Full Length Article

Prevalence and chemotherapy-induced reactivation

of occult hepatitis B virus among hepatitis B surface

antigen negative patients with diffuse large B-cell

lymphoma: Significance of hepatitis B core

antibodies screening

Tamer A. Elbedewy a,*, Hossam Eldin A. Elashtokhy b, Enaam S. Rabee c,

Gamal E. Kheder d

a Internal Medicine Department, Faculty of Medicine, Tanta University, Egyptb Medical Oncology Department, Tanta Cancer Center, Egyptc Clinical Pathology Department, Faculty of Medicine, Tanta University, Egyptd Clinical Pathology Department, Tanta Cancer Center, Egypt

Received 7 December 2014; revised 24 January 2015; accepted 25 January 2015Available online 21 February 2015

KEYWORDS

Hepatitis B virus;

HBsAg;

HBV-DNA;

Anti-HBc;

Occult HBV reactivation;

Diffuse large B-cell

lymphoma

Abstract Background: Occult hepatitis B infection (OBI) is characterized by negative hepatitis B

surface antigen (HBsAg) and detectable hepatitis B virus (HBV)-DNA in the liver and/or serum,

with or without hepatitis B core antibody (anti-HBc). Anti-HBc is the most sensitive marker of pre-

vious HBV. HBV reactivation in patients under immunosuppressive treatment is life-threatening,

occurring in both overt and occult HBV especially in hematological malignancies.

Aim of the work: To evaluate the prevalence and chemotherapy-induced reactivation of OBI

among hepatitis B surface antigen negative patients with diffuse large B-cell lymphoma (DLBCL)

patients and to determine the significance of anti-HBc screening among this group of patients

before receiving chemotherapy.

Patients and methods: This cross-sectional study included 72 DLBCL patients negative for HBsAg,

HBsAb and hepatitis C virus antibodies (anti-HCV). Patients were subjected to investigations

including anti-HBc. All patients underwent alanine transaminase (ALT) monitoring before each

cycle of chemotherapy and monthly for 12 months after the end of chemotherapy. Patients with

suspected OBI were tested for HBV-DNA using real-time polymerase chain reaction (PCR).

Results: Anti-HBc was detected in 10 of 72 HBsAg negative sera (13.89%) (95% confidence

interval 6.9–22.2%). Five of the 10 anti-HBc positive patients in this study had OBI reactivation.

* Corresponding author. Tel.: +20 01151681120; fax: +20

01094680720.

E-mail address: tamerelbedewy2006@yahoo.com (T.A. Elbedewy).

Peer review under responsibility of The National Cancer Institute,

Cairo University.

Journal of the Egyptian National Cancer Institute (2015) 27, 11–18

Cairo University

Journal of the Egyptian National Cancer Institute

www.elsevier.com/locate/jnciwww.sciencedirect.com

http://dx.doi.org/10.1016/j.jnci.2015.01.0041110-0362 ª 2015 Production and hosting by Elsevier B.V. on behalf of National Cancer Institute, Cairo University.This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Conclusion: The study concluded that anti-HBc screening is mandatory before chemotherapy.

HBsAg-negative/anti-HBc-positive patients should be closely observed for signs of HBV reactiva-

tion through the regular monitoring of ALT. Prophylaxis lamivudine is recommended for

anti-HBc positive patients before chemotherapy.

ª 2015 Production and hosting by Elsevier B.V. on behalf of National Cancer Institute, Cairo University.

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-

nd/4.0/).

Introduction

Hepatitis B virus (HBV) infection is a major health problem,affecting about 2 billion people worldwide despite of the effec-tive vaccination. There are 350 million HBV carriers world-wide and about one million die annually from HBV-related

liver disease [1]. The prevalence of HBV infection varies indifferent parts of the world (<1–15%) [2]. Intermediateendemicity of HBV infection had been recorded in Egypt [3].

Occult HBV infection (OBI) is characterized by negativeserum hepatitis B surface antigen (HBsAg) and detectableHBV-DNA in the liver and/or serum, with or without hepatitis

B core antibody (anti-HBc) [4]. Anti-HBc is the most sensitivemarker of previous HBV infection [5]. Anti-HBc is the firstantibody to appear and present in all different phases of

HBV. Anti-HBc may persist longer than hepatitis B surfaceantibody (anti-HBs) or hepatitis B envelope antibody (anti-HBe); however, it is not protective. Anti-HBc IgM may helpin the diagnosis of the acute HBV and also during flares [6].

