Effect of prophylactic lamivudine for chemotherapy-associated hepatitis B reactivation in lymphoma: a meta-analysis of published clinical trials and a decision tree addressing prolonged prophylaxis and maintenance

Long-term comparisons of the durability of 6 months versus 12 months antiviral therapy for hepatitis B after chemotherapy cessation

BACKGROUND

Prophylaxis antiviral therapy is recommended for patients with hepatitis B receiving chemotherapy but the ideal treatment duration after chemotherapy cessation needs more evidence for clarification.

AIMS

This study aimed to compare the relapse rate of short finite intervals of 6 months and 12 months of -nucleos(t)ide analogue (NA) therapy in patients stratified by low hepatitis B virus (HBV)-DNA of < 2000 IU/ml or high HBV DNA of ≥ 2000 IU/ml.

METHODS

Patients started tenofovir or entecavir treatment 1 week before chemotherapy and were assigned to different treatment duration groups randomly after stratified by HBV DNA pretreatment: (1) HBV DNA of < 2000 IU/ml at 6-month or 12-month duration; (2)HBV DNA of ≥ 2000 IU/ml at 6-month or 12-month duration. Virological relapse (VR) was defined as HBV DNA of > 2000 IU/ml, and clinical relapse (CR) was defined as HBV DNA of > 2000 IU/ml and alanine aminotransferase of > 80 IU/L during the follow-up period. The primary endpoint was to compare the durability between groups 1 year after antiviral therapy cessation. The secondary endpoint was VR and CR rate at long-term follow-up after antiviral therapy cessation.

RESULTS

This study enrolled 61 patients, and 5 patients were lost to follow-up or tumor recurrence. VR and CR rates were 46.4% and 14.3% at 1-year and 55.3% and 16.1%, at long-term follow-up, respectively. VR and CR rates demonstrated no difference between the groups. Pretreatment HBV DNA at ≥ 2000 IU/ml and end-of-treatment hepatitis B surface antigen (HBsAg) at ≥ 500 IU/ml were the predictor of VR (hazard ratio [HR]: 2.98; p = 0.010 and HR: 2.38; p = 0.037).

CONCLUSIONS

Prolongation from 6 months to 12 months of NA consolidation after chemotherapy cessation did not affect the VR or CR of HBV. High pretreatment HBV DNA and end-of-treatment HBsAg levels could predict VR after antiviral therapy cessation for chemotherapy.

Lamivudine 24-month-long prophylaxis is a safe and efficient choice for the prevention of hepatitis B virus reactivation in HBsAg-negative/HBcAb-positive patients with advanced DLBCL undergoing upfront R-CHOP-21

Introduction

Occult hepatitis B infection (OBI) is a condition where replication-competent hepatitis B virus-DNA (HBV-DNA) is present in the liver, with or without HBV-DNA in the blood [<200 international units (IU)/ml or absent] in HB surface antigen (HBsAg)-negative/HB core antibody (HBcAb)-positive individuals. In patients with advanced stage diffuse large B-cell lymphoma (DLBCL) undergoing 6 cycles of R-CHOP-21+2 additional R, OBI reactivation is a frequent and severe complication. There is no consensus among recent guidelines on whether a pre-emptive approach or primary antiviral prophylaxis is the best solution in this setting of patients. In addition, questions still unresolved are the type of prophylactic drug against HBV and adequate prophylaxis duration.

Methods

In this case-cohort study, we compared a prospective series of 31 HBsAg-/HBcAb+ patients with newly diagnosed high-risk DLBCL receiving lamivudine (LAM) prophylaxis 1 week before R-CHOP-21+2R until 18 months after (24-month LAM series) versus 96 HBsAg-/HBcAb+ patients (from January 2005 to December 2011) undergoing a pre-emptive approach (pre-emptive cohort) and versus 60 HBsAg-/HBcAb+ patients, from January 2012 to December 2017, receiving LAM prophylaxis [1 week before immunochemotherapy (ICHT) start until 6 months after] (12-month LAM cohort). Efficacy analysis focused primarily on ICHT disruption and secondarily on OBI reactivation and/or acute hepatitis.

Results

In the 24-month LAM series and in the 12-month LAM cohort, there were no episodes of ICHT disruption versus 7% in the pre-emptive cohort (P = 0.05). OBI reactivation did not occur in any of the 31 patients in the 24-month LAM series versus 7 out of 60 patients (10%) in the 12-month LAM cohort or 12 out of 96 (12%) patients in the pre-emptive cohort (P = 0.04, by χ ² test). No patients in the 24-month LAM series developed acute hepatitis compared with three in the 12-month LAM cohort and six in the pre-emptive cohort.

Discussion

This is the first study collecting data regarding a consistent and homogeneous large sample of 187 HBsAg-/HBcAb+ patients undergoing standard R-CHOP-21 for aggressive lymphoma. In our study, 24-month-long prophylaxis with LAM appears to be the most effective approach with a null risk of OBI reactivation, hepatitis flare-up, and ICHT disruption.

Multiple sclerosis and the risk of infection: Association of British Neurologists consensus guideline

Infection in people with multiple sclerosis (MS) is of major concern, particularly for those receiving disease-modifying therapies. This article explores the risk of infection in people with MS and provides guidance-developed by Delphi consensus by specialists involved in their management-on how to screen for, prevent and manage infection in this population.

Infection risk and prophylaxis in patients with lymphoid cancer

Infections are a common cause of morbidity and mortality in patients with lymphoid cancer. With evolving cancer therapeutics, including new targeted and immunotherapies, clinicians need to be aware of additional risk factors and infections that may arise in patients treated with these agents. This "How I Treat" article will highlight fundamental issues including risk factors for infection, infectious diseases screenings and antimicrobial prophylaxis recommendations in patients with lymphoid cancers. We present 4 scenarios of patients with lymphoid cancers with varied infections and describe a treatment approach based on a combination of evidence-based data and experience, as there are limitations in objective infection data especially with newer agents. The goal of this discussion is to provide a framework for institutions and health care providers to develop their own approach in preventing and treating infections in patients with lymphoid cancer.

HBV Reactivation During the Treatment of Non-Hodgkin Lymphoma and Management Strategies

Hepatitis B virus reactivation (HBV-R), which can lead to HBV-related morbidity and mortality, is a common and well-known complication that occurs during the treatment of non-Hodgkin lymphoma (NHL) patients with current or past exposure to HBV infection. HBV-R is thought to be closely associated with chemotherapeutic or immunosuppressive therapies. However, immunosuppressive agents such as anti-CD20 antibodies (e.g., rituximab and ofatumumab), glucocorticoids, and hematopoietic stem cell transplantation (HSCT) administered to NHL patients during treatment can cause deep immunodepression and place them at high risk of HBV-R. In this review, we explore the current evidence, the guidelines of several national and international organizations, and the recommendations of expert panels relating to the definition, risk factors, screening and monitoring strategies, whether to use prophylaxis or pre-emptive therapy, and the optimal antiviral agent and duration of antiviral therapy for HBV-R.

