Thalidomide, Lenalidomide and Pomalidomide Disrupt Epstein-Barr Virus (EBV) Latency: Clinical Implications
Authors: Jones Richard Julian , Kenney Shannon C. , Dawson Christopher , Orlowski Robert Z. 
Published: October 2019

Abstract

Introduction
Thalidomide (THAL), and the IMiDs® immunomodulatory agents lenalidomide (LEN), and pomalidomide (POM) are all approved for use in multiple myeloma (MM) either as single agents, or in combination with dexamethasone (DEX). Despite the enhanced efficacy of these novel agents, concern has arisen as to the increased incidence of secondary primary malignancies (SPM). For example, the IFM 2005-002 trial reported cases of lymphoblastic leukemia and Hodgkin’s disease (HD) following LEN use (Attal, Lauwers-Cances et al. 2012) in MM patients on maintenance therapy. Also, a recent case report described a MM patient who developed HD who had been treated with salvage therapy containing THAL(Chim, Choi et al. 2013), and two publications reported EBV reactivation in MM patients treated with LEN (Kneppers, van der Holt et al. 2011; Kroger, Zabelina et al. 2013). As HD is causally linked to EBV, this raises the question as to whether the IMiDs reactivate latent EBV infection in normal memory B-cells, and thereby increase the risk of EBV-related malignancies. To this end, we have investigated the ability of the IMiD’s to induce reactivation of latently infected B-cell lines.

Methods
A panel of latently infected EBV-positive B-cell lines including Burkitt’s lymphoma (BL) cells and lymphoblastoid cell lines (LCL) were treated with either LEN, THAL or POM, and the status of the EBV lytic cycle was evaluated using in vitro and in vivo models.

Results
Treatment of BL and LCL cell lines with physiological concentrations of IMiDs (1-5 μM) induced the immediate early gene BZLF1 and the early gene BMRF1. Interestingly, the ability to induce EBV reactivation was in their potency order (i.e. POM>LEN>THAL). The IMiD’s also induced lytic cell death, as an LCL carrying a BZLF1-deleted EBV, which is incapable of undergoing a lytic cycle, showed no change in cell viability, compared to wild-type cells which had increased cell death. The addition of the nucleoside analogue ganciclovir (GCV) enhanced the cytotoxic effect of LEN and POM alone in BL cells lines. An in vivo xenograft model of BL demonstrated that the combination of LEN and GCV was highly efficacious at suppressing tumor cell growth, thus confirming the ability of LEN to stimulate the EBV-lytic life cycle. The ability to induce EBV reactivation was directly related to the stimulation of phosphatidylinositol-3 kinase (PI3K) signaling, which was completely blockaded by the PI3K-δ inhibitor, CAL101. The combination of LEN with either, DEX or rituximab, induced increased BMRF1 compared to the LEN alone.

Conclusions
The IMiD class of drugs has a potent ability to reactivate the lytic cycle in B-cells latently infected with EBV. We hypothesize that the IMiD’s reactivate latently infected resting memory B cells through enhancing PI3K signaling. This reactivation may be further potentiated when the IMiDs are used in combination with rituximab or DEX, which may simultaneously enhance the EBV lytic cycle and suppress the host immune response. These findings suggest the possibility that immunocompromised patients who receive IMiDs should be monitored for evidence of EBV reactivation. Also, this may suggest a mechanism by which patients may develop EBV-associated SPM, an effect which is similar to the methotrexate induced EBV-positive lymphomas seen in rheumatoid arthritis patients (Feng, Cohen et al. 2004).
References
Attal, M., V. Lauwers-Cances, et al. (2012). “Lenalidomide maintenance after stem-cell transplantation for multiple myeloma.” The New England journal of medicine 366(19): 1782-1791.
Chim, C. S., P. T. Choi, et al. (2013). “Hodgkin's lymphoma as a second cancer in multiple myeloma never exposed to lenalidomide.” Annals of hematology 92(6): 855-857.
Feng, W. H., J. I. Cohen, et al. (2004). “Reactivation of latent Epstein-Barr virus by methotrexate: a potential contributor to methotrexate-associated lymphomas.” Journal of the National Cancer Institute 96(22): 1691-1702.
Kneppers, E., B. van der Holt, et al. (2011). “Lenalidomide maintenance after nonmyeloablative allogeneic stem cell transplantation in multiple myeloma is not feasible: results of the HOVON 76 Trial.” Blood 118(9): 2413-2419.
Kroger, N., T. Zabelina, et al. (2013). “Toxicity-reduced, myeloablative allograft followed by lenalidomide maintenance as salvage therapy for refractory/relapsed myeloma patients.” Bone marrow transplantation 48(3): 403-407.

Disclosures:
Orlowski: Bristol-Myers Squibb: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding; Celgene: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding; Millennium: The Takeda Oncology Company: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding; Onyx: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding; Resverlogix: Research Funding; Array Biopharma: Honoraria, Membership on an entity’s Board of Directors or advisory committees; Genentech: Honoraria, Membership on an entity’s Board of Directors or advisory committees; Merck: Membership on an entity’s Board of Directors or advisory committees.