HBV reactivation in patients under immunosuppressivetreatment is life-threatening occurring in both overt and occultHBV infection [7,8]. The risk of HBV reactivation is high with

marked immunosuppression, especially in hematologicalmalignancies chemotherapy (21–67%), bone marrow trans-plantation and monoclonal antibody therapy [9,10]. Under

these conditions, HBV reactivation is associated with a mor-tality rate close to 20%, due to hepatic failure [11].

Diffuse large B-cell lymphoma (DLBCL) is the most com-mon non-Hodgkin’s lymphoma (NHL). Standard treatment

for newly diagnosed DLBCL is anthracycline-based che-motherapy regimen, usually cyclophosphamide, doxorubicin,vincristine, and prednisone with or without rituximab [12].

Hence, the aim of this study was to evaluate the prevalenceand chemotherapy-induced reactivation of OBI among hepati-tis B surface antigen negative patients with diffuse large B-cell

lymphoma (DLBCL) patients and to determine the sig-nificance of anti-HBc screening among this group of patientsbefore receiving chemotherapy.

Patients and methods

This cross-sectional study included 72 patients with diffuse

large B-cell lymphoma (DLBCL) before receiving chemother-apy. Patients of this study were selected from the HematologyUnit, Internal Medicine Department, Faculty of Medicine,Tanta University and Tanta Cancer Center from May 2012

to October 2014. All patients included were negative forHBsAg, HBsAb and antibody for hepatitis C (anti-HCV). Thisstudy was conducted in accordance with the guidelines of the

declaration of Helsinki 1975 and its subsequent amendments(1983). Participation in the study was voluntary after an

informed written consent was obtained from the patients priorto the study.

All the patients were asked questions regarding age, sex,blood transfusion, past surgical procedures, intravenous drugabuse, jaundice, admission to fever hospital, and history of

HBV vaccination.Patients with recent jaundice, recent hospitalization due to

fever, pregnancy, recent delivery less than 12 weeks or close

contact with a patient suffering from hepatitis in the last6 months were excluded. Exclusion criteria also included acuteor chronic HBV infection as marked by positive HBsAg.Patients with HCV, human immunodeficiency virus (HIV),

any hematological malignancy other than DLBCL or previousimmunosuppressive treatments of any kind were also excluded.

Prior to start of the DLBCL treatment every patient under-

went full history talking, complete physical examination, rou-tine biochemistry assays including alanine transaminase (ALT)and aspartate transaminase (AST).

Diffuse large B-cell lymphoma (DLBCL) was diagnosedbased on histopathological examination of lymph nodes and/or extranodal tissue biopsy specimen according to the Revised

European-American Lymphoma (REAL) classification criteriarevised by Harris [13]. Patients were staged according to theAnn Arbor staging system with Cotswolds modifications [14].Ann Arbor staging was determined for all patients at the onset

of DLBCL by physical examination, computed tomographyscan (abdomen & pelvis, chest and neck) and bone marrowexamination. The International Prognostic Index (IPI) was

used for determining the prognosis of DLBCL [15]. Cheson’scriteria were used to define the response to chemotherapy [16].

The standard protocol chemotherapy for DLBCL used in

this study was CHOP [intravenous cyclophosphamide 750 mg/m2,doxorubicin 50 mg/m2, and vincristine 1.4 mg/m2 (maximumdose: 2 mg) on day 1 and oral prednisone 100 mg/day on days1–5] every 3 weeks for (6–8) cycles [17]. For patients with

relapsed or progressed disease second line therapy ICE [24 hintravenous infusion ifosfamide 5000 mg/m2 on day 2, intra-venous carboplatin using the Calvert formula with maximum

800 mg on day 2 and intravenous etoposide 100 mg/m2 on day1–3] every 14 days or CEOP [intravenous cyclophosphamide750 mg/m2 on day 1, intravenous etoposide 50 mg/m2 on day

1 and 100 mg/m2 orally on day 2 and 3, intravenous vincristine1.4 mg/m2 IV (maximum dose: 2 mg) on day 1 and orally pred-nisone 100 mg/m2 on day 1–10) every 3 weeks for patients candi-

date andnoncandidate for highdose therapy respectively [18,19].All patients underwent total bilirubin and ALT monitoring

during therapy before each cycle of chemotherapy and month-ly for 12 months after the end of chemotherapy. If the patient

experienced an ALT elevation more than threefold above theupper normal value, complete investigations including HBsAg,HBV-DNA levels, anti-HBc IgM, IgM hepatitis A virus anti-

body (anti-HAV) and HCV-RNA were performed to prove

12 T.A. Elbedewy et al.

OBI reactivation and exclude other causes of hepatitis. WhenOBI reactivation occurred, lamivudine therapy was promptlystarted at the standard dosage (100 mg orally once daily).

