Supportive Care in Cancer

, Volume 21, Issue 5, pp 1265–1271

Efficacy of prophylactic lamivudine to prevent hepatitis B virus reactivation in B-cell lymphoma treated with rituximab-containing chemotherapy

Authors

  • Yin-Hua Wang
    • Department of HematologyThe First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital
  • Lei Fan
    • Department of HematologyThe First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital
  • Li Wang
    • Department of HematologyThe First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital
  • Run Zhang
    • Department of HematologyThe First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital
  • Ji Xu
    • Department of HematologyThe First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital
  • Cheng Fang
    • Department of HematologyThe First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital
  • Jian-Yong Li
    • Department of HematologyThe First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital
    • Department of HematologyThe First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital
Original Article

DOI: 10.1007/s00520-012-1656-8

Cite this article as:
Wang, Y., Fan, L., Wang, L. et al. Support Care Cancer (2013) 21: 1265. doi:10.1007/s00520-012-1656-8

Abstract

Purpose

Reactivation of hepatitis B virus (HBV) is a common complication in patients with HBV infection who receive cytotoxic chemotherapy. In rituximab-containing chemotherapy for B-cell lymphoma, severe hepatitis due to HBV reactivation occurred. The aim of this study is to estimate the effect of prophylactic lamivudine on the risk of HBV reactivation in patients with HBV infection who receive rituximab-containing chemotherapy.

Methods

In this study, HBV markers and liver function tests were monitored in 268 consecutive patients with B-cell lymphoma, who received rituximab-containing chemotherapy between January 2008 and November 2011. Sixty-nine patients (25.7 %) with either chronic HBV infection or past HBV infection received prophylaxis with lamivudine 100 mg daily by oral intake.

Results

In the HBsAg-positive group, six (6/38) patients developed hepatitis, only one of which was attributed to HBV reactivation. In the HBsAg-negative and HBcAb-positive group, two (2/31) patients developed hepatitis, none of which was attributed to HBV reactivation.

Conclusions

These results support that prophylactic lamivudine can prevent HBV reactivation for B-cell lymphoma with HBV infection who was receiving rituximab-containing chemotherapy.

Keywords

Hepatitis B virusLamivudineRituximabB-cell lymphoma

Introduction

Hepatitis B virus (HBV) is a DNA virus transmitted predominantly by sexual contact or percutaneous exposure. HBV infection is the most common chronic viral infection affecting the liver in the world. China is a highly endemic area with about 170 million Chinese infected chronically with HBV and 10 % suffer from chronic hepatitis [1]. Reactivation of HBV is a common complication in patients with HBV infection who receive cytotoxic chemotherapy, which may manifest clinically as asymptomatic self-limiting to severe hepatitis, hepatic failure, and even death [2, 3]. The mechanism for HBV reactivation is believed to be increased viral replication and antigen expression in hepatocytes during cytotoxic chemotherapy, followed by cytolysis of HBV-infected hepatocytes upon immune recovery [4, 5].

Rituximab, an anti-CD20 chimeric monoclonal antibody, has been developed and is widely used for the treatment of B-cell lymphoma as one of the molecular-targeted therapies. Combined with cytotoxic chemotherapy, rituximab showed a synergistic effect for the treatment of B-cell lymphoma [6]. However, rituximab can induce profound and durable B-cell depletion, which results in impaired secondary humeral immunity and increases the vulnerability to viral reactivation [710]. Severe hepatitis due to HBV reactivation after rituximab administration occurred both in HBsAg-positive and HBsAg-negative patients [1117].

Lamivudine, one of the nucleoside analogues that block RNA-dependent DNA polymerase in the replication cycle of HBV, reduces HBV DNA in serum and improves liver injury in patients with HBV infection. Lamivudine is well tolerated and provides an excellent long-term safety profile. Some researchers have reported the effectiveness of lamivudine in preventing HBV reactivation in rituximab-containing chemotherapy for B-cell lymphoma [1820].

