Epstein-Barr Virus in Nasopharyngeal Carcinoma

內科部 血液腫瘤科05-20-2011

徐正龍

(Cancer.Net)

Symptoms/signsSymptoms/signs

Tumor mass in the nasopharynx (epistaxis, nTumor mass in the nasopharynx (epistaxis, nasal obstruction, and discharge)asal obstruction, and discharge)

Dysfunction of the eustachian tube, mass in Dysfunction of the eustachian tube, mass in paranasopharyngeal space ( tinnitus and deafparanasopharyngeal space ( tinnitus and deafness)ness)

Neck mass (upper neck) Neck mass (upper neck) Skull-base erosion and palsy of the V and VI cSkull-base erosion and palsy of the V and VI c

ranial nerves and up extension of tumor (hearanial nerves and up extension of tumor (headache, diplopia, facial pain and numbness)dache, diplopia, facial pain and numbness)

Signs:Enlarged neck nodes (75%), cranial nerSigns:Enlarged neck nodes (75%), cranial nerve palsy (20%)ve palsy (20%)

Trends Microbiol. 2004 Aug;12(8):356-60

EpidemiologyEpidemiology Male:Female = 2~3:1Male:Female = 2~3:1 Chinese native > Chinese immigrant > NortChinese native > Chinese immigrant > Nort

h American nativeh American native Both genetic and environmental factorsBoth genetic and environmental factors

EnvironmentalEnvironmental VirusesViruses

EBV- well documented viral “fingerprints” in tumor EBV- well documented viral “fingerprints” in tumor cells and also anti-EBV serologies with WHO type II cells and also anti-EBV serologies with WHO type II and III NPCand III NPC

HPV - possible factor in WHO type I lesionsHPV - possible factor in WHO type I lesions Nitrosamines - salted fishNitrosamines - salted fish Others - polycyclic hydrocarbons, chronic nasaOthers - polycyclic hydrocarbons, chronic nasa

l infection, poor hygiene, poor ventilationl infection, poor hygiene, poor ventilation

ClassificationClassification WHO classes (Based on light microscopy fWHO classes (Based on light microscopy f

indings)indings) Type I - moderate to well differentiated sqType I - moderate to well differentiated sq

uamous cell carcinomauamous cell carcinoma Type II - “non-keratinizing” carcinomaType II - “non-keratinizing” carcinoma Type III - “undifferentiated” carcinomaType III - “undifferentiated” carcinoma Differences between type I and Differences between type I and

types II & IIItypes II & III 5 year survival5 year survival

Type I - 10% Types II, III - 50%Type I - 10% Types II, III - 50% Long-term risk of recurrence for types II & IIILong-term risk of recurrence for types II & III Viral associationsViral associations

Type I - HPVType I - HPV Types II, III - EBVTypes II, III - EBV

Y S Chang, J Clin Microbiol. 1990 Nove

mber; 28(11): 2398–2402.

Detection of Epstein-Barr virus DNA sequences in nasopharyngeal carcinoma cells by enzymatic DNA amplification

 The Epstein–Barr virus genome (1)

Epstein–Barr virus(2)Epstein–Barr virus(2)

(Cell Research 2006)

Latent membrane Latent membrane proteins(3)proteins(3)

(Cell Research 2006)

The EBV-encoded nuclear antigens (4)

Role of Epstein–Barr virus in the pathogenesis of NPC (5)

Role of Epstein–Barr virus in the pathogenesis of NPC (5)

(2004)

Table 1. Major gene alterations in nasopharyngeal carcinoma

Cancer Cell. 2004 May;5(5):423-8.

Role of Epstein–Barr virus in the pathogenesis of NPC (6)

1

2

3

4

5

Genetic background (1)Genetic background (1)

three new susceptibility loci, three new susceptibility loci, TNFRSF19TNFRSF19 on 13q12, EBV-LMP1, activat on 13q12, EBV-LMP1, activat

e JNK pathwaye JNK pathway MDS1-EVI1MDS1-EVI1 on 3q26, on 3q26, EVI1, MDS1 and thEVI1, MDS1 and th

e fusion protein MDS1-EVI1, e fusion protein MDS1-EVI1, transcriptitranscription factor, on factor, TGF-β signaling TGF-β signaling

CDKN2ACDKN2A--CDKN2BCDKN2B gene cluster on 9p21. gene cluster on 9p21. tumor suppressor genetumor suppressor gene

leukemogenesisleukemogenesis HLAHLA

(Nature Genetics 2010)

A gender-specific (A gender-specific (malemale) association of CNV a) association of CNV at 6p21.3 with NPC susceptibilityt 6p21.3 with NPC susceptibility

the CNV (Copy number variations, a major sothe CNV (Copy number variations, a major source of human genetic polymorphism ) locateurce of human genetic polymorphism ) located at chromosome 6p21.3, with single-copy deld at chromosome 6p21.3, with single-copy deletion of the etion of the MICAMICA and and HCP5HCP5 genes, showed th genes, showed the highest association with NPC.e highest association with NPC.