ALT monitoring was performed every 2 weeks and completeliver functional tests including HBV-DNA quantitative assaywere performed monthly.

Definition of OBI reactivation

Hepatitis was defined as a threefold or greater increase in

serum ALT levels that exceeded the reference range (normalvalue, <42 IU/L) or an absolute increase of ALT to more than100 IU/L. Hepatitis was attributed to OBI reactivation when

there was evidence of HBsAg seroreversion (the reappearanceof HBsAg) with an increase in HBV-DNA levels when com-pared with baseline HBV-DNA levels (>2000 IU/mL), in theabsence of history, clinical or laboratory features of all other

possible etiological factors of hepatitis [20].

Serological assays

Ten milliliters of blood were collected from each patient in asterile, capped tube (before chemotherapy and after OBI reac-tivation). Blood was centrifuged and serum stored at �80 �Cuntil it was needed for testing.

Another portion of blood was collected in vacutainer tubescontaining citrate to separate plasma used for the assay of pro-thrombin time and activity.

All serum samples were tested for serum alanine transami-nase (ALT; upper normal limit UNL 42 IU/L), aspartate trans-aminase (AST; UNL 37 IU/L) and total bilirubin (UNL 1

mg/dl) using chemistry autoanalyzer (Synchron CX5, BeckmanInstrument Inc., Scientific Instrument Division, Fullerton, CA).

Hepatitis B markers (hepatitis B core antibodies, hepatitis

B surface antigen and hepatitis B surface antibody) weredetected by electrochemiluminescence immunoassay on RocheElecsys 201014. Antibodies to HCV (anti-HCV) were detected

using a standard third generation ELISA test (Murex anti-HCV, version 4.0). HAV was detected by commercial enzymeimmunoassays (Cobas Core Anti-HAV IgM EIA, RocheDiagnostics GmbH, Mannheim, Germany). All procedures

were performed according to the manufacturers’ instructions.

Detection of HBV-DNA and HCV-RNA: [21]

DNA was extracted from patient’s serum with OBI reactiva-tion and stored serum for these patients. Samples from eachpatient were tested for HBV-DNA using highly sensitive and

specific real-time PCR. HBV-DNA was extracted from850 lL of plasma by the Cobas AmpliPrep instrument. TheCobas TaqMan 48 analyzer was used for automated real-time

PCR amplification and detection of PCR products.HBV-DNA levels were expressed in IU/mL. The HBV detec-tion limit was 12 IU/mL.

Patients with OBI reactivation, HCV-RNA was carried out

using real time PCR. The HCV detection limit was 15 IU/mL.

Statistical analysis

The collected data were analyzed using SPSS version 17software (SPSS Inc, Chicago, ILL Company). Comparison

of continuous data between two groups was made by usingMann–Whitney test for non-parametric data. Fisher’s exacttest was used for comparison between categorical data.

Survival analysis was done using Kaplan–Meier method andcomparison between two survival curves was done usinglog-rank test. The accepted level of significance in this work

was stated at 0.05 (P < 0.05 was considered significant).

Results

Patient characteristics

This study included 72 patients with diffuse large B-celllymphoma (DLBCL) before receiving chemotherapy; theirages ranged from 23 to 67 years (mean 50.79 ± 9.381 years),

51 were males (70.83%) while the other 21 were females(29.17%). All patients did not receive HBV vaccination before.Fifteen patients (20.83%) had history of blood transfusion and24 patients (33.33%) had history of surgical operations. Other

demographical characteristics of the study population areshown in Table 1.

All patients were followed up for 18 months from the start

of chemotherapy with median 18 months (range 7–18 months)due to death of 2 patients due to OBI reactivation at the 10thand 11th months from the start of chemotherapy and death of

6 patients due to tumor progression at the 7th, 8th, 9th, 12th,13th and 15th months from the start of chemotherapy.

HBV serology before receiving chemotherapy

Among the 72 HBsAg negative sera, anti-HBc was detected in10 of 72 (13.89%) (95% confidence interval 6.9–22.2%). Allthe anti-HBc positive sera were anti-HBs negative.

