Case 5 -

EBV-associated B Cell Lymphoma (Plasmblastic Lymphoma) in the Setting of Iatrogenic Immune Dysregulation Presenting Initially in the Skin Cynthia M. Magro Ohio State University Columbus, OH

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Introduction Epstein Barr virus (EBV) is a member of the human herpes virus family and causes an acute self-limited illness. As with other herpes viruses, a state of latency may occur following acute infection whereby the genome is incorporated into the cell in the absence of active viral synthesis. This latent infection in B cells is postulated to contribute to the development of lymphoma. Most patients who develop EBV-associated lymphoma have underlying iatrogenic and/or endogenous immune dysregulation. Among the broad categories of EBV-associated lymphoproliferative disease are post-transplant lymphoproliferative disease (PTLD), lymphoproliferataive disease in patients with human immunodeficiency syndrome, and lymphomas developing in the setting of methotrexate therapy, typically in patients with underlying rheumatoid arthritis (RA). Perhaps the most frequently reported association is in the context of PTLD, which has a reported incidence of 1% to greater than 20% depending on the organ transplanted and the degree to which the patient is immunosuppressed. A role for EBV in the propagation of PTLD has been proposed based on the higher incidence of primary or reactivated EBV infection in patients with PTLD compared to the general transplant population, a high level of EBV DNA in the blood of affected patients, and EBV genome is detected in 95% of PTLD associated lymphomas. The presumptive basis is one related to iatrogenic immune dysregulation. While EBV-associated lymphoproliferative disease of the immunosuppressed is well described, only rarely does the disease first manifest itself in the skin. Clinical History A 36-year-old female status post living related donor renal transplant in 1991 developed redness, swelling and warmth in her right lower extremity from the mid-calf down in September 2001. Her primary care physician treated her with antibiotics for a presumptive diagnosis of cellulitis without improvement. In March 2002, an incisional biopsy was performed and showed a pandermal and subcutaneous infiltrate of atypical plasmacytic cells in the 15-20 micron range with many of the cells manifesting a blastic appearance. The plasmacytic cells expressed CD79a with focal expression of CD56. Case 5 - Figure 1 - There is a confluent proliferation of severely atypical plasmacytic cells associated with effacement of the dermal architecture. Case 5 - Figure 2 - There is a confluent proliferation of severely atypical plasmacytic cells associated with effacement of the dermal architecture. Case 5 - Figure 3 - Detection of EBV RNA by in situ hybridization. EBV RNA was detected in some of the tumor cells after in situ hybridization for EBER-1 and -2; note the strong nuclear signal. Case 5 - Figure 4 - Detection of HHV8 RNA by RT in situ PCR. HHV8 RNA was detected after in situ amplification of the corresponding cDNA using primers specific for the T0.7 viral message, which is expressed in latent and active infection. Note the strong nuclear signal in many of the tumor cells. The EBER RT-IS-PCR assay revealed numerous cells demonstrating dominant nuclear expression; the vTK assay was negative. HHV8 RT-IS-PCR revealed positive co-expression of the virus in the tumor cells. The oligoprobe assay showed λ light chain restriction. Subsequent studies showed monoclonal IgG λ paraproteinemia. Computed Tomography (CT), magnetic resonance imaging (MRI) and positron emmision tomography (PET) scans demonstrated a soft tissue mass associated with her transplanted kidney; however, a biopsy of the mass was never obtained. At the time of diagnosis of her plasmablastic lymphoma, the patient had been on immunosuppressive therapy for 11 years which consisted of cyclosporin, imuran and prednisone. The patient was treated with decrease in her immunosuppressive regimen and was started on intravenous acyclovir. This resulted in normalization of the PET scan; however, her cutaneous disease continued to progress. Surgical resection of the mass revealed a diffuse large B cell lymphoma with λ light chain restriction; many of the cells showed EBER-1 and EBER-2 expression. Following resection of the tumor mass, the patient was treated