Prophylactic antiviral therapy for hepatitis B virus surface antigen-positive patients with diffuse large B-cell lymphoma treated with rituximab-containing chemotherapy

We conducted a nationwide retrospective analysis of 116 hepatitis B virus (HBV) surface antigen (HBsAg)‐positive patients with diffuse large B‐cell lymphoma (DLBCL) and 278 HBsAg‐negative patients with DLBCL, as a control cohort, who received rituximab‐containing regimens as an induction chemotherapy at 30 Japanese medical centers between January 2004 and December 2014. Hepatitis was defined as an absolute serum alanine aminotransferase (ALT) level of ≥100 U/L. HBV reactivation‐related hepatitis was defined as hepatitis with an absolute serum HBV DNA level of ≥3.3 log IU/mL or an absolute increase of ≥2 log compared with the baseline value. HBsAg‐positive patients were divided into three groups based on anti–HBV prophylactic therapy: no nucleos(t)ide analogue (non–NA, n = 9), lamivudine (LAM, n = 20), and entecavir (ETV, n = 87). The 4‐year cumulative incidence (CI) of hepatitis in HBsAg‐positive and HBsAg‐negative patients was 21.1% and 14.6% (P = .081), respectively. The 4‐year CI of HBV reactivation‐related hepatitis was higher in HBsAg‐positive patients than in HBsAg‐negative patients (8.0% vs 0.4%; P < .001). Among HBsAg‐positive patients, the 4‐year CI of HBV reactivation‐related hepatitis was the highest in the non–NA group (33.3%), followed by the LAM (15.0%) and ETV (3.8%) groups (P < .001). Of note, 3 non–NA patients (33%) and 1 LAM patient (5%) (but no ETV patients) died due to HBV hepatitis. Based on Cox multivariate analysis, HBsAg positivity was not associated with poor overall survival. Prophylactic use of ETV would reduce the occurrence of HBV reactivation‐related hepatitis and mortality in HBsAg‐positive DLBCL patients receiving rituximab‐containing chemotherapy.

Fatal Fulminant Hepatitis from Rituximab-induced Hepatitis B Reactivation in a Patient with Follicular Lymphoma: A Case Report and a Brief Review of Literature

The objective of our study was to recognize hepatitis B reactivation as a complication of rituximab chemotherapy and to realize the importance of screening for prior Hepatitis B virus (HBV) exposure in all patients with hematologic malignancies who will receive rituximab as part of their therapy. Rituximab is a monoclonal antibody targeting CD 20 receptors on the membrane of B cells. In this case report, we described a 79-year-old man who presented to our department with nausea, fatigue, and jaundice. Two months ago, he had received the last dose of the chemotherapy regimen containing rituximab for follicular B cell lymphoma. Ultrasound and computed tomography (CT) scan of abdomen did not show any focal lesions. Liver function tests showed worsening hepatic failure and viral serology demonstrated active HBV infection. Antiviral therapy with entecavir and tenofovir disoproxil fumarate failed to improve his symptoms, and he died of fulminant hepatic failure. Rituximab targets CD 20 receptors positive B cells. It can destroy both cancerous and normal B cells. A decline in immune function can activate occult HBV infection. Prior to initiation of rituximab therapy, screening should be conducted in all cases for HBV associated serological markers. Patients with active or occult HBV infection must be started on appropriate antiviral therapy to prevent any severe outcomes with rituximab-containing regimens.

ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies: an infectious diseases perspective (Agents targeting lymphoid cells surface antigens [I]: CD19, CD20 and CD52)

BACKGROUND

The present review is part of the ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies.

AIMS

To review, from an Infectious Diseases perspective, the safety profile of agents targeting CD19, CD20 and CD52 and to suggest preventive recommendations.

SOURCES

Computer-based MEDLINE searches with MeSH terms pertaining to each agent or therapeutic family.

CONTENT

Although CD19-targeted agents (blinatumomab or inebilizumab) are not associated with an increased risk of infection, they may cause IgG hypogammaglobulinaemia and neutropenia. The requirement for prolonged intravenous infusion of blinatumomab may increase the risk of catheter-associated bloodstream infections. Infection remains the most common non-haematological adverse effect of anti-CD20 monoclonal antibodies, including severe respiratory tract infection, hepatitis B virus (HBV) reactivation and varicella-zoster virus infection. Screening for chronic or resolved HBV infection is recommended for patients receiving anti-CD20 monoclonal antibodies. Antiviral prophylaxis should be offered for 12-18 months to hepatitis B surface antigen (HBsAg)-positive and HBsAg-negative/anti-hepatitis B core antibody (HBc)-positive patients. Anti-Pneumocystis prophylaxis should be considered in patients receiving concomitant chemotherapy, particularly steroids. Alemtuzumab (anti-CD52) increases the risk of infections, in particular among leukaemia and solid organ transplant patients. These populations benefit from anti-Pneumocystis prophylaxis, prevention strategies for cytomegalovirus infection, and screening for HBV, hepatitis C virus and tuberculosis. Antiviral prophylaxis for at least 6-12 months should be provided for HBsAg-positive patients.

IMPLICATIONS

As there are limited clinical data for many of the reviewed agents, special attention must be given to promptly detect and report emerging infectious complications.

Nucleos(t)ide analogues for preventing HBV reactivation in immunosuppressed patients with hematological malignancies: a network meta-analysis

BACKGROUND

We aimed to evaluate the efficacy of five oral nucleos(t)ide analogues (NAs), including lamivudine, entecavir, adefovir, telbivudine and tenofovir, for the prevention of hepatitis B virus (HBV) reactivation and HBV-related complications in chronic hepatitis B virus (CHB) infected patients with hematological malignancies receiving chemotherapy or hematopoietic stem cell transplantation (HSCT) by network meta-analysis.

METHODS

The search identified 28 articles involving 5 different prophylactic regimens covering 1478 participants.

RESULTS

Among five prophylactic regimes, tenofovir (predicted probability, 90%), was the most effective intervention followed by entecavir (88%) in preventing HBV reactivation. There was no significant difference between tenofovir and entecavir for preventing HBV reactivation. With regards to other outcomes, tenofovir and telbivudine was not included to evaluate due to lack of relevant studies. Entecavir was the most effective intervention in reducing the risk of HBV related hepatitis (100%), HBV related death (61%) and all other causes of hepatitis (98%).

CONCLUSION

Tenofovir and entecavir might be the most potent regimes in prevention of HBV reactivation for CHB infected patients with hematological malignancies undergoing chemotherapy or HSCT.

