- Research article
- Open Access
Risk of classical Kaposi sarcoma by plasma levels of Epstein-Barr virus antibodies, sCD26, sCD23 and sCD30
Infectious Agents and Cancer volume 5, Article number: 18 (2010)
To clarify the immunological alterations leading to classical Kaposi sarcoma (cKS) among people infected with KS-associated herpesvirus (KSHV).
In a population-based study of 119 cKS cases, 105 KSHV-seropositive controls, and 155 KSHV-seronegative controls, we quantified plasma soluble cluster of differentiation (sCD) levels and antibodies against Epstein-Barr virus nuclear antigen-1 (anti-EBNA-1) and viral capsid antigen (anti-VCA). Differences between groups in prevalence of low-tertile anti-EBNA-1 and high-tertile anti-VCA were compared by logistic regression. Continuous levels between groups and by presence of cKS co-factors among controls were compared by linear regression and Mann-Whitney-Wilcoxon methods.
Comparisons of cKS cases to seropositive controls and of seropositive to seronegative controls revealed no significant differences. However, controls with known cKS cofactors (male sex, nonsmoking, diabetes and cortisone use) had significantly lower levels of anti-EBNA (P = 0.0001 - 0.07) and anti-VCA (P = 0.0001 - 0.03). Levels of sCD26 were significantly lower for male and non-smoking controls (Padj ≤ 0.03), and they were marginally lower with older age and cortisone use (Padj ≤ 0.09).
Anti-EBV and sCD26 levels were associated with cofactors for cKS, but they did not differ between cKS cases and matched controls. Novel approaches and broader panels of assays are needed to investigate immunological contributions to cKS.
Kaposi sarcoma (KS) develops in develops in a minority of people who have been infected with Kaposi sarcoma-associated herpesvirus (KSHV). KS is the predominant malignancy occurring in people with the acquired immunodeficiency syndrome (AIDS), illustrating that cell-mediated immunity modifies the risk KS. However, the abnormalities with AIDS are so varied in type and severity that dissecting those specifically associated with KS is challenging. Studies of people who do not have overt immunologic abnormalities may be more informative, although consistent, unambiguous perturbations have yet to be reported in non-AIDS KS [1–4].
KSHV reactivation with viremia is predictive for KS , but study of the underlying immunologic mechanisms is technically difficult and unsettled [6–8]. In lieu of a KSHV-specific approach, generic measures of immunity may be helpful. Loss of immunologic control of the related gammaherpesvirus, Epstein-Barr virus (EBV), results in viral reactivation and is marked by higher antibodies against viral capsid antigen (anti-VCA) and lower antibodies against nuclear antigen-1 (anti-EBNA-1). This EBV serology pattern, as well as altered levels of soluble cluster of differentiation (sCD) markers (sCD26, sCD23 and sCD30), have been associated with immune-mediated clinical conditions [9–14]. The Th1/Th2 cellular immunity paradigm has been the rationale [9–14]. We examined whether these markers were associated with classical KS (cKS) in a population-based study in Sicily.
We included 119 cKS cases, 105 KSHV seropositive controls, and 155 KSHV seronegative controls (Table 1). Anti-EBNA-1 levels ranged from 0.59 - 9.59, and anti-VCA from 0.87 - 9.47. High-tertile anti-VCA was associated with KSHV seropositivity among controls (Table 2, lower panel), but overall anti-EBV levels were not correlated with anti-KSHV levels (Pearson R ≤ 0.07, P≥0.29). Radiation and chemotherapy history in cases was infrequent and unrelated to anti-EBV and sCD levels. Excluding such cases did not substantially alter the results (data not shown).
Mean [standard deviation (SD)] anti-EBNA-1 levels were 5.39 (SD 1.93) in cases, 5.56 (SD 1.72) in seropositive controls, and 5.25 (SD 1.78) in seronegative controls. Mean anti-VCA levels were 5.53 (SD 1.68) in cases, 5.71 (SD 1.82) in seropositive controls, and 5.40 (SD 1.69) in seronegative controls. Adjusted for age and sex, mean differences between cases and seropositive controls were -0.23 [95% confidence interval (CI): -0.70, 0.24] for anti-EBNA-1 and -0.25 (95% CI: -0.72, 0.22) for anti-VCA. With further adjustment for cKS cofactors, anti-EBV levels were virtually identical (mean difference 0.02 for anti-EBNA-1, 0.03 for anti-VCA). Anti-EBV levels did not confound or modify the associations of the cofactors with cKS (data not presented) . Only 5 cases and 6 seropositive controls had low-EBNA-1/high-VCA, which was associated with a non-significantly lower risk of cKS (Table 2, upper panel).