with local external beam radiation with resolution of the skin lesions. She has had no cutaneous recurrences to date, but she has a persistent, albeit quantitatively decreased, IgG lambda monoclonal gammopathy and persistence of the mass within the transplanted kidney. Comment This case fulfilled light microscopic, phenotypic and molecular features to be categorized as a form of plasmablastic lymphoma whereby there was a role for both EBV and HHV8 in lesional propagation. Over the last 3 years we have encountered other cases of EBV -associated B cell lymphoproliferative disease which presented initially in the skin. These cases have manifested considerable morphologic heterogeneity, comprising plasmablastic lymphoma(the case illustrated), marginal zone lymphoma, and diffuse large cell B cell lymphoma. All patients were receiving immunosuppressive agents for an average of 7 years prior to the development of the lymphoma. In half of the cases simple withdrawal of immunosuppression led to complete lesional regression without recurrence. The remaining cases however proved to be more refractory, requiring additional therapy including radiation in one and chemotherapy. One patient developed progressive extracutaneous disease and ultimately death. Although all patients had initial presentations in the skin, only half of our cases could be definitively categorized as primary cutaneous B-cell lymphoma based on the absence of extracutaneous disease within 6 months following initial diagnosis. Other reports have emphasized the indolent nature of cutaneous EBV associated PTLD The categories of post transplant lymphoproliferative disease encompass reactive plasmacytic hyperplasia, polymorphic post transplant lymphoproliferative disease, monomorphic post transplant lymphoproliferative disease, T cell neoplasms (and Hodgkin's disease). A summary of reported primary cutaneous EBV-positive B cell lymphomas is shown in Table 1: Table 1: Summary of previously reported cases of EBV associated primary cutaneous B cell lymphoma Lymphoma Type # cases Age Sex Year Site of presentation Immunosuppressed Condition CD30+ large B-cell 1 72 F 2003 Upper back None Anaplastic large B-cell 1 39 M 2002 Foot HIV B-cell 1 65 F 2002 Intermammary PTLD T-cell rich B-cell 1 86 M 2002 Right abdomen None Centroblastic B-cell 1 47 F 2001 Arms, chest, abdomen Dermatomyositis Follicle center 1 NA NA 2000 Unknown None Marginal zone 2 NA NA 2000 Unknown None Diffuse large B-cell 1 54 F 2000 Legs PTLD Diffuse large B-cell 1 61 M 1999 Left flank PTLD Diffuse large B-cell 1 38 F 1999 Upper back Dermatomyositis Diffuse large B-cell 1 58 F 1999 Legs, distal thighs Rheumatoid arthritis Immunoblastic 1 40 M 1999 Legs HIV Lymphoblastic B-cell 1 74 F 1997 Face T-cell lymphoma Plasmacytoma 1 NA NA 1997 Unknown None B-cell 1 64 M 1997 Right leg PTLD T-cell rich B-cell 1 74 M 1996 Generalized None Diffuse large B-cell 1 NA NA 1995 Unknown HIV Centroblastic B-cell 1 NA NA 1994 Unknown None B-cell 3 46-76 M 1993 Forehead(2), lower lip PTLD In one series comprising 673 renal allograft patients with PTLD, four patients were diagnosed as having primary cutaneous lymphoma; the lymphomas were of B and T cell lineage in three patients and one patient respectively. EBV DNA was identified by PCR in all of the B cell lymphomas and was absent in the T cell lymphoma. The patients with cutaneous B cell lymphoma were treated with surgery or radiotherapy for the primary lesion, remaining free of the disease for an average duration of 3.9 years. Plasmablastic lymphoma is not listed as a distinctive form of monomorphic PTLD. This lymphoma was first described in the oral cavity in the setting of HIV disease whereby other sites of involvement include the stomach, nasal cavity, and its origin in sacrococcygeal cysts. The lesions follow an aggressive clinical course with an average survival of 6 months, succumbing to multiorgan dissemination. The demonstration of HHV8 is a very recently described phenomenon in the setting of PBL. HHV8 expresses polypeptides which enhances cell proliferation and produces viral interleukin-6, a promoter of B-cell and plasma cell proliferation. It is possible that the significant elevation in circulating IL-6 levels in EBV associated post transplant lymphoproliferative disease may be attributable to co-infection with HHV8 as well . Plasmacytic marginal zone lymphoma defined another form type of