However, the role of prophylactic lamivudine in rituximab-containing chemotherapy for B-cell lymphoma with HBV infection has not been well established. The aim of this study is to estimate the effect of prophylactic lamivudine on the risk of HBV reactivation in patients with HBV infection who receive rituximab-containing chemotherapy.

Patients and methods

Patients

This was a retrospective study with an unselected and consecutive series of 268 B-cell lymphoma patients who received rituximab-containing chemotherapy between January 2008 and November 2011. The diagnostic criteria used to determine lymphoma subtype were based on the World Health Organization (WHO) classification [21]. All patients undertook the following examinations: hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HBsAb), hepatitis B core antibody (HBcAb), hepatitis B e antigen (HBeAg), and hepatitis B e antibody (HBeAb) by serology; a complete blood count; renal function tests (urea and creatinine); and liver function tests [total protein, albumin, total bilirubin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma glutamyl transferase (GGT), and alkaline phosphatase (ALK)]. In addition, we tested HBV DNA levels for patients with either chronic HBV infection or past HBV infection. The HBV DNA tests used were branched DNA signal amplification (lower detection limit: 500 copies/mL). During the course of chemotherapy, a complete blood count, renal function tests, and liver function tests were monitored in all patients, and HBV DNA tests were monitored in patients with either chronic HBV infection or past HBV infection every cycle of chemotherapy during treatment and every 3 months after chemotherapy.

Serology of HBV

The presence of HBsAg, HBsAb, HBcAb, HBeAg, and HBeAb was determined using commercial assay kits (HBsAg, EIA, KHB Inc., Shanghai, China; HBsAb, EIA, KHB Inc.; HBcAb, EIA, KHB Inc.; HBeAg, EIA, KHB Inc.; HBeAb, EIA, KHB Inc.). Fasting blood samples (2 ml) were collected in non-heparin tubes and stored for less than 2 h at room temperature. The drawn venous blood was centrifuged at 3,000 rpm for 15 min. Serum samples were analyzed according to the manufacturer’s protocol using enzyme-linked immunosorbent assay. Setting blank wells, testing sample wells, positive control wells, and negative control wells in a plate separately, 50 μl of serum samples, positive and negative controls were firstly added to different wells correspondingly (only the test of HBsAg needed incubation for 60 min at 37 °C). Then 50 μl of HRP conjugate was gently mixed in each well. The plate was blocked with closure plate membrane. After incubation for 30 min at 37 °C, each well was washed with washing buffer five times and pat dried. Subsequently, chromogen solution A 50 μl and chromogen solution B 50 μl were added and the plate was incubated for 15 min at 37 °C. Finally, stop solution 50 μl was applied to stop the reaction. Taking blank well as zero, the optical density (OD) values were read at 450 nm. Cutoff values were established with different formulas according to the OD values of positive and negative controls.

Definition of hepatitis

A patient with chronic HBV infection was defined as having detectable serum HBsAg. A patient who was tested negative for HBsAg but positive for HBcAb was defined as having past HBV infection [22]. The severity of hepatitis was defined according to WHO criteria. Grade I was defined as a rise in ALT or total bilirubin more than 1.25 upper limits of normal (ULN) and up to 2.5 ULN. Grade II was more than 2.5 ULN and up to 5 ULN. Grade III was more than 5 ULN and up to 10 ULN. Grade IV was more than 10 ULN. Hepatitis attributed to HBV reactivation was defined as an increase in HBV DNA levels of tenfold or more when compared with baseline levels or an absolute increase >105 copies/mL in the HBV DNA levels. Disruption of chemotherapy was defined as either a premature termination of chemotherapy or a delay of more than 7 days of chemotherapy between cycles.

Usage of lamivudine

Patients with either chronic HBV infection or past HBV infection received prophylaxis with lamivudine 100 mg daily by oral intake. Prophylaxis was started 7 days before the first cycle of chemotherapy and continued for at least 6 months after the end of the last cycle.

