Retrospective and prospective studies of hepatitis B virus reactivation ...

original article

Annals of Oncology 20: 2013–2017, 2009 doi:10.1093/annonc/mdp230 Published online 26 June 2009

Retrospective and prospective studies of hepatitis B virus reactivation in malignant lymphoma with occult HBV carrier N. Fukushima1*, T. Mizuta2, M. Tanaka1, M. Yokoo1, M. Ide1, T. Hisatomi1, N. Kuwahara4, R. Tomimasu1, N. Tsuneyoshi1, N. Funai3 & E. Sueoka1 1

Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Saga University; 2Division of Hepatology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Saga University; 3Department of Hematology, Saga Prefectural Hospital Koseikan and 4Department of Blood Transfusion Medicine, Faculty of Medicine, Saga University, Saga, Japan

Received 8 September 2008; revised 4 March 2009; accepted 17 March 2009

lymphoma, it is well recognized that reactivation of hepatitis B virus (HBV) occasionally occurs. However, there have been only a few studies of HBV reactivation in serum HBsAg-negative and hepatitis B core antigen (HBcAb)-positive occult HBV carriers. We looked at both retrospective and prospective studies to determine the prevalence, clinical course and risk factor of HBV reactivation during chemotherapy in lymphoma patients. Patients and methods: Forty-eight of 127 (37.8%) lymphoma patients were HBsAg negative and HBcAb positive, and 24 of these patients were then given liver function tests and HBsAg tests monthly and serum HBV DNA every 3 months. Results: HBV reactivation was observed in two patients (4.1%) who had received intensive chemotherapy including steroid and rituximab. Immediate administration of entecavir therapy after elevation of HBV DNA level was conducted, and this resulted in reduction of it and improvement of liver function test. Conclusions: Rituximab plus steroid-containing regimens may increase the risk of HBV reactivation in HBsAgnegative and HBcAb-positive lymphoma patients. More ambitious prospective studies are required to establish clinically useful or cost-effective follow-up methods for control of HBV reactivation in lymphoma patients with occult HBV infection. Key words: HBV reactivation, lymphoma, occult hepatitis B carrier

introduction For chronic carriers of hepatitis B virus (HBV) who are treated with anticancer agent, HBV reactivation has become a wellrecognized complication [1], and HBV reactivation has been mainly observed in patients with hematological malignancies [1–4]. Recently, rituximab (anti-CD 20 antibody) has been used as a newly established treatment of CD20-positive B-cell lymphomas in combination with CHOP (cyclophosphamide, doxorubicin, vincristine and prednisolone) therapy. However, there have been reports of HBV reactivations accompanied by fulminant hepatitis, hepatic failure and death in patients with hematological malignancies who received rituximab treatment [5–7]. The Food and Drug Administration in United States recommends that patients with a high risk of HBV infection *Correspondence to: Dr N. Fukushima, Division of Hematology, Department of Internal of Medicine, Faculty of Medicine, Saga University, Nabeshima 5-1-1, Saga 849-8501, Japan. Tel: +81-952-34-2366; Fax: +81-952-34-2017; E-mail: [email protected]

should be screened before introduction of rituximab therapy, and HBV carriers should be carefully monitored for clinical, laboratory signs and symptoms accompanying active hepatitis induced by HBV during and after administration of rituximab. It has been reported that prophylactic antiviral agents (lamivudine, interferon) significantly reduced the incidence of HBV reactivation and the overall morbidity of cancer patients undergoing chemotherapy [7–9], and according to such leading studies, antiviral prophylaxis for surface antigen of hepatitis B virus (HBsAg)-positive cancer patients undergoing cytotoxic chemotherapy is becoming the standard treatment at present. Recently, it was reported that HBV reactivation occurred even in HBsAg-negative individuals after cytotoxic chemotherapy or treatment with immunosuppressive agents, and most of these patients were hepatitis B core antigen (HBcAb) positive or/and Hepatitis B surface antibody (HBsAb) positive [10–13]. Many HBV carriers exist in Asian countries and HBcAb-seropositive occult carriers have been