Efficacy of Prophylactic Entecavir for Hepatitis B Virus-Related Hepatocellular Carcinoma Receiving Transcatheter Arterial Chemoembolization

BACKGROUND AND AIMS

Hepatitis B virus (HBV) reactivation was reported to be induced by transcatheter arterial chemoembolization (TACE) in HBV-related hepatocellular carcinonma (HCC) patients with a high incidence. The effective strategy to reduce hepatitis flares due to HBV reactivation in this specific group of patients was limited to lamivudine. This retrospective study was aimed to investigate the efficacy of prophylactic entecavir in HCC patients receiving TACE.

METHODS

A consecutive series of 191 HBV-related HCC patients receiving TACE were analyzed including 44 patients received prophylactic entecavir. Virologic events, defined as an increase in serum HBV DNA level to more than 1 log10 copies/ml higher than nadir the level, and hepatitis flares due to HBV reactivation were the main endpoints.

RESULTS

Patients with or without prophylactic were similar in host factors and the majorities of characteristics regarding to tumor factors, HBV status, liver function and LMR. Notably, cycles of TACE were parallel between the groups. Ten (22.7%) patients receiving prophylactic entecavir reached virologic response. The patients receiving prophylactic entecavir presented significantly reduced virologic events (6.8% vs 54.4%, p=0.000) and hepatitis flares due to HBV reactivation (0.0% vs 11.6%, p=0.039) compared with patients without prophylaxis. Kaplan-Meier analysis illustrated that the patients in the entecavir group presented significantly improved virologic events free survival (p=0.000) and hepatitis flare free survival (p=0.017). Female and Eastern Cooperative Oncology Group (ECOG) performance status 2 was the only significant predictors for virological events in patients without prophylactic antiviral. Rescue antiviral therapy did not reduce the incidence of hepatitis flares due to HBV reactivation.

CONCLUSION

Prophylactic entecavir presented promising efficacy in HBV-related cancer patients receiving TACE. Lower performance status and female gender might be the predictors for HBV reactivation in these patients.

Comparison of entecavir and lamivudine in preventing HBV reactivation in lymphoma patients undergoing chemotherapy: a meta-analysis

Background Multiple studies have compared the efficacy of entecavir with lamivudine in preventing hepatitis B virus (HBV) reactivation among HBV-carrying lymphoma patients with chemotherapy treatment. However, the results were slightly varied. Aim of the review to combine the findings of independent studies assessing the clinical efficacy of the two drugs using a systematic review and meta-analysis. Methods PubMed, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), Chongqing VIP and WanFang Data were retrieved. Two independent reviewers evaluated the study eligibility and extracted eight studies, with 770 patients in total. The meta-analysis was conducted using RevMan 5.3 and STATA software. Results HBV-carrying lymphoma patients receiving lamivudine during chemotherapy had a statistically significantly higher odds of HBV reactivation compared to those receiving entecavir (OR 5.0, 95 % CI 2.85-8.78, P < 0.001). The odds of hepatitis, HBV-Reactivation caused hepatitis and chemotherapy disruption was statistically significantly elevated in the patient group receiving lamivudine compared to the entecavir group (OR 4.12, 95 % CI 1.70-9.98, P = 0.002; OR 11.44, 95 % CI 2.70-48.52, P < 0.001; OR 6.71, 95 % CI 2.34-19.26, P < 0.001, respectively). Furthermore, the HBV reactivation rate in Ann Arbor stages I - II patient group was statistically significantly lower than the one in Ann Arbor stages III-IV group, with an overall pooled value of 0.37 (95 % CI 0.17-0.82, P = 0.01). Conclusion The metaanalysis result suggested that among HBV-carrying lymphoma patients undergoing chemotherapy, entecavir is more effective than lamivudine in preventing HBV reactivation.

Association of Lymphomagenesis and the Reactivation of Hepatitis B Virus in Non-Hodgkin Lymphoma

BACKGROUND

Hepatitis B virus (HBV) has been associated with the development of non-Hodgkin lymphoma (NHL) and can be reactivated in patients being treated for NHL.

METHODS

Articles published between 2000 and 2015 that discussed an association between NHL and HBV, mechanisms of HBV induction of NHL, and HBV reactivation in patients with NHL were reviewed and the results compiled to help health care professionals better understand the risk of developing NHL in HBV-seropositive individuals, describe potential etiologies by which HBV infection may lead to lymphomagenesis, and highlight the recent medical literature with respect to the reactivation of HBV in the setting of NHL.

RESULTS

An association exists between HBV infection and NHL development. Immunosuppression due to HBV, chronic viral stimulation, and dysregulation of the immune system are possible ways in which lymphoma can develop in patients with HBV infection. All patients being treated with anti-CD20 antibodies or those from or living in HBV-endemic regions should be tested for hepatitis B surface antigen, core antibody, and surface antibody prior to initiating therapy. HBV DNA polymerase chain reaction (PCR) may also be useful in certain cases. Among HBV-seropositive patients or those with detectable HBV DNA, prophylaxis with an antiviral agent should be initiated for 1 year after NHL therapy. HBV DNA PCR monitoring should be undertaken each month during the course of treatment and every 3 months after treatment for a 1-year duration.

CONCLUSIONS

Health care professionals should become more comfortable treating these high-risk patients with NHL as they become more informed about potential lymphomagenesis and the reactivation of HBV.

Progress in Treatment of Viral Infections in Children with Acute Lymphoblastic Leukemia

In children, the most commonly encountered type of leukemia is acute lymphoblastic leukemia (ALL). An important source of morbidity and mortality in ALL are viral infections. Even though allogeneic transplantations, which are often applied also in ALL, carry a recognized risk for viral infections, there are multiple factors that make ALL patients susceptible to viral infections. The presence of those factors has an influence in the type and severity of infections. Currently available treatment options do not guarantee a positive outcome for every case of viral infection in ALL, without significant side effects. Side effects can have very serious consequences for the ALL patients, which include nephrotoxicity. For this reason a number of strategies for personalized intervention have been already clinically tested, and experimental approaches are being developed. Adoptive immunotherapy, which entails administration of ex vivo grown immune cells to a patient, is a promising approach in general, and for transplant recipients in particular. The ex vivo grown cells are aimed to strengthen the immune response to the virus that has been identified in the patients' blood and tissue samples. Even though many patients with weakened immune system can benefit from progress in novel approaches, a viral infection still poses a very significant risk for many patients. Therefore, preventive measures and supportive care are very important for ALL patients.

A review of supportive care and recommended preventive approaches for patients with chronic lymphocytic leukemia

Chronic lymphocytic leukemia (CLL) is the most prevalent type of adult leukemia encountered in the western world. Patients with CLL are typically older, with a median age in the 70s, and are at risk for certain complications due to the disease itself and due to the therapies imparted for this. Patients with CLL are at a higher risk of infections, partly due to disease and partly due to the immune dysfunction induced by treatment, such as purine analogous-based chemoimmunotherapy, which leads to lymphocyte depletion. Infections are a leading cause of complications and death in CLL patients. Also, CLL patients have been shown to have a higher incidence of other malignancies. Despite this knowledge, there are no definite guidelines as to what is the best approach to manage or prevent these associated complications of CLL. In this review, the authors discuss the data available and outline recommendations as to the best way to approach this issue in daily practice.