Results

Patient characteristics

From January 2008 to November 2011, we treated 268 patients with B-cell lymphoma using rituximab-containing chemotherapy. Serological screening identified 69/268 patients (25.7 %) as positive for HBsAg or HBcAb: 38/69 patients (55 %) were HBsAg-positive, including 22 patients with HBV DNA >500 copies/mL; 31/69 patients (45 %) were HBsAg-negative and HBcAb-positive, including two patients with HBV DNA >500 copies/mL. We divided the 69 patients into HBsAg-positive group, and HBsAg-negative and HBcAb-positive group. The HBsAg-positive group included 18 males and 20 females (median age, 56.5 years; range, 29–75 years), while HBsAg-negative and HBcAb-positive group included 20 males and 11 females (median age, 60 years; range, 34–83 years). The characteristics of these patients were provided in Table 1.
Table 1

Characteristics of 69 patients with either chronic HBV infection or past HBV infection

Group characteristics

Value in HBsAg-positive group

Value in HBsAg-negative and HBcAb-positive group

Total, number of patients

38

31

Gender, number of patients

Male

18

20

Female

20

11

Age (years)

Median

56.5

60

Range

29–75

34–83

B-cell lymphoma type, number of patients

DLBCL

19

12

CLL

5

5

MZL

4

3

MCL

2

1

FL

2

3

Others

6

7

Chemotherapy regimens containing rituximab, number of patients

R-CHOP

12

9

R-FFP

9

6

R-EPOCH

7

6

R-FC

4

4

Others

6

6

Treatment modality, number of patients

Primary treatment

28

28

Salvage treatment

10

3

HBeAg status, number of patients

Positive

5

1

Negative

33

30

HBV DNA level before treatment (copy/ml)

Median

1.4 × 103

<500

Range

<500–2.54 × 108

<500–4.03 × 106

HBV DNA level after treatment (copy/ml)

Median

<500

<500

Range

<500–2.42 × 104

<500–3.04 × 104

Cycles of rituximab administration (375 mg/m2)

Median

4

4

Range

1–14

1–10

The duration of lamivudine prophylaxis (months)

Median

9.5

10

Range

7–17

7–16

The follow-up time after withdrawal of lamivudine (months)

Median

18

15.5

Range

1–42

2–36

CLL chronic lymphocytic leukemia; DLBCL diffuse large B-cell lymphoma; FFP fresh frozen plasma; FL follicular lymphoma; MCL mantle cell lymphoma; MZL marginal zone lymphoma; R-CHOP rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone; R-EPOCH rituximab, etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin; R-FC rituximab, fludarabine and cyclophosphamide; R-FFP rituximab and fresh frozen plasma

Clinical outcomes of prophylactic lamivudine

Sixty-nine patients with either chronic HBV infection or past HBV infection received prophylaxis with lamivudine 100 mg daily by oral intake. The median duration of lamivudine prophylaxis was 9.5 months (range, 7–17 months) in HBsAg-positive group and 10 months (range, 7–16 months) in HBsAg-negative and HBcAb-positive group. The median follow-up time after withdrawal of lamivudine were 18 months (range, 1–42 months) in HBsAg-positive group and 15.5 months (range, 2–36 months) in HBsAg-negative and HBcAb-positive group.

At the time of May 2012, the HBV DNA levels decreased gradually in most of the patients who had high HBV DNA copies before treatment. In the HBsAg-positive group, six (6/38) patients developed hepatitis, only one of which was attributed to HBV reactivation, and the severity of hepatitis was grade I in two patients, grade II in three patients, and grade III in one patient (Table 2). In the HBsAg-negative and HBcAb-positive group, two (2/31) patients developed hepatitis, none of which was attributed to HBV reactivation, and the severity of hepatitis was grade I in one patients and grade III in one patient (Table 2). Generally, eight of the 69 patients developed hepatitis during or after chemotherapy, only one of which was attributed to HBV reactivation. The clinical characteristics of the other seven patients with hepatitis were shown in Table 3. Among the eight patients who developed hepatitis, only one had interval delay in chemotherapy. No patient had total abnormal bilirubin. No patient had died as a result of hepatitis during the treatment. The lamivudine was well tolerated and was not associated with any unexpected or additional toxicity of chemotherapy.
Table 2

