Kaposi sarcoma-associated herpesvirus (KSHV): Molecular biology and oncogenesis

Kaposi sarcoma-associated herpesvirus (KSHV) is a double-stranded DNA herpesvirus belonging to the γ-herpesvirinae subfamily. KSHV has been associated with the development of three neoplastic diseases: Kaposi sarcoma (KS), primary effusion lymphoma (PEL), and multicentric Castleman disease (MCD). In this review, we discuss the three KSHV-associated malignancies, KSHV genome, latent and lytic aspects of the viral lifecycle, putative viral oncogenes, as well as therapeutic regimens used for the treatment of KS, PEL, and MCD.     

An unusual case of posttransplant peritoneal primary effusion lymphoma with T-cell phenotype in a HIV-negative female, not associated with HHV-8

Primary effusion lymphoma (PEL) is a recently individualized form of non-Hodgkin’s lymphoma (WHO classification) that mainly develops in HIV infected males, more frequently in homosexuals and advanced stages of the disease (total CD4+ lymphocyte count below 100–200/μL). Occasionally, it appears in other immunodepressive states (such as solid organs transplant period) and even, although very rarely, in immunocompetent patients. From a pathogenetic point of view, PEL has been related to Kaposi’s sarcoma associated herpes virus (also named human herpesvirus 8, HHV-8), an etiological factor of Kaposi’s sarcoma. The relative infrequency of this disease, the absence of wide casuistics allowing a better characterization, and its unfavorable outcome support the need of a deeper knowledge. We present here the clinical-biological findings of a patient, HIV -seronegative, who was diagnosed with peritoneal PEL of T-cell origin, and not HHV-8-associated, five years after renal transplantation.     

Immune evasion in Kaposi's sarcoma-associated herpes virus associated oncogenesis

A hallmark of herpesviruses is a lifelong persistent infection, which often leads to diseases upon immune suppression of infected host. Kaposi's sarcoma-associated herpesvirus (KSHV), also known as human herpesvirus 8 (HHV8), is etiologically linked to the development of Kaposi's sarcoma (KS), primary effusion lymphoma (PEL), and Multicentric Castleman's disease (MCD). In order to establish a persistent infection, KSHV dedicates a large portion of its genomic information to sabotage almost every aspect of host immune system. Thus, understanding the interplay between KSHV and the host immune system is important in not only unraveling the complexities of viral persistence and pathogenesis, but also discovering novel therapeutic targets. This review summarizes current knowledge of host immune evasion strategies of KSHV and their contributions to KSHV-associated diseases.     

KSHV/HHV8-associated lymphoproliferations in the AIDS setting

Kaposi's sarcoma-associated herpesvirus (KSHV) or human herpesvirus 8 (HHV8) is associated with two lymphoproliferative disorders in the AIDS setting, primary effusion lymphoma (PEL) and the plasma cell variant of multicentric Castleman's disease (MCD). In PEL, KSHV persists in a latent form in most lymphoma cells, although viral production has been seen infrequently. In MCD, the viral gene expression pattern is less restrictive, virus production appears to occur and to correlate with the severity of this disease. Several viral genes may contribute to the particular features of these two disorders: among them a viral homologue of interleukin 6 (vIL6) has attracted much attention and been shown to promote the growth of plasma cells. It is thought that its activity is important in the pathogenesis of both PEL and MCD. Other viral genes, in particular a D-type cyclin homologue, the latent nuclear antigen LANA, and one or more of the viral homologues of interferon regulatory factors (vIRFs) may also contribute. Although it is conceivable that viral infection per se could explain much, if not all, of the features of MCD, it is likely that additional genetic alterations play a role in the pathogenesis of PEL.     