Comparing KSHV-seropositive versus -seronegative controls, adjusted for age and sex, mean differences were 0.34 (95% CI: -0.11, 0.80) for both anti-EBNA-1 and anti-VCA. With further adjustment for cKS cofactors, mean differences were 0.21 (95% CI: -0.24, 0.66) and 0.18 (95% CI: -0.26, 0.62) for anti-EBNA-1 and anti-VCA, respectively.
In the combined group of controls, levels of anti-EBNA-1 and especially anti-VCA were substantially and significantly lower with three cKS cofactors: male sex, nonsmoking, and diabetes (Table 3). The anti-EBNA-1 and anti-VCA levels also were marginally lower with the fourth cKS cofactor, cortisone use (Table 3).
All sCD26, sCD23 and sCD30 levels were within detectable limits. Medians and interquartile ranges were similar across groups (cKS cases, KSHV seropositives, and seronegatives), and no significant differences were found (P≥0.35, data not presented).
Considering cKS cofactors in the control subjects, sCD26 levels were higher in females (median 459 ng/mL vs 416 ng/mL, Padj = 0.006) and current smokers versus never smokers (median 508 ng/mL vs 425 ng/mL, Padj = 0.03); and sCD26 levels tended to be lower in cortisone users (median 422 ng/mL vs 446 ng/mL, Padj = 0.09). Older controls tended to have lower sCD26 (Padj = 0.06) and higher sCD30 (Padj = 0.08) levels. Otherwise, cKS cofactors were not associated with sCD levels (Padj > 0.09, data not presented).
Cases of cKS did not differ from KSHV-seropositive controls in anti-EBV or sCD levels. A posteriori, we found that cKS cofactors among controls were significantly associated with low anti-EBNA-1 and especially low anti-VCA. Levels of sCD26 tended to be lower in older controls and cortisone users, and they were significantly lower in never smokers and males.
Our assays have been used as measures of immunity for epidemiologic research, specifically invoking the Th1/Th2 cellular immunity paradigm [9, 10, 16]. However, in vitro data to support their use are sparse. Especially with a single plasma sample, these assays may be too crude to distinguish a chronic condition, such as cKS, with the limited statistical power that we had herein.
Although cases did not differ from controls, our findings on cKS cofactors among controls should be noted, particularly because these cofactors are also associated with Th1/Th2 alteration. Th1 responses are generally lower and Th2 responses generally higher in women, smokers, diabetics, and corticosteroid users [17–22]. Classical KS risk is increased for corticosteroid users and perhaps diabetics, but cKS risk is reduced for women and smokers [15, 23]. The effect of smoking on Th1/Th2 cytokine levels may also differ by sex . These complex and even inverse relationships suggest that differences in cKS risk may reflect differences in immunity or inflammation that are captured, but only weakly, by anti-EBV and sCD26 levels.
In summary, anti-EBV and sCD26 levels were associated with cofactors for cKS, but not with cKS risk per se. Perhaps Th1/Th2 imbalance is poorly measured by these assays or is unrelated to cKS risk. Further studies of cKS risk with a more comprehensive panel of cytokine and inflammatory markers will be needed to illuminate the abnormalities that contribute to this malignancy.
The parent case-control study, including KSHV serostatus definition, has been reported . The current study included all cKS cases, all KSHV-seropositive controls, and a sample of KSHV-seronegative controls with ≥0.5 mL previously unthawed plasma for the assays. Seronegatives were matched to seropositive controls and cases on cKS cofactors (sex, age group, cigarette smoking and diabetes).
EBV enzyme immunoassays were performed as described . Antibody levels were the ratio of each specimen's average optical density (OD450) divided by the average OD450, plus 2 standard deviations, of four negative controls on each plate. Ratio value is highly correlated with anti-EBV immunofluorescence end-point titer . Commercial kits were used to quantify sCD26, sCD23 and sCD30 [Bender MedSystems GmbH (Vienna, Austria)].
Three sets of comparisons were made: cKS cases versus KSHV-seropositive controls; KSHV-seropositive versus-seronegative controls; and all controls by cKS-related cofactors (including KSHV serostatus). We used linear regression (for anti-EBV levels) or Mann-Whitney-Wilcoxon (for sCD levels) methods. As done previously [8, 9], cKS risk was postulated to be highest with low-EBNA-1/high-VCA, defined using tertiles among controls. Odds of cKS was estimated with unconditional logistic regression and with conditional logistic regression, conditioning on assay batch.
(Acquired Immunodeficiency Syndrome)
(classical Kaposi sarcoma)
(Epstein-Barr virus nuclear antigen-1)
(soluble cluster of differentiation proteins)
(T-helper type 1/T-helper type 2 cellular immunity)
(Epstein-Barr virus viral capsid antigen).