monomorphic PTLD in our patient cohort. The basic architecture and phenotypic profile of marginal zone lymphoma is seen; however, a preponderance of light chain restricted neoplastic plasma cells and greater accentuation around blood vessels is observed. Previously recognized infective triggers have included hepatitis C as well as Borrelia burgdorferi. While the skin lesions in this case responded to a reduction in this patient's immunosuppressive regimen, he later developed a disseminated multiorgan plasmablastic large cell lymphoma which was also EBV positive. Since there was no recurrence of his skin lesions one could surmise that the more aggressive lymphoma was clonally unrelated to the earlier skin lymphoma, defining in essence a second PTLD associated lymphoma. Diffuse large B cell lymphoma with or without CD30 expression defined the presentation in half of the cases in our series and remains the most common form of EBV associated monomorphic PTLD. Large B cell lymphoma expressing CD30 has mainly been described in extranodal sites including the lung, gastrointestinal tract and brain; their association with EBV infection has been previously made. There are two prior reported cases of primary cutaneous CD30 positive B cell lymphoma including one case associated with EBV infection. MTX associated lymphoproliferative disease is the other form of iatrogenic EBV associated lymphoproliferative disease; it was first described in 1985. There are only three reports of methotrexate EBV-associated primary CBCL . The most common lymphoproliferative disease associated with MTX therapy is diffuse large B cell lymphoma. One study reported that 33% of lymphomas developing in patients with RA or dermatomyositis contain the EBV genome, while only 4% of lymphomas in the general population show molecular evidence of EBV infection. Conversely 83% of the lymphoid lesions that were associated with EBV occurred in patients treated with immunosuppressive therapy, most commonly MTX. Partial regression and or spontaneous resolution of lymphoma after withdrawal of the MTX is commonly reported. Patients with RA have also developed lymphoma in the setting of cyclosporine and penicillamine therapy. The question arises regarding the role of immunosuppression in EBV associated lymphomagenesis. EBV-infected B cells express a host of EBV-related components including six EBV nuclear antigens (EBNAs), two EBV-encoded RNAs (EBERs), and three latent membrane proteins (LMPs). Two latent proteins, EBNA-2 and LMP-1 are important for viral clearance, as they are recognized target antigens for cytotoxic T lymphocytes. However, even in immunocompetent persons, the virus is never completely eradicated and a small number of EBV-infected B cells remain latently infected and capable of reactivation at a later time. Furthermore the gene products of latently infected B cells may contribute to B cell immortalization. For example, LMP-1 augments B-cell proliferation, and protects infected B-cells from apoptosis. EBV also transforms B-cells, making them susceptible to other genetic mutations including proto-oncogene and onco-suppressor mutations. Based on the known association between immunosuppression and lymphoproliferative disease, one can hypothesize that T cell modulating agents may lead to unchecked B cell proliferation. The main implicated agents in our cases were MTX and cyclosporine. In regards to potential mechanisms by which methotrexate may exert its T cell immunomodulating properties, methotrexate can inhibit various T cell derived cytokines including interleukin-4, IL-13, IFN gamma, tumour necrosis factor-alpha (TNF alpha) and granulocyte-macrophage colony-stimulating factor. Methotrexate also directly inhibits the Th1 subset. Cyclosporine A promotes the expression of anti-apoptotic genes. Additionally, this drug along with azathioprine has been shown to cause chromosome breaks and nuclear abnormalities. Clearly other drugs with similar adverse T cell immunomodulating properties could be implicated. A recent case of primary EBV-positive B cell lymphoma of the skin developed in the setting of imatinib therapy for chronic myelogenous leukemia. EBV-encoded viral thymidine kinase (vTK) is expressed only during the lytic form of infection and was demonstrated in half of the cases reported in our series. We are only aware of one other study looking at PTLD following renal allografting showed