Lymphoid disorders associated with HHV-8/KSHV infection: facts and contentions

Following the demonstration in 1994, that Kaposi's sarcoma (KS) was associated with a novel virus (KSHV or HHV-8) belonging to the lymphotropic herpes family, this virus was also found in certain lymphoid neoplasias of immunodeficient (HIV⁺) and immune competent hosts. The association of HHV-8/KSHV infection is now well established with primary effusion lymphoma (PEL) or body cavity based lymphoma (BCBL) and multicentric Castleman's disease (MCD) of the plasma cell type. A possible pathogenic role of HHV-8/KSHV in other lymphoid tumours including primary central nervous system lymphoma (PCNSL) and multiple myeloma (MM) as well as some atypical lymphoproliferations and sarcoidosis has also been suggested, but this is at present a controversial matter, or not confirmed. SeveralHHV-8/KSHV genes, including potential oncogenes, genes homologous to various cellular genes and growth factors have been incriminated in the pathogenesis of KS and PEL/BCBL, but a common pathogenic mechanism for the clearly diverse proliferations represented by PEL, MCD and KS is at present not evident.     

Monoclonality or oligoclonality of human herpesvirus 8 terminal repeat sequences in Kaposi's sarcoma and other diseases

BACKGROUND: Infection with human herpesvirus 8 (HHV8), also termed Kaposi's sarcoma (KS)-associated herpesvirus, is associated with all forms of KS, with primary effusion lymphoma (PEL), and with some forms of multicentric Castleman's disease (MCD), but the pathogenic role of HHV8 in these tumors and the clonal nature of KS are still unclear. The purpose of this study was to examine whether the number of terminal repeats (TRs) contained in the fused TR region of HHV8 could be used as a marker of clonality in HHV8-associated tumors. METHODS: Pulsed-field gel electrophoresis (PFGE) and multiple-probe Southern blot analysis of the HHV8 TR region were performed on high-molecular-weight DNA obtained from tumoral KS, PEL, and MCD lesions. RESULTS: These analysis showed that the fused TR region contains a large but variable number of TR units (ranging from 16 to 75) and that the viral genome is present as extrachromosomal circular DNA in these tumors in vivo, with occasional ladders of heterogeneous linear termini reflecting lytic replication. All PEL tumors and PEL-derived cell lines as well as some KS tumors contained monoclonal or oligoclonal fused TR fragments; however, the TR region appeared polyclonal in MCD tumors and in a few KS lesions. CONCLUSION: Several KS and PEL lesions are monoclonal expansions of a single infected cell, suggesting that HHV8 infection precedes tumor growth and thus supporting an etiologic role of latent HHV8 in these proliferations. Our finding that nodular KS lesions display all possible patterns of clonality supports the model according to which KS begins as a polyclonal disease with subsequent evolution to a monoclonal process.     

KSHV‐associated multicentric Castleman disease: A tangle of different entities requiring multitarget treatment strategies

Multicentric Castleman Disease (MCD) is a lymphoproliferative disorder presenting with heterogeneous pathological and clinical features. It comprises disease entities with a complex aetiology and overlapping pathogenesis. MCD can be found in association with HIV infection, plasma‐cell dyscrasias, Kaposi sarcoma (KS), B‐cell lymphomas including primary effusion lymphoma (PEL) and its solid variant, and Hodgkin lymphoma. In KSHV‐associated MCD cases, a common association is KS and a specific variant of lymphoma referred to as “plasmablastic lymphoma,” also called “large B‐cell lymphoma arising in KSHV‐associated MCD” lacking EBV infection. MCD is often referred to as human interleukin‐6 (hIL‐6) syndrome, since an overproduction of IL‐6 occurs in MCD‐associated diseases as well as in MCD itself. hIL‐6 and a viral IL‐6 (vIL‐6) homolog encoded by KSHV can independently or together lead to flares of KSHV‐associated MCD. Recently, a new clinical entity was proposed to describe a severe systemic infection/reactivation of KSHV: KSHV inflammatory syndrome (KICS). KICS may contribute in inducing the inflammatory symptoms seen in some patients with severe KS or PEL. The precise relationship of KICS to KSHV‐associated MCD is unclear and it is possible that KICS may be prodromal symptoms to frank KSHV‐associated MCD. Options for treatment of KSHV‐associated MCD and related diseases include monoclonal antibodies, chemotherapy, immune modulators, virus‐activated cytotoxic therapy and antiviral therapies. A comprehensive understanding of the intricacies of the HIV‐KSHV coinfection will probably lead to additional advances in therapy and managements for these disorders.     