ª The Author 2009. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For permissions, please email: [email protected]

original article

Background: In surface antigen of hepatitis B virus (HBsAg)-positive carrier for anticancer treatment of malignant

original article estimated at 60% in the population of their countries [14– 16]. However, the incidence of reactivation of HBV during cytotoxic/immunosuppressive treatment, effective monitoring, risk assessment for reactivation and the benefit of viral prophylaxis for malignant lymphoma patients need to be further investigated. We further looked at both prospective and retrospective studies to determine the prevalence, clinical course and risk factor of HBV reactivation in HBcAbseropositive occult carriers for lymphoma patients undergoing cytotoxic chemotherapy including rituximab.

patients and methods patients Two hundred and forty-eight patients diagnosed with malignant lymphoma at Saga University Hospital from January 2003 to March 2008 were given HBsAg test, and 127 patients who had received HBcAb (SRL, Inc., Chemiluminescent Immuno Assay) test were included in this study. All the patients were also given a physical examination and blood tests for antiHCV and liver function tests [alanine aminotransaminase (ALT), aspartate aminotransaminase, alkaline phosphatase, c-glutamyl transpeptidase and bilirubin]. Most of the patients received chest–abdominal computed tomography scan for staging of lymphoma.

retrospective analysis Twenty-four HBsAg-negative and HBcAb-positive patients treated with chemotherapy alone or chemotherapy combined with radiation were retrospectively analyzed, with follow-up visits at 2–4 weekly intervals during and after treatment. At each follow-up visit, clinical status and liver function test results were examined. If abnormal liver function was observed or hepatitis was suspected, HBsAg or HBV DNA test was conducted immediately. De novo HBV-related hepatitis was diagnosed when HBsAg or HBV DNA turned positive (>2.6 log copies/ml) accompanied by elevation of serum ALT exceeding the upper limit (36 IU/l) after the initiation of chemotherapy.

prospective analysis In January 2005, we had started a prospective study (named HBc-Rx05) for malignant lymphoma with HBsAg-negative and HBcAb-positive patients who would undergo cytotoxic chemotherapy alone or chemotherapy combined with radiation. Eligible were untreated or relapsed lymphoma patients defined as HBsAg negative and HBcAb positive serologically and age >15 years. The following patients were excluded: (i) those with HBsAgpositive, active chronic hepatitis or liver cirrhosis; HCV carrier was included in this study and (ii) those patients who had received only radiotherapy. All patients gave informed consent, and the study was approved by the Saga University Institutional Review Board Committee. Enrolled patients were given HBsAb, ‘e’ antigen-associated HBV infection (HBeAg), Hepatitis B envelope antibody (HBeAb), HBV DNA and Hepatitis C virus antibody tests at registration, liver function and HBsAg tests monthly and HBV DNA checks every 3 months during and after chemotherapy. We defined HBV reactivation as elevation of serum HBV DNA to >2.6 log copies/ml or a change to a positive value in HBsAg.

statistical analysis All statistical analyses were carried out using the Statistical Program for Stat-View 5.0, Mac OS 9.2. Student’s t-test was used to compare the average of two samples. Fisher’s exact test was used to compare two categorical variables. Statistical significance was defined as P < 0.05 (two tailed).

2014 | Fukushima et al.