Clinical outcomes of prophylactic lamivudine therapy

Clinical outcomes

No. of patients in HBsAg-positive group

No. of patients in HBsAg-negative and HBcAb-positive group

Total incidence of hepatitis

6/38

2/31

Severity of hepatitis

Grade I

2/38

1/31

Grade II

3/38

0/31

Grade III

1/38

1/31

Grade IV

0/38

0/31

Hepatitis attributable to HBV reactivation

1/38

0/31

Premature termination

0/38

0/31

Table 3

The clinical characteristics of the other seven patients with hepatitis

Sex

Age

HBsAgHBcAb

Severity of hepatitis

Baseline HBV DNA (copies/mL)

Peak HBV DNA (copies/mL)

Baseline ALT (U/L)

Peak ALT (U/L)

Female

47

+, +

I

2.16 × 104

2.16 × 104

42.0

97.4

Male

47

+, +

I

3.07 × 103

1.46 × 104

35.5

101.9

Male

37

+, +

II

<500

1.69 × 103

30.6

119.7

Female

57

+, +

II

<500

<500

16.7

167.6

Male

62

+, +

II

2.7 × 104

2.7 × 104

44.2

193.2

Male

75

−, +

I

4.03 × 104

4.03 × 104

38.1

66.7

Male

62

−, +

III

<500

<500

21.5

285.6

Our study population consisted of 15 patients who were treated with rituximab and fresh frozen plasma (R-FFP) regimen. Supplying FFP-derived complement could enhance complement-dependent cell lysis by rituximab [23]. However, patients receiving FFP were at the risk of HBV or other hepatitis virus infection. Therefore, we also analyzed these patients separately. In this patient group, three patients developed hepatitis, none of which was attributed to HBV reactivation, and the severity of hepatitis was grade I in one patient and grade II in two patients. All the three patients were HBsAg-positive before treatment.

HBV reactivation with prophylaxis of lamivudine

One of the 69 patients developed HBV reactivation during prophylaxis of lamivudine. This patient has an absolute increase >105 copies/mL in the HBV DNA level. In addition, the ALT reached 278.5 U/L when HBV was reactivated. Further investigation demonstrated that this patient had mutated tyrosine–methionine–aspartate–aspartate motif of the HBV DNA polymerase gene (the YMDD mutation). This patient recovered after alteration of adefovir therapy and is still alive at the time of May 2012. The characteristics of this patient were shown in Table 4. Moreover, none of the patients who finished prophylaxis developed HBV reactivation.
Table 4

Clinical characteristics of one patient with HBV reactivation with prophylaxis of lamivudine

Clinical characteristics

Age (year)

39

Gender

Male

HBsAg, HBsAb, HBcAb, HBeAg, HBeAb |before rituximab

+, −, +, −, −

HBV DNA copies per milliliter before rituximab

1.03 × 103

ALT units per liter when HBV was reactivated

278.5

HBV DNA copies per milliliter when HBV was reactivated

2.57 × 107

Time of HBV reactivation after initiation of rituximab

12 Months

Clinical intervention

Adefovir

HBV DNA copies per milliliter after clinical intervention

2.1 × 103

Outcome

Recovered

Discussion

HBV reactivation during chemotherapy for hematological malignancies is a well-recognized complication [24]. Rituximab is a chimeric monoclonal antibody that targets CD20 antigen. It destroys B lymphocytes and has been used to treat B-cell lymphoma recently. Although its treatment efficacy and relatively low adverse effects have been confirmed, the increasing use of rituximab seems to be associated with more frequent HBV reactivation. Moreover, fatal hepatitis due to HBV reactivation in patients with lymphoma treated with rituximab-containing chemotherapy has also been reported [25]. Thereby the screening and monitoring of HBV infection is currently mandatory in patients with hematological malignancies who are candidates for cytotoxic chemotherapy.