HIV-1 infection of primary effusion lymphoma cell line triggers Kaposi's sarcoma-associated herpesvirus (KSHV) reactivation

Kaposi's sarcoma-associated herpesvirus (KSHV) is a gammaherpesvirus etiologically linked to primary effusion lymphoma (PEL), to a subset of multicentric Castleman's disease and to Kaposi's sarcoma (KS), the most common neoplasm associated with AIDS. Among KSHV-infected individuals, the risk of KS is much higher in those with human immunodeficiency-1 (HIV-1) infection than among those with other types of immunosuppression, suggesting a direct action of HIV-1 on KSHV replication. We show in our report that BC-3 cells, a chronically KSHV-infected B-cell line of a PEL origin, are permissive to HIV-1, offering a new tool for studying the interactions between these 2 viruses. In these cells, HIV-1 infection leads to reactivation of latent KSHV genomes, as demonstrated by the expression of KSHV lytic viral mRNAs. Although recombinant HIV-1 gp120 fails to enhance herpesvirus expression, transient transfection of the HIV-1 trans-activator Tat suffices to reactivate latent KSHV. By showing that HIV-1 infection directly reactivates latent KSHV, our results suggest a direct role of HIV-1 in the onset of KS in coinfected individuals.     

Seroepidemiology of Kaposi's sarcoma-associated herpesvirus (KSHV).

Since the Kaposi's sarcoma-associated herpesvirus (KSHV also referred to as HHV-8, human herpesvirus-8) was discovered it has been shown that the virus is associated with all cases of Kaposi's sarcoma (KS) classical, endemic, or AIDS associated. In the numerous countries where the seroprevalence of this virus has been studied, data demonstrate that the virus is not ubiquitous in general healthy human populations as is the case with other human herpesviruses. Many seroprevalence studies to detect antibodies to HHV-8 have now been conducted using a variety of immunologic techniques. While these assays are not in total agreement and may overstate or understate the positivity of sera in the general population, they all show similar general antibody trends. For general populations the seroprevalence in sub-Saharan Africa is the highest, approximately 40% positive; in Mediterranean countries the seroprevalence is approximately 10%; whereas northern European, southeast Asian, and Caribbean countries have seroprevalence rates in the 2-4% range. In the United States, a 'mixing bowl' country the seroprevalence is in the range of 5-20%. In people with KS whether AIDS associated, classical, or endemic and other HHV-8 associated diseases such as multicentric Castleman's disease and certain body cavity lymphomas (BCL), also called primary effusion lymphoma (PEL) the seroprevalency rates are >90%. In populations with HIV-1 infection but no diagnosis of KS, the seroprevalency rates are elevated (20-50%) above those in the general population except in southeast Asia and the Caribbean where no AIDS associated KS has been reported. No correlation has been found between the presence of KSHV antibodies and other malignancies.     

High incidence of Kaposi sarcoma-associated herpesvirus infection in HIV-related solid immunoblastic/plasmablastic diffuse large B-cell lymphoma.

Kaposi sarcoma-associated herpesvirus (KSHV) is known to be associated with two distinct lymphoproliferative disorders: primary effusion lymphoma (PEL) and multicentric Castleman disease (MCD)/MCD-associated plasmablastic lymphoma. We here report a high incidence of KSHV infection in solid HIV-associated immunoblastic/plasmablastic non-Hodgkin's lymphomas (NHLs), in patients lacking effusions and without evidence of (prior) MCD. Within a cohort of 99 HIV-related NHLs, 10 cases were found to be KSHV positive on the basis of immunostaining for KSHV LNA-1 as well as KSHV-specific polymerase chain reaction. All but one of the tumors coexpressed Epstein-Barr virus. Interestingly, all KSHV-positive cases belonged to a distinctive subgroup of 26 diffuse large B-cell lymphomas characterized by the expression of CD138 (syndecan-1) and plasmablastic/immunoblastic morphology. These KSHV-positive lymphomas were preceded by Kaposi sarcoma in 60% of the patients and involved the gastrointestinal tract in 80%. Our results indicate that KSHV infection is not restricted to PEL and MCD; it is also common (38%) in HIV-related solid immunoblastic/plasmablastic lymphomas.     