Annals of Oncology

results patients’ characteristics Of the 248 malignant lymphoma patients, five (2.0%) were HBsAg positive, a prevalence slightly higher than that in Saga prefecture (1.42%). The patients received antiviral prophylaxis when informed consent was obtained. Of the 127 HBsAgnegative lymphoma patients who received HBcAb test, 48 (37.8%) were positive (occult HBV carrier). The clinical characteristics of these patients are summarized in Table 1. Mean age of the HBcAb-positive group is significantly higher than that of the HBcAb-negative group (P < 0.05), while no differences were found in sex, subtype of lymphoma, HCV carrier rate, International Prognostic Index or 3-year survival rates in the two groups. In the HBcAb-positive group, 18 cases (38%) showed high antibody titer for HBc antigen (>10.0 S/CO) (Table 2), thirty-two (67%) patients were treated with Table 1. Differences in clinical characteristics of HBsAg-negative lymphoma patients between negative group and positive group in HBcAb test HBsAg2/HBcAb2 HBsAg2/HBcAb+ P Number Age (average) Sex (male/female) Histological subtype B cell FCL MCL MALT DLBCL IVL Other B-cell type T cell AILT PTCL-U ATL Nasal NK/T ALCL Other T type Hodgkin’s lymphoma Subtype unknown HCV carrier IPI Low Low-intermediate High-intermediate High Undetermined 3-year survival rate (%)

79 22–89 (61.5) 38/41

48 39–89 (67.4) 26/22

60 9 2 3 39 3 4 15 3 2 8 0 1 1 3 1 5

39 6 1 0 26 1 5 8 2 1 4 1 0 0 0 1 4

n.s. n.s.

26 16 15 18 4 59.7

13 13 12 10 0 76.1

n.s. n.s.

< 0.05 n.s.

HBsAg, surface antigen of hepatitis B virus; HBcAb, hepatitis B core antigen; FCL, follicular center lymphoma; MCL, mantle cell lymphoma; MALT, mucosal associated lymphoid tissue lymphoma; DLBCL, diffuse large B-cell lymphoma; IVL, intravascular lymphoma; AILT, angioimmunoblastic T-cell lymphoma; PTCL-U, peripheral T-cell lymphoma uncertain; ATL, Adult T-cell leukemia/lymphoma; nasal NK/T, nasal type natural killer/T-cell lymphoma; ALCL, anaplastic large cell lymphoma; HCV, positive of HCV Ab; IPI, International Prognostic Index; n.s, not significance.

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original article

Annals of Oncology

Table 2. Clinical characteristics with and without the HBV reactivation in HBsAg-negative and HBcAb-positive group

Table 3. Summary of patients registered in HBc-Rx05 n = 24

No. of patients [No. of HBV reactivations(+)] High titer (‡10.00 S/CO) Yes No Subtype B cell T cell Others Chemotherapy used Anthracyclin Yes No Vinca alkaloid Yes No Alkylating Yes No Steroid Yes No Rituximab Yes No Stem-cell transplantation Yes No

39 (2) 9

Age (median) Sex (male/female) Subtype of lymphoma B cell T cell No. of HBsAg positive Titer of HBsAb (median) Titer of HBcAb (median) No. of high-titer HBcAb (>10.0 S/CO) No. of high HBV DNA (>2.6 log copies/ml) ALT (IU/l) No. of patients who used rituximab No. of HBV reactivations (+)

39 (2) 9

HBsAg, surface antigen of hepatitis B virus; HBcAb, hepatitis B core antigen; HBV, hepatitis B virus.

41 (2) 7

including rituximab, but she did not achieve remission. We decided to carry out a related allogeneic stem-cell transplantation on the patient, but the HBV status of her donor (her brother) was negative for HBsAg and positive for HBcAb (7.60 S/CO) and HBsAb (10 mIU/ml). However, she was desperately ill, and there was no other donor but her brother. She received stem-cell transplantation using conditioning regimen with fludarabine, cyclophosphamide and low-dose total-body irradiation (4 Gy) in May 2006. She achieved partial remission and continued to be given cyclosporine to suppress graft versus host disease until February 2007. At that time, her HBsAg was negative. In July 2007, her ALT level suddenly elevated to the maximum level 450 IU/l, her HBsAg turned positive and serum HBV DNA level rose to a detectable level of 6.1 log copies/ml. She was administered entecavir of 0.5 mg per day, and ALT level normalized within 4 weeks. In addition, HBV DNA decreased to an undetectable level and HBsAb turned positive 10 months after entecavir therapy. The other patient in the prospective HBc-Rx05 study, a 77year-old male patient, was diagnosed with diffuse large B-cell lymphoma at stage IV in September 2006. Before chemotherapy, his HBcAb titer was 9.38 S/CO and HBV DNA was not detectable. He had received six cycles of rituximab and THP-COP (THP-adriamycin, cyclophosphamide, vincristine and prednisolone) therapy and resulted in complete remission. But he then developed acute myelogenous leukemia in March 2007. He was given multidrug chemotherapy until June 2007 and then followed with no treatment with anticancer drugs or corticosteroid. In September 2007, his HBV DNA level rose to 2.8 log copies/ml, but HBsAg was negative and ALT was normal. Entecavir therapy was started with 0.5 mg per day after informed consent was obtained, and his HBV DNA then decreased to an undetectable level immediately.