Consequences of HBV serology after chemotherapy

After the initiation of systemic chemotherapy, examination of

the HBV serology revealed that 5 of the 10 anti-HBc-positivepatients (50%) (6.94% as regarding all patients) became sero-logically positive for the HBsAg with a marked increase in

ALT levels exceeding threefold which was molecularly

Table 1 Demographical characteristics of the study

population.

Variables Number (%)

Diffuse large B-cell

lymphoma stages

I 9 (12.5%)

II 25 (34.72%)

III 31 (43.06%)

IV 7 (9.72%)

International Prognostic Index Low 7 (9.72%)

Low/intermediate 8 (11.11%)

Intermediate/high 42 (58.33%)

High 15 (20.83%)

Cheson’s criteria for response Complete Remission 49 (68.06%)

Partial remission 13 (18.06%)

Relapse or progression 10 (13.88%)

Fate of all patients Alive 64 (88.89%)

Died 8 (11.11%)

Chemotherapy-Induced OBI reactivation 13

detectable for the HBV-DNA (OBI reactivation) as shown inTable 2.

Characteristics of occult HBV reactivated patients

Five of the 72 patients (6.94%) treated for DLBCL manifestedwith OBI reactivation. All of the five patients had OBI reacti-

vation after the completion of all their chemotherapy cycleswith mean time 9.4 ± 1.517 months; range 7–11 months afterchemotherapy was started. Patients with OBI had mean

baseline ALT (35 ± 6.595; range 29–45 U/L), mean ALT afterreactivation (1092.2 ± 533.22; range 450–1776 U/L),mean HBV-DNA after reactivation (84.6 ± 26.71; range

48–121 · 104 IU/mL), mean total bilirubin after reactivation(5.42 ± 3.419; range 2.2–9.4 mg/dl), and mean prothrombinactivity after reactivation (52.8 ± 15.531; range 36–72%). Allof the five patients had negative result of Anti-HAV-IgM

and HCV-RNA. All of them received lamivudine therapybut 2 of them died due to liver failure and the other threepatients had been recovered. Characteristics of occult HBV

reactivated patients are shown in Table 2.Comparison between patients with OBI reactivation and

patients without OBI reactivation in Anti-HBc positive

patients as regard different variables were shown in Table 3.Survival analysis was done using Kaplan–Meier method

and comparison between two survival curves was done usinglog-rank test which revealed insignificant difference between

patients with negative anti-HBc and patients with positiveanti-HBc, also insignificant difference between patients withor without OBI reactivation as regard survival rate (Table 4

and Figs. 1, 2).

Discussion

The natural course of HBV infection is determined by theinterplay between virus replication and host’s immuneresponse [22]. Chemotherapy may lead to an increase in virus

replication and infection of more hepatocytes in the absence ofan active host immune response [23].

Chemotherapy decreases the host’s immune response, so a

period of time is necessary for the immune system to beginattacking the hepatocytes, where a massive replication ofHBV has taken place [24]. For this reason, HBV reactivationoften manifests between cycles of chemotherapy or at the

end of therapy after the recovery of the host immune system[25]. The reported interval ranges from 1 to 9 months from ini-tiation of chemotherapy. HBV reactivation can easily be

missed, particularly in early stages, when salvage anti-viraltherapy could be lifesaving [26]. Since OBI reactivation isasymptomatic and transient, regular frequent monitoring of

ALT is essential although there is no guideline regarding fre-quency of testing [27].

Prophylaxis of HBsAg-negative/anti-HBc-positive patients

undergoing highly immunosuppressive treatment for hemato-logical malignancies is not conclusive and not routinely recom-mended [28,29]. Although the data of a recent meta-analysisrecommended prophylaxis therapy for patients receiving ritux-

imab-based chemotherapy due to increases the risk of OBIreactivation [30].

In Egypt, testing for the presence of HBsAg is the initial

diagnostic examination used to determine HBV infection.Table

2Characteristics

ofoccultHBV

reactivatedpatients.

