Iranian Journal of Medical Sciences

Document Type : Original Article(s)


1 Department of Pathology, Faculty of Medicine, Zagazig University, Zagazig, Egypt

2 Department of Pathology, Faculty of Medicine, University of Benghazi, Benghazi, Libya

3 Department of Clinical Oncology, Faculty of Medicine, Zagazig University, Zagazig, Egypt

4 Department of Medical Oncology, Faculty of Medicine, Zagazig University, Zagazig, Egypt

5 Hematology Unit, Department of Internal Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt

6 Department of Medical Biochemistry and Molecular Biology, Faculty of Medicine, Zagazig University, Zagazig, Egypt

7 Department of General Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt

8 Department of Basic Medical Sciences, College of Medicine, University of Bisha, Bisha, Saudi Arabia

9 Department of Pathology, Faculty of Medicine and Health Sciences, University of Kordofan, Elobeid, Sudan

10 Department of Basic Medical Sciences, Unaizah College of Medicine and Medical Sciences, Qassim University, Unaizah, Kingdom of Saudi Arabia

11 Department of Pathology, Faculty of Medicine, Zagazig University, Egypt.Department of Pathology, Faculty of Medicine, Zagazig University, Zagazig, Egypt



Background: Epstein-Barr virus (EBV) is detected in 40% of patients with Hodgkin lymphoma (HL). During latency, EBV induces epigenetic alterations to the host genome and decreases the expression of pro-apoptotic proteins. The present study aimed to evaluate the expression levels of mRNA molecules and the end product of proteins for the JAK/STAT and NF-κB pathways, and their association with clinicopathological and prognostic parameters in patients with EBV-positive and -negative classical Hodgkin lymphoma (CHL).
Methods: A prospective cohort study was conducted from 2017 to 2022 at the Faculty of Medicine, Zagazig University Hospital (Zagazig, Egypt). Biopsy samples of 64 patients with CHL were divided into EBV-positive and EBV-negative groups. The expression levels of mRNA molecules (JAK2, STAT1, IRF-1, PD-L1, IFN-γ, NF-κB, Bcl-xL, COX-2) and the end product of proteins (PD-L1, Bcl-xL, COX-2) were determined and compared with clinicopathological and prognostic parameters. Data were analyzed using the Chi square test and Kaplan-Meier estimate. 
Results: EBV-positive CHL patients were significantly associated with positive expression of mRNAs molecules (P<0.001) and the end product of proteins (P<0.001) for the JAK/STAT and NF-κB pathways, B-symptoms (P=0.022), extra-nodal involvement (P=0.017), and advanced stage of CHL (P=0.018). These patients were more susceptible to cancer progression, higher incidence of relapse (P=0.008), poor disease-free survival rate (P=0.013), poor overall survival rate (P=0.028), and higher mortality rate (P=0.015).
Conclusion: Through the activation of JAK/STAT and NF-κB signaling pathways, EBV-positive CHL is associated with poor clinicopathological parameters, higher incidence of disease progression, relapse, and poor overall survival.


