HBV reactivation in malignant lymphoma patients treated with rituximab and bendamustine

Excerpt

HBV reactivation is a not uncommon complication in patients who receiving chemotherapy with rituximab and steroid. We report two cases in which HBV reactivation occurred after bendamustine treatment combined with rituximab. The first case, a 79-year-old female patient, was diagnosed on November 30, 2004 with clinical stage IIIA mantle cell lymphoma, as indicated by swelling of the neck, supraclavicular, and inguinal lymph nodes. Seventy percent R-CHOP was administered from January 7, 2005. At the end of sixth course of R-CHOP, no severe liver damage was detected. At the end of the series of treatments, the lymphoma was considered to be in complete remission; however, in July 2006 a recurrence was detected by PET. The patient initially wished to follow a wait-and-see course, but an enlargement was observed in right submaxillary gland in November 2006, and six courses of R-THP-COP therapy (375 mg/m² of rituximab, 1 day; 30 mg/m² of Pinorubin, 1 day; 500 mg/m² of cyclophosphamide, 1 day; 1 mg/m² of vincristine, 1 day; 30 mg/m² of Predonine, 5 days) were administered. It was suspected that the lesion remained, at least in part, and radiation therapy was performed 20× at 40 Gy, leading to a complete remission. Again, no severe liver damage was observed. On August 20, 2008, a recurrence in left infra-axillary lymph node was detected by PET. Radiation therapy was performed 16× at 40 Gy. In May 2009, a recurrence was observed in the hilar area and around abdominal aorta, and in June 2009, treatment (CMR) was started (0.09 mg/kg of cladribine, 5 days; 6 mg/m² of mitoxantrone, 1 day; 375 mg/m² of rituximab, 1 day). However, protracted myelosuppression continued for 4 months. In October, three courses of CMR therapy with doses reduced to 20 % were performed, and complete remission was confirmed by CT and PET. The efficacy of the treatment decreased due to the prolonged interval of treatments caused by protracted myelosuppression, and the patient was elderly, so rituximab was administered every 2–3 months without Cladribine. In April 2010, invasion of mantle cell lymphoma was found in ileum terminal, indicating a relapse, after which rituximab was administered four times per week, and another dose of rituximab was added once a month. No relapse was observed by CT. In December 2010, however, enlargement of left supraclavicular, infra-axillary, and mediastinal lymph nodes was found, and a relapse was confirmed. The patient was hospitalized on January 18, 2011 as the invasion of mantle cells into the gastrointestinal tract had caused diarrhea. After dehydration was improved by transfusion, treatment with rituximab and bendamustine was started on February 1 (375 mg/m² of rituximab, 1 day; 60 mg/m² of bendamustine, 2 days). At that time, HBV-DNA was 2.4 log copy/mL, HBs antibody was 86.3 mIU/mL, and HBs antigen was negative (These examinations were performed with stored serum, so we suspect that the detected HBV-DNA was a false positive due to contamination). The patent had not received the vaccination. The patient subsequently continued to receive this regimen about once a month. The patient visited the hospital on May 13, 2011 due to general malaise. ALT was increased to 180 IL/L, AST was increased to 340 IU/L, and HBs antibody was decreased to 8.3 mIU/mL. HBs antigen was positive, and HBV-DNA was increased to 3.7 log copy/mL (Taqman PCR) (Fig. 1). We concluded that this patient had hepatitis due to HBV reactivation, and 0.5 mg of entecavir was administered from May 19, 2011. Liver function returned to normal by June 17; HBV-DNA was negative, and HBs antibody recovered to 22.5 mIU/mL. Subsequently, four courses of rituximab and bendamustine were administered, and a complete remission was achieved. Maintenance treatment with rituximab with entecavir is currently ongoing.

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