Patient

number

Age

(years)

Sex

Ann-arbor

stage

International

Prognostic

Index

(IPI)

Outcome

(Cheson’s

criteria)

Baseline

ALT

(U/L)

ALT

after

reactivation

(U/L)

HBV-D

NA

after

reactivation

(IU/m

l)·104

Serum

total

bilirubin

after

reactivation

(mg/dl)

Prothrombin

activityafter

reactivation

(%)

Number

of

chem

otherapy

cycles

before

occultHBV

reactivation

Tim

eofoccultHBV

reactivationafter

thestart

of

chem

otherapy

(months)

Tim

eofrecovery

after

thestart

of

lamivudine

(months)

Fate

of

thepatients

164

MII

I/H

CR

30

450

93

2.5

72

87

1Alive

242

FIII

I/H

CR

29

1225

121

9.4

36

810

–Dead

354

MIII

L/I

CR

38

1776

87

8.7

38

89

–Dead

459

MIII

I/H

CR

33

1340

74

4.3

62

810

2Alive

546

FIII

I/H

CR

45

670

48

2.2

56

811

1Alive

ALT,alaninetransaminase;CR,complete

remission;F,female;HBV-D

NA,hepatitisBvirus–deoxyribonucleicacid;I/H,interm

ediate/high;L/I,interm

ediate/high;M,male.

14 T.A. Elbedewy et al.

Anti-HBc was not used to as screening test to determineprevious exposure to the hepatitis B virus. Hence, the aim ofthis study was to evaluate the prevalence and chemotherapy-

induced reactivation of OBI among hepatitis B surface antigennegative patients with diffuse large B-cell lymphoma (DLBCL)patients and to determine the significance of anti-HBc

Table 3 Comparison between patients with OBI reactivation and patients without OBI reactivation in anti-HBc positive patients as

regards different variables.

Variables Patients with OBI

reactivation (N= 5)

Patients without OBI

reactivation (N= 5)

P-value (significance)

Age (years) (mean ± SD) 53 ± 9.06 51.2 ± 8.11 0.75 (NS)

Sex Male (N) (%) 3 (60%) 4 (80%) 1.00 (NS)

Female (N) (%) 2 (40%) 1 (20%)

Stage II (N) (%) 1 (20%) 2 (40%) 1.00 (NS)

III (N) (%) 4 (80%) 3 (60%)

IPI L/I (N) (%) 1 (20%) 1 (20%) 1.00 (NS)

I/H (N) (%) 4 (80%) 4 (80%)

Response CR (N) (%) 5 (100%) 4 (80%) 1.00 (NS)

PR (N) (%) Zero (0%) 1 (20%)

Fate Alive (N) (%) 3 (60%) 5 (100%) 0.44 (NS)

Dead (N) (%) 2 (40%) Zero (0%)

Anti-HBc, hepatitis B core antibody; CR, complete remission; I/H, intermediate/high; IPI, International Prognostic Index; L/I, intermediate/

high; N, number; NS, non-significant; OBI, occult hepatitis B infection; PR, partial remission.

Table 4 Overall survival probability for different groups of patients.

Number of

patients

Events

(N)

Censored

(N) (%)

Median survival

(years)

Range

(years)

Statistic test for equality

of survival distributions

(Log Rank)

Statistic df P-value

(significance)

Patients with negative anti-HBc 62 6 56 (90.32%) 18 7–18 0.95 1 0.329 (NS)

Patients with positive anti-HBc 10 2 8 (80%) 18 10–18

Patients with OBI reactivation 5 2 3 (60%) 18 10–18 2.24 1 0.134 (NS)

Patients without OBI reactivation 5 0 5 (100%) Can’t be computed since

all patients are censored

Anti-HBc, hepatitis B core antibody; N, number; NS, non-significant; OBI, occult hepatitis B infection.

Figure 1 Kaplan–Meier analysis of the overall survival probability in patients with positive and negative hepatitis B core antibody

(anti-HBc).

Chemotherapy-Induced OBI reactivation 15

screening among this group of patients before receiving

chemotherapy.Our study revealed that, among the 72 HBsAg negative sera

of patients with DLBCL, anti-HBc was detected in 10 of 72(13.89%) (95% confidence interval 6.9–22.2%). All the anti-

HBc positive sera were anti-HBs negative. After the initiationof systemic chemotherapy, examination of the HBV serologyrevealed that 5 of the 10 anti-HBc-positive patients (50%)

(6.94% as regarding all patients) became serologically positivefor the HBsAg with a marked increase in ALT levels exceedingthreefold which was molecularly detectable for the HBV-DNA

(OBI reactivation). All of the 5 patients had OBI reactivationafter the completion of all their chemotherapy cycles withmean time 9.4 ± 1.517 months after chemotherapy start

(range 7–11 months). All of them received lamivudine therapybut 2 of them died due liver cell failure and the other threepatients had been recovered.