Kestens L, Melbye M, Biggar RJ, Stevens WJ, Piot P, De Muynck A, Taelman H, De Feyter M, Paluku L, Gigase PL: Endemic African Kaposi's sarcoma is not associated with immunodeficiency. Int J Cancer. 1985, 36: 49-54. 10.1002/ijc.2910360109.
Marfella A, Ruocco V, Capobianco A, Perna M, Santelli G, Frigione G, Kyalwazi SK, Mugerwa RD, Serwadda D, Beth-Giraldo E, Giraldo G: Neopterin and alpha-interferon in patients affected by Kaposi's sarcoma from Africa. Eur J Cancer Clin Oncol. 1989, 25: 1145-1150. 10.1016/0277-5379(89)90407-0.
Touloumi G, Hatzakis A, Potouridou I, Milona I, Strarigos J, Katsambas A, Giraldo G, Beth-Giraldo E, Biggar RJ, Mueller N, Trichopoulos D: The role of immunosuppression and immune-activation in classic Kaposi's sarcoma. Int J Cancer. 1999, 82: 817-821. 10.1002/(SICI)1097-0215(19990909)82:6<817::AID-IJC8>3.0.CO;2-7.
Brown EE, Whitby D, Vitale F, Marshall V, Mbisa G, Gamache C, Lauria C, Alberg AJ, Serraino D, Cordiali-Fei P, Messina A, Goedert JJ: Virologic, hematologic, and immunologic risk factors for classic Kaposi sarcoma. Cancer. 2006, 107: 2282-2290. 10.1002/cncr.22236.
Engels EA, Biggar RJ, Marshall VA, Walters MA, Gamache CJ, Whitby D, Goedert JJ: Detection and quantification of Kaposi's sarcoma-associated herpesvirus to predict AIDS-associated Kaposi's sarcoma. AIDS. 2003, 17: 1847-1851. 10.1097/00002030-200308150-00015.
Brander C, Suscovich T, Lee Y, Brander C, Suscovich T, Lee Y, Nguyen PT, O'Connor P, Seebach J, Jones NG, van Gorder M, Walker BD, Scadden DT: Impaired CTL recognition of cells latently infected with Kaposi's sarcoma-associated herpes virus. J Immunol. 2000, 165: 2077-2083.
Guihot A, Dupin N, Marcelin AG, Gorin I, Bedin AS, Bossi P, Galicier L, Oksenhendler E, Autran B, Carcelain G: Low T cell responses to human herpesvirus 8 in patients with AIDS-related and classic Kaposi sarcoma. J Infect Dis. 2006, 194: 1078-1088. 10.1086/507648.
Flores R, Goedert JJ: Reconstitution of immune responses against Kaposi sarcoma-associated herpesvirus. AIDS. 2010, 24: 2245-2252. 10.1097/QAD.0b013e32833c7bb8.
Birmann BM, Mueller N, Okayama A, Hsieh CC, Tachibana N, Tsubouchi H, Lennette ET, Harn D, Stuver S: Serologic assessment of type 1 and type 2 immunity in healthy Japanese adults. Cancer Epidemiol Biomarkers Prev. 2004, 13: 1385-1391.
Birmann BM, Mueller NE, Okayama A, Hsieh CC, Tsubouchi H, Harn D, Stuver SO: Patterns of serum type 1 and type 2 immune markers in healthy carriers of HTLV-I. J Med Virol. 2006, 78: 847-852. 10.1002/jmv.20633.
Willheim M, Ebner C, Baier K, Kern W, Schrattbauer K, Thien R, Kraft D, Breiteneder H, Reinisch W, Scheiner O: Cell surface characterization of T lymphocytes and allergen-specific T cell clones: Correlation of CD26 expression with T(H1) subsets. J Allergy Clin Immunol. 1997, 100: 348-355. 10.1016/S0091-6749(97)70248-3.
Pellegrini P, Berghella AM, Contasta I, Adorno D: CD30 antigen: Not a physiological marker for TH2 cells but an important costimulator molecule in the regulation of the balance between TH1/TH2 response. Transpl Immunol. 2003, 12: 49-61. 10.1016/S0966-3274(03)00014-5.
Yang SS, Fu LS, Chang CS, Yeh HZ, Chen GH, Kao JH: Changes of soluble CD26 and CD30 levels correlate with response to interferon plus ribavirin therapy in patients with chronic hepatitis C. J Gastroenterol Hepatol. 2006, 21: 1789-1793. 10.1111/j.1440-1746.2006.04677.x.
Ajdary S, Riazi-Rad F, Jafari-Shakib R, Mohebbali M: Soluble CD26/CD30 levels in visceral leishmaniasis: Markers of disease activity. Clin Exp Immunol. 2006, 145: 44-47. 10.1111/j.1365-2249.2006.03105.x.