Methicillin-resistant Staphylococcus aureus prevention strategies in the ICU: a clinical decision analysis*

OBJECTIVES

ICUs are a major reservoir of methicillin-resistant Staphylococcus aureus. Our aim was to estimate costs and effectiveness of methicillin-resistant Staphylococcus aureus prevention policies.

DESIGN AND INTERVENTIONS

We evaluated three up-to-date methicillin-resistant Staphylococcus aureus prevention policies, namely, 1) nasal screening and contact precautions of methicillin-resistant Staphylococcus aureus-positive patients; 2) nasal screening, contact precautions, and decolonization (targeted decolonization) of methicillin-resistant Staphylococcus aureus carriers; and 3) universal decolonization without screening. We implemented a decision-analytic model with deterministic and probabilistic analyses. Methicillin-resistant Staphylococcus aureus infections averted, quality-adjusted life years gained, and incremental cost-effectiveness ratios were calculated. Cost-effectiveness planes and acceptability curves were plotted for various willingness-to-pay thresholds to address uncertainty.

MEASUREMENTS AND MAIN RESULTS

At base-case scenario, universal decolonization was the dominant strategy; it averted 1.31% and 1.59% of methicillin-resistant Staphylococcus aureus infections over targeted decolonization and screening and contact precautions, respectively, and saved $16,203/quality-adjusted life year over targeted decolonization and 14,562/quality-adjusted life year over screening and contact precautions. Results were robust in sensitivity analysis for a wide range of input variables. In probabilistic analysis, universal decolonization increased quality-adjusted life years by 1.06% (95% CI, 1.02-1.09) over targeted decolonization and by 1.29% (95% CI, 1.24-1.33) over screening and contact precautions; universal decolonization resulted in average savings of $172 (95% CI, $168-$175) and $189 (95% CI, $185-$193) over targeted decolonization and screening and contact precautions, respectively. With willingness-to-pay threshold per quality-adjusted life year gained ranging from $0 to $50,000, universal decolonization was dominant over targeted decolonization in 67.5-75.4% and dominant over screening and contact precautions in 66.0-75.4%.

CONCLUSIONS

In the ICU setting, universal decolonization outperforms the other two strategies and is likely to be cost-effective even at low willingness-to-pay thresholds. Assuming 700 annual ICU admissions in an average 12-bed ICU, the projected annual savings reach $129,500 to $135,100.

Prophylactic lamivudine to improve the outcome of HBsAg-positive lymphoma patients during chemotherapy: a systematic review and meta-analysis

Hepatitis B viral (HBV) reactivation in lymphoma patients undergoing chemotherapy is associated with significant morbidity and mortality. Increasingly, lamivudine is being used to prevent hepatitis B reactivation. To assess the effects of prophylactic lamivudine on reactivation and mortality following chemotherapy in lymphoma patients who are hepatitis B surface antigen (HBsAg)-positive, we searched Medline/PubMed, Ovid MEDLINE, EMBASE, Web of Knowledge and the Cochrane Library for studies through November 2013. Statistical analysis was performed using REVMAN. Fourteen studies consisting of 636 patients were included in the analysis. The rate of HBV reactivation, incidence of hepatitis and incidence of hepatitis due to HBV reactivation in patients with lamivudine prophylaxis was significantly lower than those with no prophylaxis. Risk ratios [RRs] were 0.25 (95% confidence intervals [CI] 0.13-0.51; P=0.0001), 0.40 (95% CI 0.26-0.63; P<0.0001), and 0.21 (95% CI 0.09-0.51; P=0.0005) respectively. In addition, patients given prophylactic lamivudine had significant reductions in overall mortality and mortality attributable to HBV reactivation compared with control group. Risk ratios [RRs] were 0.45 (95% CI 0.29-0.70; P=0.0004) and 0.41 (95% CI 0.20-0.84; P=0.01) respectively. Chemotherapy disruption was not significantly different between the two groups. Risk ratios [RRs] were 0.34 (95% CI 0.09-1.26; P=0.11). Prophylactic therapy with lamivudine for HBsAg-positive lymphoma patients who are undergoing chemotherapy may reduce the risk for HBV reactivation, hepatitis due to HBV reactivation, overall mortality and mortality attributable to HBV reactivation. Additionally, patients with preventive lamivudine had a trend towards the decreased incidence of chemotherapy disruption.

Hepatitis B virus reactivation in hepatitis B surface antigen seropositive patients with metastatic non-small cell lung cancer receiving cytotoxic chemotherapy: the efficacy of preemptive lamivudine and identification of risk factors

Little is known about the likelihood and degree of hepatitis B virus (HBV) reactivation in hepatitis B surface antigen (HBsAg) seropositive patients with disseminated non-small cell lung cancer (NSCLC) receiving chemotherapy. Between January 2003 and December 2013, all HBsAg seropositive patients with metastatic NSCLC receiving cytotoxic chemotherapy were retrospectively evaluated. The morbidity and mortality of HBV reactivation, risk factors associated with reactivation, as well as the efficacy of preemptive lamivudine were investigated. Of 258 patients who were eligible for the present study, 176 were treated without antiviral prophylaxis and 82 received preemptive lamivudine. Patients without lamivudine prophylaxis had a significantly higher prevalence of HBV reactivation (19.3 vs 6.1 %, p = 0.006) and severe hepatitis attributable to reactivation (11.8 vs 3.7 %, p = 0.034) than those with preemptive lamivudine. However, no significant difference in mortality due to reactivation was noted between patients with or without prophylactic lamivudine (0 vs 2.3 %, p = 0.310). Furthermore, patients who developed HBV reactivation were indentified to have a higher rate of HBeAg seropositivity (74.4 vs 43.4 %, p < 0.001), serum HBV-DNA level of 10(4) copies/ml or greater (76.9 vs 47.9 %, p = 0.001), coexisting liver metastasis (50.0 vs 40.6 %, p = 0.033) and treatment with more than 4 cycles of chemotherapy (56.4 vs 39.3 %, p = 0.046) than those who did not experienced reactivation. The current study has demonstrated that preemptive lamivudine significantly reduced the prevalence of HBV reactivation in HBsAg seropositive patients with metastatic NSCLC receiving systemic chemotherapy.

Clinical features and treatment outcomes of Hodgkin's lymphoma in Hong Kong Chinese

INTRODUCTION

Little information is available on the outcomes of Hodgkin's lymphoma in Chinese patients. We analyzed the clinical and histopathological characteristics, treatment types, clinical course and treatment outcomes of Hong Kong Chinese patients.

MATERIAL AND METHODS

Patients with Hodgkin's lymphoma diagnosed from January 1991 to December 2010 were recruited. A retrospective analysis of these patients was performed.