Pathogenesis of Kaposi's sarcoma

Kaposi's sarcoma (KS) is a disease characterized by proliferative vascular lesions, which almost invariably contain the KS-associated herpesvirus (KSHV), also called human herpesvirus 8. KSHV is a lymphotrophic and angiotrophic herpesvirus, whose genome encodes several proteins involved in proliferation, antiapoptotic functions, and inflammation. Most KS spindle cells express latent KSHV genes, but a few express lytic genes, which might be involved in angiogenic and paracrine mechanisms that contribute to KS pathogenesis. A number of tissue culture and mouse models have been established, but a comprehensive system that accurately portrays KS pathogenesis still does not exist.     

Involvement of oxidative stress and caspase activation in paclitaxel-induced apoptosis of primary effusion lymphoma cells

Paclitaxel has significant antitumor activity in several human tumors, including Kaposis sarcoma (KS). Human herpesvirus 8 (HHV-8) is implicated in all forms of Kaposis sarcoma, primary effusion lymphoma (PEL), and multicentric Castlemans disease (MCD), indicating that it is a DNA tumor virus. Since it is difficult to culture cell lines derived from KS patients, we used a cell line derived from PEL (BCBL-1) to investigate whether oxidative stress is involved in the cytotoxicity of paclitaxel on the HHV-8-related tumors. We found that the generation of reactive oxygen species (ROS) in the BCBL-1 cells was increased by paclitaxel treatment, and the increase in ROS production was suppressed by antioxidants, including catalase and ascorbic acid. Moreover, ascorbic acid also attenuated the cytotoxicity induced by paclitaxel. Upon paclitaxel treatment, caspase-2, caspase-3, and caspase-8 were activated in BCBL-1 cells. Cotreatment with antioxidants did not affect caspase-2, caspase-3 or caspase-8 activation. Paclitaxel-induced apoptosis was also accompanied by an increase in the protein levels of Bax, and this effect was attenuated by antioxidants. Paclitaxel slightly decreased the expression of Bcl-2 protein, but antioxidants induced Bcl-2 protein. These results suggest that oxidative stress is only partially involved in the cytotoxicity of paclitaxel in BCBL-1 cells, and that paclitaxel-induced apoptosis of BCBL-1 cells is primarily mediated by the caspase activation pathway.     

Human herpesvirus 8 open reading frame 26 and open reading frame 65 sequences from multiple myeloma patients: a shared pattern not found in Kaposi's sarcoma or primary effusion lymphoma.

Human herpesvirus 8 (HHV-8), also known as Kaposi's sarcoma-associated herpesvirus, has been implicated in the pathogenesis of Kaposi's sarcoma (KS), primary effusion lymphoma (PEL), multicentric Castleman's disease, and recently multiple myeloma (MM). DNA sequence analyses of HHV-8 suggest that multiple HHV-8 strains exist. We extracted DNA from 24 patients with MM and 3 patients with monoclonal gammopathy of undetermined significance and compared HHV-8 open reading frames (ORFs) 26 and 65 sequences with those derived from patients with KS, PEL, and two HHV-8-positive PEL cell lines KS-1 and BC-1. ORF26 sequence data suggest that MM patients are consistently carriers of HHV-8 strain subtype C3. All MM patients also consistently revealed either a single bp deletion or substitution at position 112197 in ORF65. This unique alteration is not present in patients with KS or PEL or in PEL cell lines. It occurs in the portion of ORF65 that is known to be responsible for a serological response to HHV-8.     