18 30 (2) 39 (2) 8 1

43 (2) 5 32 (2) 16 6 (1) 42 (1)

HBV, hepatitis B virus; HBsAg, surface antigen of hepatitis B virus; HBcAb, hepatitis B core antigen.

a regimen including rituximab and 43 (90%) patients received steroid treatment (Table 2). Thirty-one (64%) patients were administered both rituximab and steroid, and six patients (four autologous and two allogeneic) received stem-cell transplantation. Twenty-four of the 48 (50%) HBcAb-positive patients were enrolled in a prospective HBc-Rx05 study. No patients showed a detectable level of serum HBV DNA (>2.6 log copies/ml) at registration, and these patients were followed for a median of 14 (1–24) months. All 21 patients with B-cell lymphoma were treated with the regimen including rituximab, and three B-cell lymphoma patients received autogenic stem-cell transplantation. One patient, diagnosed as adult T-cell leukemia/lymphoma, received allogeneic stem-cell transplantation. Details of these patients are shown in Table 3.

clinical course of patients developing HBV reactivation Two patients experienced HBV reactivation in this study. One of these, a 42-year-old female patient, grouped in retrospective study, was diagnosed with lymphoplasmacytic lymphoma at stage IV in August 2004. Before chemotherapy, her virus markers were HBsAg negative and HBcAb positive (1.27 S/CO). She had received CHOP and other multidrug chemotherapy


40–85 (70) 12/12 21 3 0 0–2382 (30) 1.3–14.5 (5.89) 7 0 9–125 (18) 21 1

clinical factors and HBV reactivation The comparisons of clinical factors for the 46 patients with no HBV reactivation and the two patients who experienced HBV reactivation are shown in Table 2. HBcAb titers in patients with HBV reactivation before chemotherapy were identical to that of

doi:10.1093/annonc/mdp230 | 2015

original article patients with no HBV reactivation. Both of the patients who developed HBV reactivation received rituximab-containing chemotherapy and steroid administration, but there was no apparent statistical difference from nonreactivated patients, probably due to the small number of HBV-reactivated patients. Since only one patient registered in the HBc-Rx05 study developed HBV reactivation, there was no obvious risk factor for HBV reactivation among the titer of HBsAg, HBsAb, HBeAg, HBeAb and subtype of lymphoma.