RESULTS

Sixty-seven Chinese patients (38 males and 29 females) were identified and the median age was 36 (range 16-80). Nodular sclerosis was the most common histology (54%), followed by mixed cellularity (36%). Twenty-four patients had early favorable, 20 patients had early unfavorable and 23 patients had advanced-stage diseases. The most common presentation was palpable lymph node or mass (85%) followed by fever, weight loss, night sweating and mediastinal mass. Ninety percent of patients received chemotherapy and 40% received radiotherapy as consolidation. Seven patients with stage I lymphoma received radiotherapy alone. ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine) was the most commonly used chemotherapeutic regimen. Following treatment, 87% of patients achieved complete remission. Six patients relapsed after first remission and 3 achieved second remission after re-induction therapy. The 5-year overall survival of the entire cohort was 89% and the freedom from treatment failure (FFTF) at 5 years was 82%. The 5-year overall survival rate for early favorable, early unfavorable and advanced stages was 95.7%, 95.0% and 74.7%, respectively.

CONCLUSIONS

Despite the relatively low incidence of Hodgkin's lymphoma in Hong Kong Chinese, the treatment outcomes are comparable to Caucasian patients.

Effect of coadministration of neurovite and Lamivudine on the histomorphology of the cerebellum of wistar rats

Introduction. Lamivudine is a nucleoside reverse transcriptase inhibitor antiretroviral agent used in the treatment of human immunodeficiency virus type 1 infection. This study was to investigate the effects of coadministration of neurovite and lamivudine on the histomorphology of the cerebellum of Wistar rats. Materials and Methods. Twenty Wistar rats were divided equally into four groups. Group A animals were the control treated with distilled water. Groups B, C, and D animals were treated, respectively, with therapeutic dose of lamivudine (4.28 mg/kg), a combination of lamivudine (4.28 mg/kg) and neurovite (7.05 mg/kg), and neurovite (7.05 mg/kg) alone, daily. The rats were sacrificed using chloroform inhalation, processed, and stained using H&E method. Results. There was severe cellular degeneration with dystrophic changes, vacuolization in the molecular and granular layers, and aggregation of swollen Purkinje cells in group B animals compared with group C animals which showed only slight cellular dystrophy and inflammation. The mean cellular population was significantly (P < 0.05) higher in the treatment groups compared with the control. Conclusion. There was amelioration of damage of the cerebellum in the animals treated with neurovite and lamivudine combination compared to animals treated with only lamivudine. Therefore, there is need to give neurovite to patients on lamivudine therapy.

Clinical outcome of HCV-positive patients with diffuse large B-cell lymphoma treated with rituximab-based chemotherapy

The influence of rituximab therapy on prognosis and hepatic toxicity (HT) in patients with hepatitis C virus (HCV)-positive diffuse large B-cell lymphoma (DLBCL) is unclear. Thus, we assessed HT and clinical outcome in patients with DLBCL and HCV infection who received rituximab-containing immunochemotherapy. We carried out a prospective analysis on a total of 280 HCV-positive patients with DLBCL, 200 of whom received chemotherapy plus rituximab (R-CHT), 80 received chemotherapy (CHT)-only. Survival outcomes and HT were compared according to rituximab administration. The median follow-up was 41 months. Addition of rituximab did not significantly affect prognosis (median progression-free survival, 40 vs 35 months, P = 0.26; median overall survival, 51 vs 43 months P = 0.09). Of 200 patients who received rituximab, 53 (26.5 %) had severe HT (grade 3-4), compared with 11 of 80 (13.75 %) patients who received rituximab-free regimens (P = 0.033). Among patients treated with rituximab, 50 patients (25 %) did not complete planned course of therapy, 14 patients because of hepatic toxicity and 36 patients because of progressive disease. Pretreatment liver function impairment was predictive of severe HT. These results raise concerns regarding the routine use of rituximab with chemotherapy in individuals with HCV-positive DLBCL. However, more studies are warranted before a definitive conclusion can be made.

A drug safety evaluation of rituximab and risk of hepatitis B

INTRODUCTION

Rituximab is a widely prescribed anti-CD20 mAb for the treatment of CD20(+) B-cell non-Hodgkin Lymphoma and many other immune mediated conditions. There is a well-described association between rituximab containing chemo-immunotherapy treatment and reactivation of the hepatitis B virus (HBV). This review summarizes the current literature surrounding rituximab-associated HBV reactivation.

AREAS COVERED

Herein, we review the literature detailing the risk of HBV reactivation in inactive carriers and those with resolved hepatitis. The clinical presentation and management of HBV reactivation are also discussed along with a summary of clinical trials evaluating antiviral prophylaxis. Finally, clinical recommendations are detailed. Data from clinical trials, observational studies, reviews, and meta-analyses available in the Medline database were included in this narrative review.

EXPERT OPINION

Screening should be performed in all patients prior to the administration of any type of anti-CD20 mAb therapy. Among those with positive screening serology, testing for hepatitis B e antigen or viral load by polymerase chain reaction is appropriate. In those patients with detectable HBV DNA, the decision regarding the use of antiviral prophylaxis or observation should be individualized.

Management of the HBV reactivation in isolated HBcAb positive patients affected with Non Hodgkin Lymphoma

BACKGROUND

Occult HBV infection (OBI) is defined by the persistence of HBV in the liver without serum HBsAg and HBVDNA. It represents a life-threatening event during immunosuppressive chemotherapies. An OBI occurs in approximately 18% of HBcAb + patients. International guidelines suggest surveillance for HBV markers in immunosuppressed patients. In Non-Hodgkin Lymphoma (NHL), the prevalence of OBI reactivation remains to be established.

METHODS

In order to determine the prevalence of occult HBV reactivation in a large cohort of patients during chemotherapy for NHL, we analysed 498 NHL patients in a centre of Southern Italy. We evaluated HBV markers, NHL type, treatment type and occurrence of HBV reactivation.

RESULTS

Forty % of patients were treated with monoclonal antibodies and 60.3% without. Ninety-six patients were HBcAb+, HBsAg-. HBV reactivation occurred in ten subjects of this subgroup. All of them were successfully treated with Lamivudine. None of the patients experienced liver-related death. The prevalence of OBI reactivation was of 10.42% in HBcAb + HBsAb- patients. This event occurred in 50% of patients treated with mild immunosuppressive therapies. Each reactivation was treated with Lamivudine.

DISCUSSION

This report suggests that a strict surveillance is important and cost-effective in HBcAb + HBsAg- NHL patients treated with mild immunosuppressive therapies, in order to detect an occult HBV reactivation.