The tumor microenvironment controls primary effusion lymphoma growth in vivo

Certain lymphomas in AIDS patients, such as primary effusion lymphoma (PEL), are closely associated with the lymphotropic gamma herpes virus Kaposi's sarcoma-associated herpes virus (KSHV), also called human herpesvirus 8. The virus is thought to be essential for tumorigenesis, yet systems to investigate PEL in vivo are rare. Here we describe PEL tumorigenesis in a new xenograft model. Embedded in Matrigel, PEL cells formed rapid, well-organized, and angiogenic tumors after s.c. implantation of C.B.17 SCID mice. Without Matrigel we did not observe comparable tumors, which implies that extracellular support and/or signaling aids PEL. All of the tumors maintained the KSHV genome, and the KSHV latent protein LANA/orf73 was uniformly expressed. However, the expression profile for key lytic mRNAs, as well as LANA-2/vIRF3, differed between tissue culture and sites of implantation. We did not observe a net effect of ganciclovir on PEL growth in culture or as xenograft. These findings underscore the importance of the microenvironment for PEL tumorigenesis and simplify the preclinical evaluation of potential anticancer agents.     

Classic kaposi sarcoma: epidemiology and risk factors

BACKGROUND: Although Kaposi sarcoma (KS) initially was described over a century ago, its biology remains enigmatic and conflicting. Whereas the classic type occurs mainly in older men of Mediterranean or Eastern European backgrounds and is not linked to impairment of the host immune response, iatrogenic and human immunodeficiency virus (HIV)-associated KS are linked to such conditions. A recently discovered pathogen, KS-associated herpesvirus (KSHV) (also known as human herpesvirus 8 [HHV8]), is found in tissues from all four forms of KS (classic, iatrogenic, endemic [African], and HIV-associated). This universal detection of KSHV/HHV8 suggests a central role for the virus in the development of KS and a common etiology for all KS types. The epidemiology and risk factors of classic KS, along with the biology of KSHV/HHV8 and the prevalence of the virus among different populations, is presented. METHODS: The current review is based on multiple information sources, electronic health data in all languages from 1966 onward, and previously published scientific reports from the Americas, Europe, and Africa. RESULTS: Nearly 5000 cases of morphologically characterized classic KS have been reported in Europe, Mediterranean countries, and the Americas up to 1998. Geographic location, ethnicity, time interval, age, and gender heavily influence the incidence rate of classic KS. The rate of incidence of nonacquired immunodeficiency syndrome-associated KS correlates with the KSHV/HHV8 seroprevalence in the general population. CONCLUSIONS: Many contributory factors undoubtedly have etiologic and pathogenic significance in the development of classic KS; however, the interplay between these factors has complicated the understanding of the induction and development of the disease as well as the significance of each factor. As with other cell-transforming human DNA viruses, infection with KSHV/HHV8 alone is not sufficient for the development of KS and additional cofactors are required.     

Risk factors for Kaposi's-sarcoma-associated herpesvirus (KSHV/HHV-8) seropositivity in a cohort of homosexual men, 1981–1996

A newly identified herpesvirus has been associated with Kaposi's sarcoma. We determined risk factors for Kaposi's-sarcoma-associated herpesvirus/human herpesvirus 8 (KSHV/HHV-8) seropositivity and incidence of infection over time in a cohort of Danish homosexual men followed from 1981 to 1996. Antibodies to a latent nuclear (LANA) and a structural (orf65) antigen of KSHV/HHV-8 were measured by immunofluorescence and ELISA/WB respectively. Through linkage with the national AIDS registry, all cohort members diagnosed with AIDS as of September 1996 were identified and their hospital records were scrutinized to record all diagnoses of KS. Overall, 21.1% (52/246) of the men were KSHV/HHV-8-seropositive in 1981. Among the initially seronegative, the rate of KSHV/HHV-8 seroconversion was highest between 1981 and 1982 and declined steadily thereafter. In a multivariate analysis of the status at enrollment in 1981, KSHV/HHV-8 seropositivity was not associated with age but was independently associated both with number of receptive anal intercourses (OR = 2.83; p = 0.03) and with sex with US men (OR = 2.27; p < 0.05). In a multivariate analysis of follow-up data, risk of KSHV/HHV-8 seroconversion was independently associated with having visited homosexual communities in the United States, and current HIV-positive status. More than 5 years' homosexual experience was associated with an insignificantly increased risk (RR = 2.68). KS occurred only in HIV-positive men who were KSHV/HHV-8-positive at or prior to their KS diagnosis. In conclusion, KSHV/HHV-8 appears to be sexually transmitted, probably by receptive anal intercourse, and may have been introduced to Danish homosexual men via sex with US men. The epidemic of KSHV/HHV-8 is now declining. These findings are concordant with the view that KSHV/HHV-8 may have been actively spread simultaneously with and by the same activities that lead to the spread of HIV. Int. J. Cancer 77:543–548, 1998. © 1998 Wiley-Liss, Inc.     

