.8% [69 of 165 patients] to 91.7% [22 of 24 patients]; P<.001) and HIV infections (33.9% [56 of 165 patients] to 87.5% [21 of 24 patients]; P<.0001), providing chemotherapy education (92.7% [153 of 165 patients] to 100%), and use of rituximab for CD20+ DLBCL (83.6% [138 of 165 patients] to 100%; P=.05). All patients had positron emission tomography–computed tomography for DLBCL staging, and there was significantly lower use of bone marrow biopsy (P=.011). Conclusion Implementating a QII and employing standardized metrics can aid in improving quality of care for patients with newly diagnosed DLBCL and allow opportunities to build and ensure better adherence to evolving patient care guidelines.
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Key Words
- ASH-PIM, American Society of Hematology Practice Improvement Module
- BMB, bone marrow biopsy
- CT, computed tomography
- DLBCL, diffuse large B-cell lymphoma
- EMR, electronic medical record
- G-CSF, granulocyte colony-stimulating factor
- HAART, highly active antiretroviral therapy
- HBV, hepatitis B virus
- HCV, hepatitis C virus
- NHL, non-Hodgkin lymphoma
- PET, positron emission tomography
- QII, quality improvement initiative
- R-CHOP, rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone
- VMMC, Virginia Mason Medical Center
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11
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Kim M, Lee YK, Park B, Oh DJ, Choi HG. Hepatitis virus B and C infections are associated with an increased risk of non-Hodgkin lymphoma: A nested case-control study using a national sample cohort. J Med Virol 2019; 92:1214-1220. [PMID: 31825111 DOI: 10.1002/jmv.25653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 12/09/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Hepatitis B virus (HBV) and hepatitis C virus (HCV) are suspected of being associated with non-Hodgkin lymphoma (NHL); however, persuasive data are lacking. Hence, a nested large-population case-control study was performed to investigate such associations in Koreans. METHODS Data were collected from 929 patients with NHL and 3716 healthy subjects, who were matched 1:4 for age, sex, income, and region of residence, from the Korean Health Insurance Review and Assessment Service-National Sample Cohort. The diagnoses of NHL and HBV/HCV infection were based on the International Classification of Diseases (version 10) codes. Conditional logistic regression models were used to assess odds ratios (ORs) for NHL with respect to HBV or HCV with adjustment for the Charlson comorbidity index. RESULTS HBV and HCV rates were higher in the NHL group (3.3% and 1.3%, respectively) than in the control group (0.9% and 0.3%, respectively; P < .001 for each). The adjusted OR of hepatitis infection in patients with NHL were 3.25 (95% confidence interval [CI] = 1.99-5.31) for HBV and 3.36 (95% CI = 1.51-7.46) for HCV (P < .001 for each). Subgroups categorized by age (<55 vs ≥55 years) or sex showed significantly higher adjusted ORs of HBV for NHL. Moreover, patients with NHL ≥ 55 years of age or those who were female showed significantly higher adjusted ORs of HCV; those <55 years or who were male also tended to have higher ORs of HCV. CONCLUSION Infection with either HBV or HCV is associated with NHL in Koreans.
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Affiliation(s)
- Miyoung Kim
- Department of Laboratory Medicine, Hallym University College of Medicine, Anyang, Korea
| | - Young Kyung Lee
- Department of Laboratory Medicine, Hallym University College of Medicine, Anyang, Korea
| | - Bumjung Park
- Department of Otorhinolaryngology-Head & Neck Surgery, Hallym University College of Medicine, Anyang, Korea
| | - Dong Jun Oh
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyo Geun Choi
- Department of Otorhinolaryngology-Head & Neck Surgery, Hallym University College of Medicine, Anyang, Korea.,Hallym Data Science Laboratory, Hallym University College of Medicine, Anyang, Korea
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12
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Ferri C, Feld JJ, Bondin M, Cacoub P. Expert opinion on managing chronic HCV in patients with non-Hodgkin lymphoma and other extrahepatic malignancies. Antivir Ther 2019; 23:23-33. [PMID: 30451149 DOI: 10.3851/imp3250] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2018] [Indexed: 02/07/2023]
Abstract
HCV is a carcinogen that is well established as a major risk factor for hepatocellular carcinoma. Evidence that HCV plays a role in the development of extrahepatic malignancies is less robust; however, epidemiological studies have consistently demonstrated an association between HCV infection and B-cell non-Hodgkin lymphoma (NHL). The strongest evidence for a link between HCV and tumourigenesis is the clear association between viral eradication, as indicated by achievement of sustained virological response, and remission of B-cell NHL. All-oral direct-acting antiviral-based therapies are effective in patients with HCV-associated NHL and well tolerated. For this reason, it is important that clinicians assess HCV-infected patients for HCV-associated extrahepatic malignancies so patients can receive timely diagnosis and treatment.