discussion Chronic HBV infection is a major public health problem in Asian countries, and reactivation of HBV during or after treatment with immunosuppressive agents or with anticancer agents has been documented since 1975 [1]. Although HBV reactivation with HBsAg-positive carriers is a standard complication of treatment with immunosuppressive drugs in patients with hematological malignancies, the precise incidence or risk factors of HBV reactivation in HBsAg-negative and HBcAb-positive (occult HBV carrier) patients has not yet been defined. Hui et al. [15] reported that 8 of 244 (3.3%) occult HBV carriers among malignant lymphoma patients developed HBV reactivation and the risk of reactivation was apparently higher in the group treated with rituximab plus corticosteroid therapy than in the nontreated group. This study is the first prospective analysis evaluating HBV reactivation in occult HBV carrier patients with malignant lymphoma. It has been reported that the occult HBV carrier is found in 60% of the population in Asian countries [14–16]. In our study, the positive rate for HBcAb is 35% in lymphoma patients, and the prevalence rate is comparable to that in the patients at our hospital. Among the occult HBV carriers, 2 of 48 (4.2%) progressed to HBV reactivation, and their immunoglobulin levels and number of peripheral lymphocytes did not decrease. Although Kobayashi et al. [17] indicated that the determination of HBcAb might be a surrogate assay for HBV DNA, the titers for HBcAb in these two patients were low in our study, indicating these laboratory findings are not suitable as surrogate markers for HBV reactivation. Therefore, careful monitoring seems to be the only way to prevent life-threatening hepatitis. Hui et al. [15] reported that elevation of HBV DNA in the peripheral blood began 12–40 weeks earlier than the occurrence of acute hepatitis, indicating that serial monitoring of HBV DNA level is the best method for early detection of HBV reactivation. Our prospective monitoring of HBV DNA every 3 months detected elevation of HBV DNA in the early stage and successfully controlled it by administration of entecavir. Accumulation of clinical data on reactivation in HBV occult carrier indicates some subjects for discussion, such as the appropriate monitoring interval for HBV DNA and other serological markers of HBV and prophylactic use of an antiviral agent for occult HBV carriers. Considering the interval of DNA monitoring for HBV, the sensitivity of the quantitative realtime PCR method using Taqman probe, recently approved by Japanese health insurance, is >1.8 log copies/ml. A study using chimpanzees estimated the doubling time of HBV as 3.4 days [95% confidential interval (CI) 2.6–4.9] for genotype A and 1.9 days (95% CI 1.6–2.3) for genotype C; the windows periods

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after minimum infectious dose were 55 and 76 days for genotype A and 35 and 50 days for genotype C [18]. These results indicated that monthly monitoring of HBV DNA would be useful for early detection of HBV reactivation, but a further prospective large-scale study is required to confirm the most effective monitoring strategy considering efficacy and cost performance. Looking at the risk factor of reactivation, both patients in our study had received rituximab and steroid and one female patient had allogeneic stem-cell transplantation. In the latter case, although the HBV reactivation in the recipient might be caused by an infection by a virus from the donor, it could not be practically distinguished between reactivation by the recipient and infection from the donor. Hui et al. [15] also reported that patients who received rituximab plus steroidcontaining regimens might be at a higher risk of developing de novo HBV-related hepatitis. And Nordbø et al. [19] reported reactivation of HBV infection in occult HBV carriers after allogeneic bone marrow transplantation. Various mechanisms of HBV reactivation are possible. First, immunosuppression during treatment with cytotoxic agents and rituximab may allow enhanced HBV replication and lead to direct hepatic toxicity. Secondly, the administration of a cytotoxic/ immunosuppressive agent may repress the function of T cells, and subsequent suppressed immunological response to viral antigens allows widespread infection of HBV in hepatocytes. Thirdly, rapid withdrawal of cytotoxic reagents could induce a rebound immune response (hyperimmune response) targeting hepatocytes presenting viral antigens [15, 20]. The establishment of the guidelines on the administration of antiviral agents is also an urgent subject. Use of antiviral agent as prophylaxis of HBV in HBsAg-seropositive patients undergoing cytotoxic chemotherapy is becoming a standard strategy [7–9], but for occult HBV carrier patients, the clinical benefits of prophylactic use of antiviral agents have not been established. The probability of HBV reactivation in occult HBV carrier is quite high in Asian countries where HBV is endemic [14–16]. In addition, serial monitoring of HBV DNA has the potential to predict logarithmic growth of HBV, and thus, it is conceivable that prompt administration of antiviral agents prevents the development of acute hepatitis. More studies are certainly needed to clarify the clinical usefulness, safety and cost-effectiveness of the strategy of antiviral administration after detection of HBV-DNA in the patients.

funding Ministry of Education, Culture, Sports, Science and Technology (19591116) and Smoking Research Foundation.

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