Concurrent infection of hepatitis B virus negatively affects the clinical outcome and prognosis of patients with non-Hodgkin's lymphoma after chemotherapy

Hepatitis B virus (HBV) is hepatotropic and lymphotropic. HBV-infected individuals have an increased risk of developing malignant lymphoma, and the HBV infection rate in lymphoma patients is significantly higher than that in the general population. However, the exact mechanism and correlation between HBV infection and lymphoma onset and progression currently remain unclear. We retrospectively analyzed clinical data from non-Hodgkin’s lymphoma (NHL) patients with different HBV infection statuses. The results showed that the HBV infection rate was significantly higher in patients with B-cell type and late stage of NHL. The chemotherapy efficacy for NHL patients with chronic active HBV infection was significantly lower than that for the patients with chronic inactive HBV infection, the patients with HBV carriers and the patients without HBV infection. In addition, the NHL chemotherapy activated HBV replication and caused significant liver dysfunction, which could further reduce the chemotherapy efficacy. Through Kaplan-Meier survival curve and log-rank analysis, we found that the HBV infection status in NHL patients was significantly correlated with the patients’ progression-free survival (PFS) and overall survival (OS). Compared with the patients without HBV infection (PFS: 95% CI 47.915 to 55.640; OS: 95% CI 81.324 to 86.858), the PFS and OS of the patients with chronic active HBV infection were significantly shorter (PFS: 95% CI 9.424 to 42.589, P < 0.001; OS: 95% CI 42.840 to 82.259, P = 0.006). The study demonstrated that the sustained HBV replication in patients with chronic active HBV infection could be a key factor that influences the prognosis of NHL patients after chemotherapy, and thus may provide information for designing rational clinical treatments for NHL patients with different HBV infection statuses and improve the treatment efficacy and prognosis.

Evaluation and management of hepatitis B virus infection in hematopoietic stem cell transplantation: before and after transplantation

HBV infection remains a major global health problem and continues to be a common cause of liver-related morbidity and mortality in both immunocompetent and immunosuppressed individuals. Reactivation of HBV is a serious complication of chemotherapy/immunosuppressive therapy in patients with HBV infection. In this article, we aim to describe the diagnosis, prevention and management of HBV infection in allogeneic hematopoietic stem cell transplant candidates, from the pre- to post-transplant period. The data currently available suggest that all individuals with hemato-/onco-logical malignancies who undergo chemotherapy/immunosuppressive therapy should be screened for hepatotropic viruses such as HBV and HCV. HBV surface antigen-positive individuals who receive chemotherapy/immunosuppressive therapy are at considerable risk of HBV reactivation. Antiviral prophylaxis prevents HBV reactivation, decreases reactivation-related morbidity and mortality, and prevents interruptions in chemotherapy/immunosuppressive therapy in such individuals. The optimal duration of antiviral prophylaxis remains to be elucidated. The vaccination of HBV-naive recipients and their donors against HBV infection prior to transplantation plays an important role in preventing acquired HBV infection. The presence of hepatitis B surface antigen positivity is not an absolute contraindication for allogeneic hematopoietic stem cell transplantation.

Reactivation of hepatitis B virus and antiviral treatment in cancer patients receiving chemotherapy

AIM: To investigate the reactivation of hepatitis B virus (HBV) and the effect of antiviral treatment in cancer patients receiving chemotherapy.

METHODS: Clinical data for 2 253 cancer patients undergoing chemotherapy were reviewed. Of 125 patients who were positive for HBV surface antigen, 37 received antiviral treatment (therapy group) and 88 did not (control group). These patients were followed for at least 6 mo after the completion of treatment. During the course of chemotherapy, liver function tests, viral load (HBV-DNA), and HBV reactivation rate were determined on days 1 and 10 of each cycle.

RESULTS: A total of 879 (39.0%) cancer patients were screened for HBV status. In 125 patients who were positive for HBV surface antigen, 47 (37.6%) developed hepatitis during chemotherapy. Of these 47 patients, 7 (18.9%) were included in the antiviral treatment group and 40 (45.5%) in the control group (P = 0.008). Two patients in the antiviral treatment group developed severe hepatitis [2 (5.4%) vs 19 (21.6%), P = 0.035]. In the antiviral treatment group, there was significantly less patients developing HBV reactivation [1 (2.7%) vs 16 (18.2%), P = 0.022] or discontinuing chemotherapy (8.1% vs 33.0%, P = 0.003).

CONCLUSION: Prophylactic antiviral treatment significantly reduces the incidence of HBV reactivation in cancer patients undergoing chemotherapy.

Hepatitis B screening before chemotherapy: a survey of practitioners' knowledge, beliefs, and screening practices

PURPOSE

Hepatitis B virus (HBV) reactivation is a potentially fatal complication of chemotherapy that can be largely prevented with medication, provided that asymptomatic HBV carriers are identified. We explored the knowledge, beliefs, and practices of Canadian oncologists/hematologists regarding HBV screening before chemotherapy.

METHODS

A novel questionnaire was mailed to all practicing hematologists/oncologists, where publicly accessible online physician registries facilitated identification of these specialists (71% of the Canadian physician population).

RESULTS

Of 504 potentially eligible practitioners, 311 (62%) responded, of whom 246 indicated that they administered chemotherapy and were thus included in final analyses. Respondents tended to underestimate the risk of HBV reactivation, and recognition of the major risk factor for HBV carriage (ie, birth in an endemic area) was low. Forty percent of respondents reported rarely or never testing for HBV before chemotherapy, and 36% reported screening only those patients with HBV risk factors. In multivariate analysis, having a predominantly hematologic practice, practitioner experience with HBV reactivation, ability to correctly estimate the risk of HBV reactivation, fewer years in practice, and female sex were independently associated with an increased likelihood of screening for HBV.

CONCLUSION

Canadian oncologists and hematologists tend to underestimate the risk of HBV reactivation and report relatively low HBV screening rates. Among those practitioners who do screen, the favored strategy is selective screening of patients with HBV risk factors. However, oncologists'/hematologists' knowledge regarding risk factors for HBV carriage seems to be low, potentially undermining the success of a selective screening strategy.

Hepatitis B virus management to prevent reactivation after chemotherapy: a review

PURPOSE

Reactivation of hepatitis B virus (HBV) infection after chemotherapy can lead to liver failure and death. Conflicting recommendations regarding HBV screening in cancer patients awaiting chemotherapy mean that some patients at risk for HBV reactivation are not being identified and treated with prophylactic antiviral therapy.

METHODS

We performed a narrative review of the existing evidence regarding screening for and management of HBV infection among patients with cancer using Ovid Medline, PubMed, and the Cochrane Library.

RESULTS

Our review showed inconsistencies in the definition and management strategies for HBV reactivation. The timeframe of reactivation is variable, and its molecular mechanisms are not clear. There are five effective antiviral agents that can be used as prophylaxis to prevent reactivation of HBV infection in cancer patients; however, the optimal drug and duration of therapy are unknown. Reactivation is more commonly reported in patients with hematologic malignancies receiving rituximab treatment, but reactivation can occur after other chemotherapies and in patients with solid tumors. Screening with all three screening tests-HBsAg, anti-HBc, and anti-HBs-allows the most thorough interpretation of a patient's serologic profile and assessment of reactivation risk; however, decision-making and cost-effectiveness studies are needed to determine optimal screening strategies.