Inhibition of HHV-8/KSHV infected primary effusion lymphomas in NOD/SCID mice by azidothymidine and interferon-alpha

Kaposi's sarcoma-associated herpesvirus/human herpesvirus type-8 (KSHV/HHV-8) is associated with primary effusion lymphomas (PEL), a rare form of B-cell lymphoma. PEL cell lines infected with HHV-8, but negative for Epstein-Barr virus (EBV), were analyzed for their tumorigenic potential in a small animal model system. Inoculation of PEL cell lines into non-obese diabetic/severe combined immunodeficient (NOD/SCID) mice results in efficient engraftment and tumorigenesis in vivo. PEL-engrafted NOD/SCID (PEL/SCID) mice displayed malignant ascites development with notable abdominal distension, consistent with the clinical manifestations of PEL in humans. Azidothymidine (AZT, zidovudine) and interferon-alpha (IFN-alpha) induce apoptosis in HHV-8+/EBV- PEL cells in culture, by induction of a tumor necrosis factor-related apoptosis inducing ligand (TRAIL) mediated suicide program and has been proposed as a therapy for herpesvirus-associated lymphomas. Daily injection of AZT and IFN-alpha significantly increased mean survival time (MST) of PEL/SCID mice suggesting that induction of apoptosis in PEL cells in vivo may be exploited as an effective relatively non-toxic therapy targeting HHV-8 infected PEL. These data demonstrate that the PEL/SCID mouse is an important preclinical model to characterize efficacy and anti-tumor mechanisms of new therapeutic targets in vivo and will be useful in the design and testing of agents in viral lymphoproliferative diseases.     

Detection of antibodies to human herpesvirus 8 in Italian children: evidence for horizontal transmission

Human herpesvirus 8 (HHV-8), also known as Kaposi's sarcoma associated herpesvirus (KSHV), has been shown to be the causative agent for Kaposi's sarcoma (KS) and to be more prevalent in populations or risk groups at increased risk for KS. HHV-8 infection is rare in children from the US and the UK, but has been reported in African children. In this study we examine HHV-8 infection in children from Italy, a country with an elevated prevalence of HHV-8 in adults and high socio-economic conditions.     

Fifty years of multicentric Castleman's disease

Benjamin Castleman first described multicentric Castleman's disease (MCD) in a series of cases in 1954. Interest in MCD has grown in recent years following an association with human immunodeficiency virus (HIV) infection. Castleman's disease is separated into localized disease and MCD. The latter is characterized by polylymphadenopathy and multiorgan involvement. Histologically, Castleman's disease is divided into the hyalinized vascular form and a plasma cell variant, the former being more common in localized disease and the latter more common in MCD. MCD is associated with Kaposi's sarcoma herpesvirus (KSHV) infection, which is alternatively termed human herpesvirus 8 (HHV8). This virus encodes a homologue of interleukin 6 (vIL 6), which may mediate some systemic features of MCD. The diagnosis of Castleman's disease is established by biopsy and treatment is often based on published case reports only, as there are no randomized trials of therapy. Surgery has less of a role in MCD than in localized disease, but debulking by splenectomy may be useful to alleviate haematological sequelae. Systemic treatments for MCD have included chemotherapy, anti-herpesvirus treatments to reduce the KSHV viral load, highly active antiretroviral therapy (HAART) to reduce HIV viraemia and latterly monoclonal antibodies against both IL 6 and CD20. The introduction of HAART has altered the natural history of HIV infection; however, its impact on MCD is difficult to ascertain. Optimization and consensus in treatment of these patients remains a target for the future.