Lamivudine is a potent reverse transcriptase inhibitor, which has a high efficacy in inhibition of viral replication. It has been approved as an antiviral treatment in patients with HBV infection. Previous study showed that the preemptive use of lamivudine successfully reduced the incidence and severity of hepatitis in patients with HBV infection who received chemotherapy for lymphoma [2628]. However, in rituximab-containing chemotherapy, the effectiveness of lamivudine prophylaxis was only reported in case reports [19, 2931] and clinical trials of small sample sizes [32]. Only HBsAg-positive patients received prophylactic lamivudine in these studies. However, Yeo et al. [33] found that five (nearly 25 %) of 21 HBsAg-negative and HBcAb-positive diffuse large B-cell lymphoma (DLBCL) patients who treated with rituximab-containing therapy developed HBV reactivation. Moreover, Pei et al. [34] insisted that HBV reactivation following rituximab-based regimens was a serious complication in both HBsAg-positive and HBsAg-negative patients. Several national organizations and practice guidelines such as the British Columbia Cancer Agency recommend prophylactic lamivudine for all patients with HBV infection.

In our study, all 69 patients with either chronic HBV infection or past HBV infection received prophylactic lamivudine while undergoing rituximab-containing chemotherapy. In the HBsAg-positive group, six (6/38) patients developed hepatitis, only one of which was attributed to HBV reactivation. The incidence of hepatitis was relatively lower in the HBsAg-negative and HBcAb-positive group. Generally, eight of the 69 patients developed hepatitis during or after chemotherapy, only one of which was attributed to HBV reactivation. In addition, this patient recovered after alteration of adefovir therapy. This study confirmed the effectiveness of lamivudine prophylaxis for the prevention of HBV reactivation in B-cell lymphoma patients who underwent rituximab-containing chemotherapy.

Our study had several limitations. Firstly, although the incidence rate of HBV reactivation was low in our study, it would be a better description of the effectiveness of lamivudine prophylaxis to have a control group and the retrospective nature of the study. Secondly, as HBV might be reactivated after withdrawal of lamivudine, the follow-up time was a little shorter in some patients.

There is also something worth mentioning. The second-generation nucleoside analogues (tenofovir, entecavir), which have a higher antiviral activity as well as genetic barrier, may also be effective for the prevention and therapy of HBV reactivation. There was one patient who had an increase of HBV DNA by one log without hepatitis. HBV DNA of this patient was 6.41 × 102 copies/mL before rituximab and became 1.68 × 104 copies/mL after the first chemotherapy. Two patients infected with HBV while undergoing rituximab-containing chemotherapy. As rituximab can result in impaired secondary humoral immunity, it probably not only increases the vulnerability to viral reactivation, but also viral infection. In the patient group of R-FFP regimen, three patients developed hepatitis, all of which were HBsAg-positive before treatment. Therefore, FFP is not likely to increase the risk of HBV infection. The incidence rate of HBV infection in patients with B-cell lymphoma is 25.7 % in our study, which is really higher than that of the normal population. HBV might play an important role in the development of B-cell lymphoma and have the potential prognosis. Wang et al. [35] analyzed that the HBsAg-positive DLBCL patients had earlier onset and more advanced stage comparing with HBsAg-negative patients.

In conclusion, prophylactic lamivudine therapy can prevent HBV reactivation in HBV carriers who were receiving rituximab-containing chemotherapy for B-cell lymphoma. Although lamivudine is well tolerated and provides an excellent long-term safety profile, the long-term use of lamivudine may induce the development of lamivudine-resistant HBV. Before making recommendation of prophylactic lamivudine therapy, a critical assessment of the risk of HBV reactivation and the associated risk factors is crucial. Further prospective studies will be needed to clarify the role of routine antiviral prophylaxis in patients with HBV infection.

Acknowledgments

This study was supported by National Natural Science Foundation of China (30971296, 81170485, and 81170488), Natural Science Foundation of Jiangsu Province (BK2010584), Key Projects of Health Department of Jiangsu Province (K201108), Jiangsu Province’s Medical Elite Program (RC2011169), University Doctoral Foundation of the Ministry of Education of China (20093234110010), Project Funded by the Priority Academic Program Development of Jiangsu Higher Education Institute (JX10231801), and National Public Health Grand Research Foundation (201202017).

Conflict of interest

The authors report no conflicts of interest.

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© Springer-Verlag Berlin Heidelberg 2012