Anderson LA, Lauria C, Romano N, Brown EE, Whitby D, Graubard BI, Li Y, Messina A, Gafà L, Vitale F, Goedert JJ: Risk factors for classical Kaposi sarcoma in a population-based case-control study in Sicily. Cancer Epidemiol Biomarkers Prev. 2008, 17: 3435-3443. 10.1158/1055-9965.EPI-08-0671.
Birmann BM, Breen EC, Stuver S, Cranston B, Martínez-Maza O, Falk KI, Okayama A, Hanchard B, Mueller N, Hisada M: Population differences in immune marker profiles associated with human T-lymphotropic virus type I infection in Japan and Jamaica. Int J Cancer. 2009, 124: 614-621. 10.1002/ijc.24012.
Snijdewint FG, Kapsenberg ML, Wauben-Penris PJ, Bos JD: Corticosteroids class-dependently inhibit in vitro Th1- and Th2-type cytokine production. Immunopharmacology. 1995, 29: 93-101. 10.1016/0162-3109(94)00048-K.
Fairweather D, Frisancho-Kiss S, Rose NR: Sex differences in autoimmune disease from a pathological perspective. Am J Pathol. 2008, 173: 600-609. 10.2353/ajpath.2008.071008.
Lang TJ: Estrogen as an immunomodulator. Clin Immunol. 2004, 113: 224-230. 10.1016/j.clim.2004.05.011.
Klein SL: Hormonal and immunological mechanisms mediating sex differences in parasite infection. Parasite Immunol. 2004, 26: 247-264. 10.1111/j.0141-9838.2004.00710.x.
Giron-Gonzalez JA, Moral FJ, Elvira J, García-Gil D, Guerrero F, Gavilán I, Escobar L: Consistent production of a higher TH1:TH2 cytokine ratio by stimulated T cells in men compared with women. Eur J Endocrinol. 2000, 143: 31-36. 10.1530/eje.0.1430031.
Cozen W, Diaz-Sanchez D, Gauderman WJ, Zadnick J, Cockburn MG, Gill PS, Masood R, Hamilton AS, Jyrala M, Mack TM: Th1 and Th2 cytokines and IgE levels in identical twins with varying levels of cigarette consumption. J Clin Immunol. 2004, 24: 617-622. 10.1007/s10875-004-6247-0.
Goedert JJ, Vitale F, Lauria C, Serraino D, Tamburini M, Montella M, Messina A, Brown EE, Rezza G, Gafà L, Romano N: Classical Kaposi's Sarcoma Working Group. Risk factors for classical Kaposi's sarcoma. J Natl Cancer Inst. 2002, 94: 1712-18.
Whetzel CA, Corwin EJ, Klein LC: Disruption in Th1/Th2 immune response in young adult smokers. Addictive Behav. 2007, 32: 1-8. 10.1016/j.addbeh.2006.03.007.
Fachiroh J, Paramita DK, Hariwiyanto B, Harijadi A, Dahlia HL, Indrasari SR, Kusumo H, Zeng YS, Schouten T, Mubarika S, Middeldorp JM: Single-assay combination of epstein-barr virus (EBV) EBNA1- and viral capsid antigen-p18-derived synthetic peptides for measuring anti-EBV immunoglobulin G (IgG) and IgA antibody levels in sera from nasopharyngeal carcinoma patients: Options for field screening. J Clin Microbiol. 2006, 44: 1459-1467. 10.1128/JCM.44.4.1459-1467.2006.
The authors thank Drs. Barry Graubard and Ruth Pfeiffer for statistical advice.
This study was supported by the Intramural Research Program of the National Cancer Institute, in part under a contract with RTI International (N02-CP-91027).
The authors declare that they have no competing interests.
CP designed the study, selected the specimens, selected the sCD markers, analyzed the data, and drafted the manuscript. JM performed the EBV antibody and sCD marker assays. SMM helped to design of the study, interpret the results, and edit the manuscript. CL, AM, NR and FV performed all of the field work, including recruitment of the participants, collection of questionnaire data, collection and initial processing of specimens, and shipment of specimens to the repository. NR also performed the KSHV immunofluorescence assays. JJG helped to design the study, interpret the results, and draft the manuscript. All authors read and approved the final manuscript.
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Pelser, C., Middeldorp, J., Mbulaiteye, S.M. et al. Risk of classical Kaposi sarcoma by plasma levels of Epstein-Barr virus antibodies, sCD26, sCD23 and sCD30. Infect Agents Cancer 5, 18 (2010). https://doi.org/10.1186/1750-9378-5-18
- sCD26 Level
- Viral Capsid Antigen
- Corticosteroid User
- Seronegative Control