vTK mRNAexpression in each of eight patients examined. The identification of lytic infection is critical in regards to therapeutic strategies used to treat EBV associated lymphoproliferative disease. Thymidine kinase is expressedonly during the lytic form of infection and converts the nucleosideanalogue gancyclovir into its active, cytotoxic form. Hence at least in those cases showing evidence of lytic infection the addition of a nucleoside analogue could be incorporated into the therapeutic regimen. In summary, EBV-positive B cell lymphomas does appear to have certain unique features that serves to distinguish itself categorically from other forms of PTLD. Specifically it occurs in the setting of prolonged iatrogenic immune dysregulation of years duration. Secondly while studies have emphasized the indolent clinical course of cutaneous PTLD we found that an aggressive clinical course could develop and as well the lesions may exhibit a recurrent tendency and or relative refractoriness to conventional B cell lymphoma therapy even when combined with reduction in immunosuppression. Given the identification of active lytic antigen expression in some of our cases, antiviral therapy may define an important therapeutic modality in this setting. The role of HHV8 in the propagation of these lymphomas should continue to be investigated albeit in our hands the identification of co-infection with this virus appears to be uncommon. Nevertheless its identification may result in an altered therapeutic approach which would encompass antiviral agents directed at HHV8. References Verma S, Nuovo G, Porcu P, and Magro CM. Cutaneous Epstein Barr Virus associated B cell lymphoproliferative diseaes in the setting of iatrogenic immune dysregulation. Journal of Cutaneous Pathology. In Press Tanner JE, Alfieri C. The Epstein-Barr virus and post-transplant lymphoproliferative disease: interplay of immunosuppression, EBV, and the immune system in pathogenesis. Transplant Infectious Disease 2001;3:60-69. Soler MJ, Puig JM, Mir M et al. Posttransplant Lymphoproliferative Disease: Treatment and Outcome in Renal Transplant Recipients. Transplantation Proceedings 2003;35:1709-1713. Johannessen J, Crawford DH. In Vivo Models for Epstein-Barr Virus (EBV)-Associated B Cell Lymphoproliferative Disease (BLPD). Rev Med Virol 1999;9:263-277. Theate I, Michaux L, Dardenne S et al. Epstein-Barr virus-associated lymphoproliferative disease occurring in a patient with sarcoidosis treated by methotrexate and methylprednisolone. Eur J Haematol 2002;69:248-253. Porcu P, Eisenbeis CF, Pelletier RP et al. Successful treatment of posttransplantation lymphoproliferative disorder (PTLD) following renal allografting is associated with sustained CD8+ T-cell restoration. Blood 2002;100:2341-2348. Verma S, Nuovo GJ, Porcu P, Baiocchi RA, Crowson AN, Magro CM. Epstein Barr virus and human herpes 8 associated primary cutaneous plasmablastic lymphoma in the setting of renal transplantation: a new form of post-transplantation lymphoproliferative disease. J Cutan Pathol (in press) Magro C, Crowson AN, Porcu P et al. Automated kappa and lambda light chain mRNA expression for the assessment of B-cell clonality in cutaneous B-cell infiltrates: its utility and diagnostic application. J Cutan Pathol 2003;30:504-511. Porcu P, Eisenbeis CF, Pelletier RP, et al. Treatment of posttransplantation lymphoproliferative disorder (PTLD) following renal allografting is associated with sustained CD8(+) T-cell restoration. Blood. 2002 Oct 1;100(7):2341-8. Morrison C, Porcu P, Caligiuri MA, Nuovo GJ. In situ determination of B-cell heavy chain, light chain, Bcl-2, and cyclin D1 expression patterns: methodology and clinical utility. Diagn Mol Pathol. 2001;10:171-178. Cioc AM, Allen C, Kalmar JR, Suster S, Baiocchi R, Nuovo GJ. plasmablastic lymphomas in AIDS patients are associated with human herpesvirus 8. Am J Surg Pathol. 