  1. Ansell SM. Hodgkin lymphoma: A 2020 update on diagnosis, risk-stratification, and management. Am J Hematol. 2020;95:978-89. doi: 10.1002/ajh.25856. PubMed PMID: 32384177.
  2. Kliszczewska E, Jarzyński A, Boguszewska A, Pasternak J, Polz-Dacewicz M. Epstein-Barr Virus-pathogenesis, latency and cancers. Journal of Pre-Clinical and Clinical Research. 2017;11:142-6. doi: 10.26444/jpccr/81214.
  3. Luo Y, Liu Y, Wang C, Gan R. Signaling pathways of EBV-induced oncogenesis. Cancer Cell Int. 2021;21:93. doi: 10.1186/s12935-021-01793-3. PubMed PMID: 33549103; PubMed Central PMCID: PMCPMC7868022.
  4. Luo Y, Liu Y, Wang C, Gan R. Signaling pathways of EBV-induced oncogenesis. Cancer Cell Int. 2021;21:93. doi: 10.1186/s12935-021-01793-3. PubMed PMID: 33549103; PubMed Central PMCID: PMCPMC7868022.
  5. Singh R, Letai A, Sarosiek K. Regulation of apoptosis in health and disease: the balancing act of BCL-2 family proteins. Nat Rev Mol Cell Biol. 2019;20:175-93. doi: 10.1038/s41580-018-0089-8. PubMed PMID: 30655609; PubMed Central PMCID: PMCPMC7325303.
  6. Stevens M, Oltean S. Modulation of the Apoptosis Gene Bcl-x Function Through Alternative Splicing. Front Genet. 2019;10:804. doi: 10.3389/fgene.2019.00804. PubMed PMID: 31552099; PubMed Central PMCID: PMCPMC6743414.
  7. Vostinaru O. Adverse effects and drug interactions of the non-steroidal anti-inflammatory drugs. InTech Open: Rijeka, Croatia. 2017:17-31. doi: 10.5772/intechopen.68198.
  8. Doroshow DB, Sanmamed MF, Hastings K, Politi K, Rimm DL, Chen L, et al. Immunotherapy in Non-Small Cell Lung Cancer: Facts and Hopes. Clin Cancer Res. 2019;25:4592-602. doi: 10.1158/1078-0432.CCR-18-1538. PubMed PMID: 30824587; PubMed Central PMCID: PMCPMC6679805.
  9. Han Y, Liu D, Li L. PD-1/PD-L1 pathway: current researches in cancer. Am J Cancer Res. 2020;10:727-42. PubMed PMID: 32266087; PubMed Central PMCID: PMCPMC7136921.
  10. Topalian SL, Drake CG, Pardoll DM. Immune checkpoint blockade: a common denominator approach to cancer therapy. Cancer Cell. 2015;27:450-61. doi: 10.1016/j.ccell.2015.03.001. PubMed PMID: 25858804; PubMed Central PMCID: PMCPMC4400238.
  11. Swerdlow SH, Campo E, Pileri SA, Harris NL, Stein H, Siebert R, et al. The 2016 revision of the World Health Organization classification of lymphoid neoplasms. Blood. 2016;127:2375-90. doi: 10.1182/blood-2016-01-643569. PubMed PMID: 26980727; PubMed Central PMCID: PMCPMC4874220.
  12. Hoppe RT, Advani RH, Ai WZ, Ambinder RF, Armand P, Bello CM, et al. NCCN Guidelines(R) Insights: Hodgkin Lymphoma, Version 2.2022. J Natl Compr Canc Netw. 2022;20:322-34. doi: 10.6004/jnccn.2022.0021. PubMed PMID: 35390768.
  13. Cheson BD, Fisher RI, Barrington SF, Cavalli F, Schwartz LH, Zucca E, et al. Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma: the Lugano classification. J Clin Oncol. 2014;32:3059-68. doi: 10.1200/JCO.2013.54.8800. PubMed PMID: 25113753; PubMed Central PMCID: PMCPMC4979083.
  14. Paydas S, Bagir E, Seydaoglu G, Ercolak V, Ergin M. Programmed death-1 (PD-1), programmed death-ligand 1 (PD-L1), and EBV-encoded RNA (EBER) expression in Hodgkin lymphoma. Ann Hematol. 2015;94:1545-52. doi: 10.1007/s00277-015-2403-2. PubMed PMID: 26004934.