CONCLUSIONS

Prevention of reactivation of HBV infection depends on identification of patients at risk and initiation of antiviral prophylaxis, but data to guide screening and treatment strategies are lacking. Additional research is necessary to accurately define and predict reactivation, identify best antiviral treatment strategies, and identify cost-effective HBV screening strategies.

Management of hepatitis B reactivation in patients receiving cancer chemotherapy

Hepatitis B virus (HBV) reactivation is well documented in previously resolved or inactive HBV carriers who receive cancer chemotherapy. The consequences of HBV reactivation range from self-limited conditions to fulminant hepatic failure and death. HBV reactivation also leads to premature termination of chemotherapy or delay in treatment schedules. This review summarizes current knowledge of management of HBV reactivation in patients receiving cancer chemotherapy. HBV surface antigen (HBsAg) testing should be performed in patients who require cancer chemotherapy. Four meta-analyses support lamivudine prophylaxis for HBV reactivation during chemotherapy in HBsAg-positive patients. Randomized controlled trials to compare different HBV antiviral agents are needed to define optimal regimens for the prevention and treatment of HBV reactivation in patients receiving cancer chemotherapy.

Management of hepatitis B reactivation in patients receiving cancer chemotherapy

Hepatitis B virus (HBV) reactivation is well documented in previously resolved or inactive HBV carriers who receive cancer chemotherapy. The consequences of HBV reactivation range from self-limited conditions to fulminant hepatic failure and death. HBV reactivation also leads to premature termination of chemotherapy or delay in treatment schedules. This review summarizes current knowledge of management of HBV reactivation in patients receiving cancer chemotherapy. HBV surface antigen (HBsAg) testing should be performed in patients who require cancer chemotherapy. Four meta-analyses support lamivudine prophylaxis for HBV reactivation during chemotherapy in HBsAg-positive patients. Randomized controlled trials to compare different HBV antiviral agents are needed to define optimal regimens for the prevention and treatment of HBV reactivation in patients receiving cancer chemotherapy.

Reactivation of hepatitis B virus and hepatitis C virus in patients with cancer

Infections with hepatitis B virus (HBV) or hepatitis C virus (HCV) are associated with significant morbidity and mortality among patients with cancer, especially in patients with hematologic malignancies and those who undergo hematopoietic stem-cell transplantation. Reported rates of HBV reactivation in HBV carriers who undergo chemotherapy range from 14-72%. In these patients, mortality rates range from 5-52%. HCV reactivation seems to be less common than HBV reactivation and is usually associated with a good outcome and low mortality. However, once severe hepatitis develops, as a result of viral reactivation, mortality rates seem to be similar among patients infected with HBV or HCV. Liver damage owing to viral reactivation frequently leads to modifications or interruptions of chemotherapy, which can negatively affect patients' clinical outcome. Risk factors for the development of severe HBV or HCV reactivation need to be better defined to permit identification of patients who may benefit from preventive measures, early diagnosis, and therapy. In this article, we review the epidemiology, pathogenesis, risk factors, and clinical and laboratory manifestations associated with reactivation of HBV and HCV during immunosuppressive therapy. We also discuss strategies for the prevention and treatment of viral reactivation, including the management of reactivation with new antiviral agents.

Dermatologists' awareness of and screening practices for hepatitis B virus infection before initiating tumor necrosis factor-α inhibitor therapy

OBJECTIVE

The aim of the study was to assess dermatologists' awareness of available guidelines and drug package insert information on the screening for and management of hepatitis B (HBV) infection in patients receiving tumor necrosis factor-α inhibitor (TNF-αI) drug therapies for dermatological disorders.

MATERIALS AND METHODS

An electronic descriptive cross-sectional questionnaire was administered to a random, nationwide sample of physician members of the American Academy of Dermatology. Each participating physician answered 8 questions regarding his or her awareness of the risk of HBV reactivation.

RESULTS

More than half of the dermatologists surveyed (52%) were aware of guidelines regarding TNF-αI use in dermatological disorders. Dermatologists who were aware of the guidelines performed universal screening 81% of the time versus 3% of those who were unaware. Approximately 30% of the dermatologists were aware of drug manufacturers' package insert warnings for risk of HBV reactivation with TNF-αIs. Screening in their high-risk patients was highly variable because >90% performed screening in patients with a history of hepatitis or with elevated liver-associated enzymes. Most (73%) screened appropriately with HB surface antigen. One case of HBV reactivation was observed with infliximab use for psoriasis treatment.

CONCLUSIONS

Based on this survey, improving education among dermatologists regarding the risks of HBV reactivation and its prevention for patients receiving TNF-αI seems warranted. More specific consensus guidelines are recommended to achieve universal screening as the standard of care in these patients.

Should we routinely treat patients with autoimmune/rheumatic diseases and chronic hepatitis B virus infection starting biologic therapies with antiviral agents? Yes

It is well established that hepatitis B virus (HBV) reactivation is common among patients with various hematological or neoplastic diseases who receive chemotherapeutic agents without appropriate antiviral prophylaxis and is associated with significant morbidity and mortality. A number of recent studies have indicated that treatment with anti-tumor necrosis factor (TNF) agents in patients with autoimmune/rheumatic diseases carries a similar risk. Furthermore, appropriate pre-emptive treatment with oral antivirals appears to significantly reduce that risk and should be routinely implemented in clinical practice. Similar data are available for B-cell depleting agents like rituximab from the hematology literature, indicating the need for a similar approach in patients with autoimmune diseases receiving such agents.

Comparison of entecavir and lamivudine in preventing hepatitis B reactivation in lymphoma patients during chemotherapy

During chemotherapy for lymphoma, the administration of cytotoxic agents and rituximab often results in hepatitis B reactivation (incidence, 14-72%). This study was designed to compare the efficacy of entecavir and lamivudine in preventing hepatitis B reactivation in lymphoma patients. Between January 2007 and February 2009, patients treated in four hospitals in China were screened to identify those most appropriate for analysis. These patients received either entecavir or lamivudine during chemotherapy and for 6 months after completion of chemotherapy. A total of 34 patients received entecavir and 89 patients received lamivudine. Compared with the lamivudine group, the entecavir group had significantly lower rates of hepatitis (5.9 vs 27.0%, P = 0.007), hepatitis B reactivation (0 vs 12.4%, P = 0.024) and disruption of chemotherapy (5.9 vs 20.2%, P = 0.042). All patients with hepatitis B reactivation had B-cell non-Hodgkin's lymphoma (stage III-IV). In lymphoma patients under chemotherapy treatment, entecavir is more effective than lamivudine in preventing hepatitis B reactivation. For patients with advanced stage disease, entecavir should be considered the primary preventive therapy.