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Affiliation(s)
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Patrice Cacoub
- Sorbonne Universités, UPMC Univ Paris 06, UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France.,INSERM, UMR_S 959, F-75013, Paris, France.,CNRS, FRE3632, F-75005, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, F-75013, Paris, France
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13
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Zhou X, Pan H, Yang P, Ye P, Cao H, Zhou H. Both chronic HBV infection and naturally acquired HBV immunity confer increased risks of B-cell non-Hodgkin lymphoma. BMC Cancer 2019; 19:477. [PMID: 31113483 PMCID: PMC6530193 DOI: 10.1186/s12885-019-5718-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 05/14/2019] [Indexed: 12/20/2022] Open
Abstract
Background Previous studies examining the relationship between hepatitis B virus (HBV) infection and non-Hodgkin lymphoma (NHL) show inconsistent results in different endemic areas. Furthermore, studies evaluating the association between stratified HBV status and NHL with a well-matched case-control design are rare. Methods We conducted a 1:2 case-control study enrolling 3502 NHL cases and 7004 controls, and performed an updated meta-analysis evaluating the association between HBV and NHL subtypes. Results The HBsAg-negative/anti-HBc-positive/anti-HBs-positive population, implying naturally acquired immunity after infection, had increased B-NHL risk (Adjusted odds ratio (AOR) (95% confidence interval (95% CI)): 2.25 (1.96–2.57)). The HBsAg-positive/HBeAg-positive population, indicating current HBV infection, had high risk of B-NHL (AOR (95% CI): 6.23 (3.95–9.82)). Specifically, for diffuse large B-cell lymphoma (DLBCL), there was no significant difference in HBsAg status between the germinal centre B (GCB) and non-GCB subtypes. Additionally, our meta-analysis showed in a random effects model, HBV-infected individuals had a pooled OR of 2.09 (95% CI 1.76–2.50; P < 0.01) for NHL. Conclusions Chronic HBV infection was positively associated with B-NHL in China. However, acquired immunity by natural infection also increased B-NHL risk. Thus, we further speculated that regardless of whether HBsAg was cleared, the infected population had higher risk of B-NHL. Our study might expand our knowledge on tumorogenesis of NHL and thus provides clues for novel treatment strategies. Electronic supplementary material The online version of this article (10.1186/s12885-019-5718-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xi Zhou
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Huaxiong Pan
- Department of Pathology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Peng Yang
- Department of General Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Pian Ye
- Department of Hepatology and Infectious Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Haiyan Cao
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Hao Zhou
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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14
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Heterogeneity and coexistence of oncogenic mechanisms involved in HCV-associated B-cell lymphomas. Crit Rev Oncol Hematol 2019; 138:156-171. [PMID: 31092372 DOI: 10.1016/j.critrevonc.2019.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 04/02/2019] [Accepted: 04/03/2019] [Indexed: 12/15/2022] Open
Abstract
The association of HCV-infection with B-lymphomas is supported by the regression of most indolent/low-grade lymphomas following anti-viral therapy. Studies on direct and indirect oncogenic mechanisms have elucidated the pathogenesis of HCV-associated B-lymphoma subtypes. These include B-lymphocyte proliferation and sustained clonal expansion by HCV-envelope protein stimulation of B-cell receptors, and prolonged HCV-infected B-cell growth by overexpression of an anti-apoptotic BCL-2 oncogene caused by the increased frequency of t(14;18) chromosomal translocations in follicular lymphomas. HCV has been implicated in lymphomagenesis by a "hit-and-run" mechanism, inducing enhanced mutation rate in immunoglobulins and anti-oncogenes favoring immune escape, due to permanent genetic damage by double-strand DNA-breaks. More direct oncogenic mechanisms have been identified in cytokines and chemokines in relation to NS3 and Core expression, particularly in diffuse large B-cell lymphoma. By reviewing genetic alterations and disrupted signaling pathways, we intend to highlight how mutually non-contrasting mechanisms cooperate with environmental factors toward progression of HCV-lymphoma.