  15. Prosnitz LR. The Ann Arbor staging system for Hodgkin’s disease: does E stand for error? Int J Radiat Oncol Biol Phys. 1977;2:1039. doi: 10.1016/0360-3016(77)90209-7. PubMed PMID: 591400.
  16. Ahmed MM, Gebriel MG, Morad EA, Saber IM, Elwan A, Salah M, et al. Expression of Immune Checkpoint Regulators, Cytotoxic T-Lymphocyte Antigen-4, and Programmed Death-Ligand 1 in Epstein-Barr Virus-associated Nasopharyngeal Carcinoma. Appl Immunohistochem Mol Morphol. 2021;29:401-8. doi: 10.1097/PAI.0000000000000903. PubMed PMID: 33480605.
  17. Moon JW, Kong SK, Kim BS, Kim HJ, Lim H, Noh K, et al. IFNgamma induces PD-L1 overexpression by JAK2/STAT1/IRF-1 signaling in EBV-positive gastric carcinoma. Sci Rep. 2017;7:17810. doi: 10.1038/s41598-017-18132-0. PubMed PMID: 29259270; PubMed Central PMCID: PMCPMC5736657.
  18. Zhang K, Jiao K, Xing Z, Zhang L, Yang J, Xie X, et al. Bcl-xL overexpression and its association with the progress of tongue carcinoma. Int J Clin Exp Pathol. 2014;7:7360-77. PubMed PMID: 25550772; PubMed Central PMCID: PMCPMC4270534.
  19. Key M. Immunohistochemistry staining methods. Education Guide Immunohistochemical Staining Methods Fourth Edition. 2006:47.
  20. Alabiad MA, Elderey MS, Shalaby AM, Nosery Y, Gobran MA. The Usefulness of 4 Immunoperoxidase Stains Applied to Urinary Cytology Samples in the Pathologic Stage of Urothelial Carcinoma: A Study With Histologic Correlation. Appl Immunohistochem Mol Morphol. 2021;29:422-32. doi: 10.1097/PAI.0000000000000905. PubMed PMID: 33480604.
  21. Khayal EE, Alabiad MA, Elkholy MR, Shalaby AM, Nosery Y, El-Sheikh AA. The immune modulatory role of marjoram extract on imidacloprid induced toxic effects in thymus and spleen of adult rats. Toxicology. 2022;471:153174. doi: 10.1016/j.tox.2022.153174. PubMed PMID: 35398170.
  22. Tawfeek SE, Shalaby AM, Alabiad MA, Albackoosh AAA, Albakoush KMM, Omira MMA. Metanil yellow promotes oxidative stress, astrogliosis, and apoptosis in the cerebellar cortex of adult male rat with possible protective effect of scutellarin: A histological and immunohistochemical study. Tissue Cell. 2021;73:101624. doi: 10.1016/j.tice.2021.101624. PubMed PMID: 34419739.
  23. Alabiad MA, Harb OA, Hefzi N, Ahmed RZ, Osman G, Shalaby AM, et al. Prognostic and clinicopathological significance of TMEFF2, SMOC-2, and SOX17 expression in endometrial carcinoma. Exp Mol Pathol. 2021;122:104670. doi: 10.1016/j.yexmp.2021.104670. PubMed PMID: 34339705.
  24. Shalaby AM, Aboregela AM, Alabiad MA, El Shaer DF. Tramadol Promotes Oxidative Stress, Fibrosis, Apoptosis, Ultrastructural and Biochemical alterations in the Adrenal Cortex of Adult Male Rat with Possible Reversibility after Withdrawal. Microsc Microanal. 2020;26:509-23. doi: 10.1017/S1431927620001397. PubMed PMID: 32366353.
  25. Elsalam SA, Mansor AE, Sarhan MH, Shalaby AM, Gobran MA, Alabiad MA. Evaluation of Apoptosis, Proliferation, and Adhesion Molecule Expression in Trophoblastic Tissue of Women With Recurrent Spontaneous Abortion and Infected With Toxoplasma gondii. Int J Gynecol Pathol. 2021;40:124-33. doi: 10.1097/PGP.0000000000000683. PubMed PMID: 32833877.