Maintenance rituximab in follicular non-Hodgkin lymphoma: facts and controversies

The advent of rituximab, a chimeric monoclonal antibody against CD20, has arguably improved and changed the natural history of non-Hodgkin lymphoma and has become an essential component of front-line and relapsed disease treatment strategies. Given its tolerability and long half-life, rituximab has been investigated in the maintenance setting in follicular lymphoma. Several landmark studies have demonstrated improvement in progression-free survival in patients receiving maintenance rituximab compared to those observed. These favorable results were witnessed in front-line and in the relapsed setting using a variety of induction programs such as rituximab monotherapy or chemoimmunotherapy. Importantly, toxicities were predictable and manageable. Despite these encouraging results, many vital and practical questions remain unanswered. In this review, we critically analyze the data that led to the widespread use of maintenance rituximab in follicular lymphoma and attempt to answer the most important questions facing practicing oncologists when deciding on using this approach in their patients.

Liver transplantation for acute hepatic failure due to chemotherapy-induced HBV reactivation in lymphoma patients

Hepatitis B (HBV) reactivation induced by chemotherapy is problem encountered recently in the management of malignant diseases. Chemotherapy-induced HBV reactivation may ultimately lead to terminal acute liver failure. Liver transplantation (LT) currently remains the only definitive treatment option for such cases, but is generally denied to patients suffering from malignancy. Here, the authors describe 2 cases of cancer-free and HBV graft re-infection-free survival after LT performed for terminal liver failure arising from HBV reactivation induced by chemotherapy for advanced stage lymphoma. These 2 cases, and some other reports in the literature, may suggest that patients suffering from hematologic malignancies and terminal liver disease can be considered for LT if the prognosis of their hematologic malignancy is good.

Antiviral treatment in patients with hepatitis B virus infection receiving chemotherapy

Reactivation of hepatitis B virus (HBV) is a frequent complication of chemotherapy in patients with HBV infection. Reactivation is characterized by increased levels of serum HBV DNA, abnormal liver function and hepatic failure. HBV reactivation inevitably leads to disruption of chemotherapy and severe clinical results in some cases. Nucleoside analogues play an important role in preventing and reducing the risk for HBV reactivation and HBV-associated morbidity and mortality. This paper gives a systematic review of the definition, mechanism and causes of HBV reactivation and summarizes the principles and problems for antiviral treatment in patients with HBV reactivation. It is strongly recommended that all patients should be screened for HBV serum markers before chemotherapy and preventive therapy with nucleoside analogues be given in patients with HBV. The use of potent antiviral drugs with low resistance potential and close viral monitoring during therapy are important for patients with HBV infection undergoing chemotherapy.

Hepatitis C reactivation in patients who have diffuse large B-cell lymphoma treated with rituximab: a case report and review of literature

BACKGROUND

Whether to interrupt or to continue induction therapy for lymphoma when hepatitis C virus (HCV) reactivation occurs during therapy with rituximab and chemotherapy remains a controversial question. There is limited evidence-based literature to help guide the management of patients with lymphoma in the setting of HCV reactivation. To address this issue we report an illustrative case and review the prevalence of non-Hodgkin lymphoma (NHL) in HCV-infected patients; the role of HCV in lymphomagenesis; the role of antiviral therapy in the management of HCV-associated lymphomas; as well as comparing the outcomes for NHL patients with and without HCV infection.

CASE REPORT

A patient diagnosed with diffuse large B-cell lymphoma was treated with rituximab and chemotherapy with the patient achieving a complete remission, but treatment was complicated by asymptomatic HCV reactivation. Because conflicting data exist regarding management of such cases, the criteria for discontinuing chemotherapy, in the event of escalation in HCV replication in an asymptomatic patient, remain unclear.

CONCLUSION

Patients with HCV have increased prevalence of marginal zone lymphoma, diffuse large B-cell lymphoma, and lymphoplasmacytic lymphoma. Whether HCV has a role in the lymphomagenesis is still uncertain, and limited to conjecture. The question whether to treat HCV-related lymphomas with antiviral therapy is debatable and not well-supported. Without initial liver dysfunction, HCV-infected patients can experience a similar outcome compared to their HCV-negative counterparts when treated with standard chemotherapy/immunotherapy despite differences in the presentation of the disease.

Risk of hepatitis B reactivation and the role of novel agents and stem-cell transplantation in multiple myeloma patients with hepatitis B virus (HBV) infection

BACKGROUND

The purpose of the study is to analyse the prevalence of hepatitis B virus (HBV) infection and its incidence of reactivation among multiple myeloma (MM) patients treated in the era of novel therapy in an endemic Asian setting.

PATIENTS AND METHODS

From 2000 to 2008, 273 patients with newly diagnosed MM were screened for the presence of hepatitis B virus surface antigen and HBV core antibody. HBV-infected patients were prospectively followed for reactivation with serial monitoring of serum alanine transferase and HBV DNA load. The patterns of HBV reactivation in relation to treatment received, exposure to high-dose therapy with autologous stem-cell transplantation (HDT/ASCT) and novel agents were studied.

RESULTS

The prevalence of HBV infection was 5.5%. Three cases of HBV reactivation despite lamivudine prophylaxis were reported. Two patients reactivated 3-5 months after HDT/ASCT while receiving thalidomide maintenance and one reactivated 3 years after HDT/ASCT and shortly after bortezomib salvage therapy. Emergence of a mutant HBV strain was documented in one patient.

CONCLUSIONS

Use of prophylaxis may reduce but will not preclude HBV reactivation. Highest risk occurs during immune reconstitution phase of HDT/ASCT. The role of immunomodulatory agents in HBV reactivation needs to be further elucidated. Separate HBV prophylaxis and surveillance guidelines ought to be developed for patients with MM.

HBV disease: HBsAg carrier and occult B infection reactivation in haematological setting

HBV reactivation in patients with haematological malignancies undergoing chemoimmunotherapy is a serious and frequent complication. This is linked to either the high frequency of inactive HbsAg carriers and occult B infection among oncohaematological patients or the profound immunosuppression caused by high dose chemotherapy, monoclonal antibody therapy or auto- and allo-haematopoietic stem cell (HSC) transplantations. Identifying the patients at risk is mandatory in this clinical setting and prophylaxis with antiviral drugs or close monitoring may reduce and/or eliminate the HBV reactivation risk and the serious consequences. In general, preemptive anti-HBV therapy is more effective than treatment at reactivation. Prompt lamivudine prophylaxis should be given to HBsAg positive patients (inactive carriers) undergoing chemotherapy-immunochemotherapy and continued after cessation of immunosuppression even though long-term lamivudine therapy involves a risk of developing drug resistance. Use of newer anti-HBV agents may be considered. HBV reactivation has also been observed in occult B infection (HBcAb positive) and the optimal management of this group of patients requires special attention.