The The MICAMICA gene (11.7 kb) encodes a 383-amin gene (11.7 kb) encodes a 383-amino-acid polypeptide and functions as a ligand fo-acid polypeptide and functions as a ligand for NKG2D on γ/δT cells, CD8+ α/β T cells and or NKG2D on γ/δT cells, CD8+ α/β T cells and NK cells. (NK cells. (Immune functionImmune function))

(Hum Mol Genet. 2011)

Genetic background (2)Genetic background (2)

EBV gene (1)EBV gene (1)

1.Circulating free EBV DNA copies increased during the initi1.Circulating free EBV DNA copies increased during the initial phase of radiotherapy after cell death.al phase of radiotherapy after cell death.118118

2.The quantity of free plasma EBV DNA is related to the stag2.The quantity of free plasma EBV DNA is related to the stage of the disease. The quantities of EBV DNA copies before e of the disease. The quantities of EBV DNA copies before and after treatment are significantly related to the rates of and after treatment are significantly related to the rates of overall and disease-free survival.overall and disease-free survival.119119

3.When EBV DNA was used together with Anti-EBV VCA I3.When EBV DNA was used together with Anti-EBV VCA IgA, the sensitivity of early diagnosis of nasopharyngeal cagA, the sensitivity of early diagnosis of nasopharyngeal carcinoma increased.rcinoma increased.121121

4.Raised levels of EBV DNA were only detected in 67% of p4.Raised levels of EBV DNA were only detected in 67% of patients with locoregional recurrence,atients with locoregional recurrence,116116 and and 122122 although in th although in those with distant metastasis levels of EBV DNA copies werose with distant metastasis levels of EBV DNA copies were heightened before the appearance of clinical abnormality.e heightened before the appearance of clinical abnormality.116116

 The Epstein–Barr virus genome (1)

Real-time Quantitative PCR

[[Cancer ResearchCancer Research 59, 1188-1191, March 15, 1999] 59, 1188-1191, March 15, 1999]Quantitative Analysis of Cell-free Epstein-Barr Virus Quantitative Analysis of Cell-free Epstein-Barr Virus DNA in Plasma of Patients with Nasopharyngeal DNA in Plasma of Patients with Nasopharyngeal Carcinoma1 Carcinoma1 Y. M. Dennis Lo, et al. Y. M. Dennis Lo, et al. The Chinese University of Hong KongThe Chinese University of Hong Kong

Y. M. Dennis Lo, et al. Cancer Research 1999

Y. M. Dennis Lo, et al. Cancer Research 1999

(NEJM, 2004)

EBV gene (2-1)

EBV gene (2-2)

(NEJM, 2004)

EBV gene (2-3)

(NEJM, 2004)

Typing of EBV DNA from Plasma and Primary Tumor (2-4)

(NEJM, 2004)

EBV DNA Kinetics EBV DNA Kinetics T1/2(1-R/T)T1/2(1-R/T)

Surge at first week after R/T Surge at first week after R/T (therapy induced cancer cell death)(therapy induced cancer cell death)

Median half life 3.8 days(2.4~4.4d)Median half life 3.8 days(2.4~4.4d)Cancer Res 2000

Median T1/2: 139minMedian T1/2: 139min Median f/u 7 d, 8/11 undetectable, 1/8 & other 3 recurMedian f/u 7 d, 8/11 undetectable, 1/8 & other 3 recur

EBV DNA T1/2 (2-OP)EBV DNA T1/2 (2-OP)

Clin Can Res 2003

EBV DNA load correlate EBV DNA load correlate with tumor volumewith tumor volume

IJROBP 2006

Complement to TNM Complement to TNM stagingstaging

JCO 2006 Early stage (I+II) high load similar to IIIEarly stage (I+II) high load similar to III

Pre-Tx EBV DNA level predict Pre-Tx EBV DNA level predict Meta/recur tx response and suMeta/recur tx response and su

rvivalrvival

Cancer. 2011 FebCancer. 2011 Feb

Pre-tx(median)Median:2.33x105

Post-txDetectable vsundetectable

EBV DNA in peripheral EBV DNA in peripheral blood cells predict distant blood cells predict distant

metastasismetastasis

(JCO 2001)

EBV DNA T1/2 (OP)EBV DNA T1/2 (OP)

T1/2: 5.4 hrsT1/2: 5.4 hrs

Local recur/ccrt

Retrosternal LN

煥

1420 0 0 0 0

916

0 0 0 0 0 0 00

200

400

600

800

1000

Recurrence-metastasis (1)

Chemo:PUL

97-2 Lung meta

興

01234567

95.06.07

95.10.18

95.11.01

95.12.13

96.01.17

96.02.14

96.03.07

96.03.28

96.05.09

96.07.04

96.08.28

LOG

10

Gem+CDDP

94.4-T3N2M095.6 bone, liver metaGem+cddp trial

Recurrence-metastasis (2)Recurrence-metastasis (2)

XX呂

0

1

2

3

4

5

695

.04.