  26. Shalaby AM, Alabiad MA, El Shaer DF. Resveratrol Ameliorates the Seminiferous Tubules Damages Induced by Finasteride in Adult Male Rats. Microsc Microanal. 2020;26:1176-86. doi: 10.1017/S1431927620024514. PubMed PMID: 33012303.
  27. Khayal EE, Ibrahim HM, Shalaby AM, Alabiad MA, El-Sheikh AA. Combined lead and zinc oxide-nanoparticles induced thyroid toxicity through 8-OHdG oxidative stress-mediated inflammation, apoptosis, and Nrf2 activation in rats. Environ Toxicol. 2021;36:2589-604. doi: 10.1002/tox.23373. PubMed PMID: 34553816.
  28. Elborai Y, Elgammal A, Salama A, Fawzy M, El-Desouky ED, Attia I, et al. Cyclooxygenase-2 expression as a prognostic factor in pediatric classical Hodgkin lymphoma. Clin Transl Oncol. 2020;22:1539-47. doi: 10.1007/s12094-020-02297-8. PubMed PMID: 31970686.
  29. Chu WS, Aguilera NS, Wei MQ, Abbondanzo SL. Antiapoptotic marker Bcl-X(L), expression on Reed-Sternberg cells of Hodgkin’s disease using a novel monoclonal marker, YTH-2H12. Hum Pathol. 1999;30:1065-70. doi: 10.1016/s0046-8177(99)90224-1. PubMed PMID: 10492041.
  30. Li Z, Zhou Z, Wu X, Zhou Q, Liao C, Liu Y, et al. LMP1 promotes nasopharyngeal carcinoma metastasis through NTRK2-mediated anoikis resistance. Am J Cancer Res. 2020;10:2083-99. PubMed PMID: 32775002; PubMed Central PMCID: PMCPMC7407352.
  31. Kim YR, Kim SJ, Cheong JW, Chung H, Jang JE, Kim Y, et al. Pretreatment Epstein-Barr virus DNA in whole blood is a prognostic marker in peripheral T-cell lymphoma. Oncotarget. 2017;8:92312-23. doi: 10.18632/oncotarget.21251. PubMed PMID: 29190917; PubMed Central PMCID: PMCPMC5696183.
  32. Mestre F, Gutierrez A, Ramos R, Martinez-Serra J, Sanchez L, Matheu G, et al. Expression of COX-2 on Reed-Sternberg cells is an independent unfavorable prognostic factor in Hodgkin lymphoma treated with ABVD. Blood. 2012;119:6072-9. doi: 10.1182/blood-2011-11-394627. PubMed PMID: 22547578.
  33. Ohno S, Ohno Y, Suzuki N, Soma G, Inoue M. Cyclooxygenase-2 expression correlates with apoptosis and angiogenesis in endometrial cancer tissue. Anticancer Res. 2007;27:3765-70. PubMed PMID: 17970040.
  34. Gravelle P, Burroni B, Pericart S, Rossi C, Bezombes C, Tosolini M, et al. Mechanisms of PD-1/PD-L1 expression and prognostic relevance in non-Hodgkin lymphoma: a summary of immunohistochemical studies. Oncotarget. 2017;8:44960-75. doi: 10.18632/oncotarget.16680. PubMed PMID: 28402953; PubMed Central PMCID: PMCPMC5546533.
  35. Kumar N, Drabu S, Mondal SC. NSAID’s and selectively COX-2 inhibitors as potential chemoprotective agents against cancer: 1st Cancer Update. Arabian Journal of Chemistry. 2013;6:1-23. doi: 10.1016/j.arabjc.2011.07.020.
  36. Cao Y, Xie L, Shi F, Tang M, Li Y, Hu J, et al. Targeting the signaling in Epstein-Barr virus-associated diseases: mechanism, regulation, and clinical study. Signal Transduct Target Ther. 2021;6:15. doi: 10.1038/s41392-020-00376-4. PubMed PMID: 33436584; PubMed Central PMCID: PMCPMC7801793.