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15
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Couronné L, Bachy E, Roulland S, Nadel B, Davi F, Armand M, Canioni D, Michot JM, Visco C, Arcaini L, Besson C, Hermine O. From hepatitis C virus infection to B-cell lymphoma. Ann Oncol 2019; 29:92-100. [PMID: 29045541 DOI: 10.1093/annonc/mdx635] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In addition to liver disorders, hepatitis C virus (HCV) is also associated with extrahepatic immune manifestations and B-cell non-Hodgkin lymphoma (NHL), especially marginal zone lymphoma, de novo or transformed diffuse large B-cell lymphoma and to a lesser extent, follicular lymphoma. Epidemiological data and clinical observations argue for an association between HCV and lymphoproliferative disorders. The causative role of HCV in NHL has been further supported by the response to antiviral therapy. Pathophysiological processes at stake leading from HCV infection to overt lymphoma still need to be further elucidated. Based on reported biological studies, several mechanisms of transformation seem however to emerge. A strong body of evidence supports the hypothesis of an indirect transformation mechanism by which sustained antigenic stimulation leads from oligoclonal to monoclonal expansion and sometimes to frank lymphoma, mostly of marginal zone subtype. By infecting lymphocytes, HCV could play a direct role in cellular transformation, particularly in de novo large B-cell lymphoma. Finally, HCV is associated with follicular lymphoma in a subset of patients. In this setting, it may be hypothesized that inflammatory cytokines stimulate proliferation and transformation of IgH-BCL2 clones that are increased during chronic HCV infection. Unraveling the pathogenesis of HCV-related B-cell lymphoproliferation is of prime importance to optimize therapeutic strategies, especially with the recent development of new direct-acting antiviral drugs.
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Affiliation(s)
- L Couronné
- Department of Hematology, Assistance Publique-Hôpitaux de Paris (APHP), Necker Hospital, Paris, France.,INSERM UMR 1163, CNRS ERL 8254, Imagine Institute, Paris, France.,Paris Descartes-Sorbonne Paris Cité University, Paris, France
| | - E Bachy
- Cancer Research Center of Lyon, INSERM U1052, CNRS UMR 5286, Lyon, France.,Department of Hematology, Lyon Sud Hospital, Lyon, France
| | - S Roulland
- Center of Immunology of Marseille-Luminy, Aix Marseille University, Marseille, France
| | - B Nadel
- Center of Immunology of Marseille-Luminy, Aix Marseille University, Marseille, France
| | - F Davi
- INSERM U1104, Marseille, France.,CNRS UMR 7280, Marseille, France.,Department of Hematology, Pitié-Salpêtrière Hospital, Pierre et Marie Curie University, Paris, France
| | - M Armand
- INSERM U1104, Marseille, France.,CNRS UMR 7280, Marseille, France.,Department of Hematology, Pitié-Salpêtrière Hospital, Pierre et Marie Curie University, Paris, France
| | - D Canioni
- Department of Pathology, Necker Hospital, AP-HP, Paris Descartes-Sorbonne Paris Cité University, Paris, France
| | - J M Michot
- Department of Hematology and Drug Development, Gustave Roussy Institute, Villejuif; France
| | - C Visco
- Department of Cell Therapy and Hematology, San Bortolo Hospital, Vicenza, Italy
| | - L Arcaini
- Department of Molecular Medicine, University of Pavia, Pavia, Italy.,Departement of Hematology Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - C Besson
- Department of Hematology and Oncology, Hospital of Versailles, Le Chesnay, France.,University of Versailles Saint Quentin en Yvelines, Paris-Saclay University, Communauté Paris-Saclay, Paris, France.,INSERM U1184, Center for Immunology of Viral Infections and Autoimmune Diseases, Le Kremlin-Bicêtre, France
| | - O Hermine
- Department of Hematology, Assistance Publique-Hôpitaux de Paris (APHP), Necker Hospital, Paris, France.,INSERM UMR 1163, CNRS ERL 8254, Imagine Institute, Paris, France.,Paris Descartes-Sorbonne Paris Cité University, Paris, France
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16
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Abstract
Infectious agents, such as HCV, account for ∼15% of human cancers. HCV infects not only hepatocytes but also extrahepatic cells. Chronic HCV infection can induce chronic inflammation with qualitative and quantitative alterations of the immune repertoire and tissue microenvironment, which could induce various neoplasias. Epidemiological studies and meta-analyses suggest an increased rate of extrahepatic cancers in patients with chronic HCV infection along with a higher risk of intrahepatic cholangiocarcinoma, pancreatic cancer and non-Hodgkin lymphoma (NHL), highlighting the need to screen for HCV infection in patients with these cancers. Development of B cell NHL has been associated with HCV infection, with a relative risk of ∼1.5. Direct transformation related to the presence of the virus and chronic antigenic stimulation are the two major non-exclusive mechanisms involved in HCV-related lymphomagenesis. HCV infection alters survival of patients with lymphoma, and sustained virologic response (SVR) substantially improves prognosis. Antiviral treatments might induce remission of indolent lymphoma when SVR is achieved even without chemotherapy, emphasizing the role of HCV in lymphomagenesis in this context. However, studies are needed to provide prospective evidence of a causal relationship between chronic HCV infection and other extrahepatic cancers and to determine whether the risk of extrahepatic cancers is reduced with SVR. In this Review, we report on recent studies analysing the risk of extrahepatic cancers associated with chronic HCV infection. Although there is no doubt regarding the direct and indirect causality between HCV and NHL, an increased risk of other cancers is less clear, with the exception of cholangiocarcinoma.