2004 Jan;28(1):41-6. Nuovo M, Nuovo G. Utility of HHV8 RNA detection for differentiating Kaposi's sarcoma from its mimics. J Cutan Pathol 2001;28:248-55. Harris NL, Swerdlow SH, Frizzera G, Knoles DM. Tumours of Haematopoietic and Lymphoid Tissues. World Health Organization Classification of Tumours. . Post Transplant Lymphoproliferative disorders. :264-269. IARC Press, Lyon McGregor JM, Yu CC, Lu QL, Cotter FE, Levison DA, MacDonald DM. Posttransplant cutaneous lymphoma. J Am Acad Dermatol 1993;29:549-554. Ojanguren J, Collazos J, Martinez C et al. Epstein-Barr virus-related plasmablastic lymphomas arising from long-standing sacrococcygeal cysts in immunosuppressed patients. AIDS 2003;17(10):1582-1584. Chetty R, Hlatswayo N, Muc R et al. Plasmablastic lymphoma in HIV+ patients: an expanding spectrum. Histopathology 2003;42:605-609. Watabe H, Kawakami T Soma Y, Baba T, Mizoguchi M. Primary cutaneous T-cell-rich B-cell lymphoma in a zosteriform distribution associated with Epstein-Barr virus infection. J Dermatol 2002;29:748-753. Oguz O, Engin B, Demirkesen C. Primary cutaneous CD30-positive large B-cell lymphoma associated with Epstein-Barr virus. Int J Dermatol 2003;42:718-720. Nagore E, Ledesma E, Collado C, Oliver V, Perez-Perez A, Aliaga A. Detection of Epstein-Barr virus and human herpesvirus 7 and 8 genomes in primary cutaneous T-and B-cell lymphomas. BrJ Dermatol 2000;143:320-323. Patriarca F, Silvestri F, Fanin R, Zaja F, Sperotto A, Baccarani M. Long-lasting complete remission of hepatitis C virus (HCV) infection and HCV-associated immunocytoma with alpha-interferon treatment. Br J Haematol. 2001;112:370-2. Abd-el-Baki J, Stefanato CM, Koh HK, Demierre MF, Foss FM. Detection of cutaneous lymphoma. Oncology (Huntingt). 1998;12:1521-30; discussion 1532-4. Review. Shimura T, Sugisaki Y, Fukino K, Node Y, Teramoto A, Kawamoto M. Detection of Epstein-Barr virus DNA and expression of CD30 antigen in primary anaplastic diffuse large B-cell lymphoma of the brain. Brain Tumor Pathol. 2001;18(2):161-5. Schwend M, Tiemann M, Kreipe HH, et al. Rapidly growing Epstein-Barr virus-associated pulmonary lymphoma after heart transplantation. Eur Respir J. 1994 Mar;7(3):612-6. Harris NL, Swerdlow SH.. Tumours of haematopoietic and lymphoid tissues. World health Organization. Classification of tumours Methotrexate associated lymphoproliferative disease2001:270-271. IARC press, Lyon Tournadre A, D'Incan M, Dubost JJ et al. Cutaneous lymphoma associated with Epstein-Barr virus Infection in 2 patients treated with methotrexate. Mayo Clin Proc 2001;76:845-848. Fam AG, Perez-Ordonez B, Imrie K. Primary cutaneous B cell lymphoma during methotrexate therapy for rheumatoid arthritis. J Rheumatol 2000;27:1546-1549. Chai C, White WL, Shea CR, Prieto VG. Epstein Barr virus-associated lymphoproliferative-disorders primarily involving the skin. J Cutan Pathol 1999;26:242-247. Kamel OW, Van De Rijn M, LeBrun DP, Wess LM, Warnke RA, Dorfman RF. Lymphoid neoplasms in patients with rheumatoid arthritis and dermatomyositis: frequency of Epstein-Barr virus and other features associated with immunosuppression. Hum Pathol 1994;25:638-643. Holmes RD, Sokol RJ. Epstein-Barr virus and post-transplant lymphoproliferative disease. Pediatric Transplantation 2002;6:456-464. Papadaki HA, Stefanaki K, Kanavaros P et al. Epstein-Barr virus-associated high-grade anaplastic plasmacytoma in a renal transplant patient. Leuk Lymphoma 2000;36:411-415. Gerards AH, de Lathouder S, de Groot ER, Dijkmans BA, Aarden LA. Inhibition of cytokine production by methotrexate. Rheumatology (Oxford) 2003;42:1189-1196. Yamaki K, Uchida H, Harada Y, Li X, Yanagisawa R, Takano H, Hayashi H, Taneda S, Mori Y, Yoshino S J Pharm Pharmacol. 2003 Dec;55(12):1661-6. Effect of methotrexate on Th1 and Th2 immune responses in mice. Ibe W, Wittlinger T, Sebastian N, Meyer J, Darius H. A nonhealing ulcer diagnosed as extramedullary plasmocytoma of the limb eight years after cardiac transplantation. Transplantation 1999;68:901-904. Jensen MK. Chromosome studies in patients treated with azathioprine and amethopterin. Acta Med Scand 1967;182:445-455. Bird AG, McLachlan SM, Britton S. Cyclosporin A promotes spontaneous outgrowth in vitro of Epstein-Barr virus-induced B-cell lines. Nature 1981;289:300-301. Feigal EG. AIDS-associated malignancies: research perspectives. Biochim Biophys Acta 1999;1423:C1-C9. Bekkenk MW, Vermeer MH, Meijer CJ et al. EBV-positive cutaneous B-cell lymphoproliferative disease after imatinib mesylate. Blood 2003;102:4243. Beynet DP, Wee SA, Horwitz SS, Kohler S, Horning S, Hoppe R, Kim YH. Clinical and pathological features of posttransplantation lymphoproliferative disorders presenting with skin involvement in 4 patients. Arch Dermatol. 2004 Sep;140(9):1140-6. J Virol. 2004 Feb;78(4):1893-902. Lytic induction therapy for Epstein-Barr virus-positive B-cell lymphomas. Feng WH, Hong G, Delecluse HJ, Kenney SC.