12

95.1

0.25

96.0

6.13

96.1

0.17

97.1

1.06

97.1

2.03

97.1

2.10

98.0

1.07

LOG

10

XX呂

T1N1M0

Recurrence-metastasis (3)

Bone meta

NPC patients (fresh)NPC patients (fresh) 2007-1~2010-11, fresh:4892007-1~2010-11, fresh:489 Male:Famale=361:121 (3:1)Male:Famale=361:121 (3:1) Age:13~84, Median:48Age:13~84, Median:48 籍貫籍貫 :total:278, :total:278, 閩閩 133 133 客客 106 106 原原 17 17 其他其他 2222 Path:scc:28, NKDC 63 NKUDC:398Path:scc:28, NKDC 63 NKUDC:398 EBV DNA:0~3,948,614, posi:75.8%, median: 812EBV DNA:0~3,948,614, posi:75.8%, median: 812 I:I: 55 (posi:40% , (posi:40% , median: 145) median: 145) II:II: 107107 (posi:67.2%: ,(posi:67.2%: , median:257 ) median:257 ) III:III: 139139 (posi:68.3%, , (posi:68.3%, , median: 812) median: 812) IVa+b:IVa+b: 190 190 (posi:82.6%, (posi:82.6%, median: 917) median: 917) M1:M1: 4040 (posi:95%, (posi:95%, median:9,643) median:9,643)

Local Recurrence:61Local Recurrence:61AgeAge Range:19~72Range:19~72 Median:48Median:48

SexSex Male:44(72.1%)Male:44(72.1%) Female:17(27.9%)Female:17(27.9%)

EBV-DNAEBV-DNA Positive:35 (57.3%)Positive:35 (57.3%) Range:0~58,632Range:0~58,632Median:261 copies/mLMedian:261 copies/mL

Recurrence>Recurrence>1 episode1 episode

8(13.1%)8(13.1%)

MetastasisMetastasis 7(11.4%)7(11.4%)

Tissue proofTissue proof 52(85.2%)52(85.2%)

PET-CTPET-CT 4848 6/48 negative6/48 negative

MRI/CTMRI/CT 6161 1/61 negative1/61 negative

TreatmentTreatment Ccrt:31, r/t:9, Ccrt:31, r/t:9, Op:8,Op+ccrt:5Op:8,Op+ccrt:5

c/t:7, Supportive:1c/t:7, Supportive:1

Survival:Survival: Expire:18, Range:3~33mExpire:18, Range:3~33mMedian:9mMedian:9m

Survive:43, Survive:43, Follow-up>24m:20Follow-up>24m:20Median:32mMedian:32m

Metastasis (1)Metastasis (1) 73 metastatic patients73 metastatic patients Male:female=5:1Male:female=5:1 Response:CR:18(24.7%), PR:21(28.8%), Response:CR:18(24.7%), PR:21(28.8%),

SD:8(10.9%)SD:8(10.9%) Median survival: 17mMedian survival: 17m EBV DNA: EBV DNA:

pretreatmen: 0~4,509,918 copies/ml, pretreatmen: 0~4,509,918 copies/ml, positive rate:70/73 (95%)positive rate:70/73 (95%)median: 2,200 copies/mlmedian: 2,200 copies/ml

Metastasis(2)Metastasis(2)

Metastasis(3)Metastasis(3)

SummarySummary Plasma EBV DNA is a Plasma EBV DNA is a novel tumor markernovel tumor marker

and independent prognostic factor in and independent prognostic factor in NPCNPC

Correlate with Correlate with tumor burdentumor burden, , complement to TNM staging (especially complement to TNM staging (especially in in early stage with high viral loadearly stage with high viral load), and ), and correlate with disease status.correlate with disease status.

More higher positive rate and viral load More higher positive rate and viral load in in metastasismetastasis than local recurrence than local recurrence

Predict prognosisPredict prognosis (treatment response (treatment response and survival) in metastasis patientsand survival) in metastasis patients

AcknowledgementAcknowledgement

長庚醫院長庚醫院醫研部醫研部內科部內科部血液腫瘤科血液腫瘤科

施麗雲教授施麗雲教授王宏銘副教王宏銘副教

授授

頭頸部腫瘤團隊頭頸部腫瘤團隊

長庚大學長庚大學 張玉生教授張玉生教授黎欣白老師黎欣白老師