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17
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Hepatitis C virus - Associated marginal zone lymphoma. Best Pract Res Clin Haematol 2017; 30:41-49. [PMID: 28288715 DOI: 10.1016/j.beha.2017.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 02/06/2017] [Indexed: 12/18/2022]
Abstract
The link between hepatitis C virus (HCV) infection and the development of B-cell non-Hodgkin lymphoma is now well established and based on a number of epidemiological studies. It is further supported by the observation of lymphoma regression after HCV eradication by antiviral treatment. The far most frequent entities are marginal zone lymphoma (MZL) and diffuse large B-cell lymphoma (DLBCL). MZL usually emerge on a background of mixed cryoglobulinemia, a low-grade lymphoproliferation, and often transform into DLBCL, thereby following a multistep oncogenesis process. The role of HCV in lymphomagenesis is not yet fully understood but several mechanisms have been proposed including (i) chronic external stimulation through the B-cell receptor and other surface receptors, and (ii) direct transformation by intracellular viral proteins, the former being probably predominant in MZL. Regression of HCV-associated MZL can be achieved with antiviral therapy and the novel generation of direct-acting antiviral agents appears highly effective and safe for the treatment of these lymphoma.
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18
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Radmehr H, Makvandi M, Samarbafzadeh A, Teimoori A, Neisi N, Rasti M, Abasifar S, Soltani H, Abbasi S, Kiani H, Mehravaran H, Azaran A, Shahani T. Prevalence of Hepatitis C virus Genotype 3a in patients with Hodgkin and Non-Hodgkin Lymphoma. IRANIAN JOURNAL OF MICROBIOLOGY 2016; 8:389-394. [PMID: 28491250 PMCID: PMC5420394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Hepatitis C virus (HCV) is a major public health problem worldwide. Replication and persistence of HCV genome have been described in the liver tissue as well as B cells lymphocyte. Several investigations have reported that long-term persistence of HCV in B cells may result in Hodgkin and Non-Hodgkin lymphoma. This study was aimed to determine frequency of HCV RNA in histological tissues obtained from patients suffered from Hodgkin and Non-Hodgkin lymphoma. MATERIALS AND METHODS 52 formalin-fixed paraffin-embedded tissue blocks including 23 (44.3%) Hodgkin and 29 (55.7%) Non-Hodgkin samples were collected and five micrometer sections were prepared. RNA was extracted and cDNA was synthesized. Two consecutive Nested RT-PCR assays were carried out for detection of HCV 5' UTR and core gene. RT-PCR products were sequenced and aligned to construct HCV phylogenic tree to evaluate the homology of sequences in comparison to the reference sequences retrieved from Genbank. RESULTS Overall, 6 Non-Hodgkin (20.6%) and 3 Hodgkin lymphoma (13.04%) samples showed positive PCR results for both 5' UTR and HCV core RNA via nested PCR (P<0.469). Sequencing results revealed that all detected HCV RNA samples belonged to the genotype 3a. CONCLUSION Despite low prevalence of HCV infection in Iran, high frequency of HCV RNA genotypes 3a (17.3%) has been found in patients with Hodgkin and Non-Hodgkin lymphoma. To improve treatment regimens, screening of HCV RNA in patients suffered from Hodgkin or Non-Hodgkin lymphoma is recommended which can be done through highly sensitive molecular means before and after immunosuppression status.
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Affiliation(s)
- Hashem Radmehr
- Health Research Institute, Infectious and Tropical Diseases Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Manoochehr Makvandi
- Health Research Institute, Infectious and Tropical Diseases Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran,Virology Department, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran,Corresponding author: Manoochehr Makvandi PhD, Health Research Institute, Infectious and Tropical Diseases Research Center, Virology Department, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. Tel: +98 9166181683, Fax: +98 61 33738313,
| | - Alireza Samarbafzadeh
- Health Research Institute, Infectious and Tropical Diseases Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran,Virology Department, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ali Teimoori
- Virology Department, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Niloofar Neisi
- Virology Department, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mojtaba Rasti
- Virology Department, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Sara Abasifar
- Virology Department, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Hasan Soltani
- Virology Department, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Samaneh Abbasi
- Virology Department, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Hadis Kiani
- Virology Department, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Hamide Mehravaran
- Virology Department, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Azarakhsh Azaran
- Virology Department, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Toran Shahani
- Virology Department, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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