Different studies had been done in patients with lymphoma

and other hematological malignancies for the incidence of OBIand reactivation of OBI during and after different regimens ofchemotherapy. Different figures in OBI and reactivation of

OBI were reported, some were with our results and the otherswere different.

In China, Hui et al. [31] estimated HBV reactivation inci-

dence in 244 HBsAg-negative lymphoma patients receivingchemotherapy was 3.3% (8/244). All the 8 patients were sero-positive for either anti-HBc or anti-HBs antibody. Also inChina, Yeo et al. [10] who made their study among 104

CD20+ DLBCL patients, found that 80 out of 104 wereHBsAg negative, 46 patients out of 104 (44.2%) were HBsAgnegative/anti-HBc positive; 25 of these patients were treated

with CHOP without HBV reactivation but among the other 21patients who were treated with R-CHOP, five developed HBVreactivation, including one patient who died of hepatic failure.

In Japan, Matsue et al. [32] conducted a retrospective studyon consecutive patients with CD20-positive B cell lymphomabefore and after rituximab-containing treatment. Five out of

230 patients negative for HBsAg (2.2%) experienced HBVreactivation, representing an incidence of 8.9% of the anti-HBc-positive patients. In Hong Kong, Cheung et al. [33]included 47 lymphoma patients in their study, 10 out of 47

(21%) had OBI. One of the 10 patients, showed virological

reactivation followed by biochemical reactivation without livercell failure where entecavir treatment was used. Regarding theother nine OBI patients, their serum hepatitis B virus DNAlevels fluctuated, but there was no associated biochemical

reactivation.In Italy, a prospective observational study of patients with

hematological malignancies, Francisci et al. [34] reported the

incidence of HBV reactivation was 18%, which is close to thatdetected in the present study. Also in Italy, Masarone et al. [35]who study 498 patients with non Hodgkin’s lymphoma 40% of

patients were treated with monoclonal antibodies and 60%without. Ninety-six patients (19.28%) were anti-HBc+,HBsAg�. HBV reactivation occurred in ten subjects of this

subgroup (10.42%). All of them were successfully treated withlamivudine.

In Egypt, Elkady et al. [36] showed that 18 (34%) out of 53HBsAg-negative Egyptian patients with hematologic malig-

nancies were found to be positive for anti-HBc. Five of the53 (9.4%) patients with hematologic malignancies experiencedHBV reactivation. In Greece, Zachou et al. [37] retrospectively

evaluated the medical records of HBsAg negative patients whosuffered HBV reactivation after chemotherapy or immunosup-pression and identified 14 patients with occult or resolved

infection. Twelve out of 14 patients were males. In 71.4% ofthem the primary diagnosis was hematologic malignancy;78.6% had received rituximab as part of the immunosuppres-sive regimen. The median time from last chemotherapy sched-

ule till HBV reactivation for 10 out of 11 patients who receivedrituximab was 3 (range 2–17) months. Three patients (21.4%)deteriorated, manifesting ascites and hepatic encephalopathy

and 2 (14.3%) of them died due to liver failure.In Taiwan, Hsu et al. [38] who made their study on 150

newly diagnosed lymphoma patients with resolved HBV infec-

tion who received rituximab-CHOP-based chemotherapy andfound that the incidence of HBV reactivation and HBV-relatedhepatitis flares was 10.4 and 6.4 per 100 person-year, respec-

tively and showed that severe HBV-related hepatitis occurredin 4 patients, despite entecavir treatment.

The reasons for the difference in the incidence in OBIreactivation among different studies remain to be elucidated.

Figure 2 Kaplan–Meier analysis of the overall survival probability in patients with or without occult hepatitis B infection (OBI)

reactivation.

16 T.A. Elbedewy et al.

However, immunosuppressive regimen, the intensity of treat-ment, study size, studied population characters, geographicdifferences in HBV prevalence, HBV genotypes, lack of a clear

definition of OBI reactivation and differences in sensitivity ofthe methods used for detection of the virus genome mayaccount for these differences [39].

Our study is not without limitation; as it lacked examina-tion of liver biopsy to certify that patients with anti-HBc andhaving negative HBV-DNA had no occult HBV. Indeed, we

found it unethical to expose the patient to this aggressive tech-nique without direct benefit to them. Also, our study lackedpatients treated with the golden standard regimen (R-CHOP)but we found it unethical to expose the patient to high inci-

dence of OBI reactivation without lamivudine prophylaxiswhich may affect the result of this study.

Conclusion

The study concluded that anti-HBc screening is mandatorybefore chemotherapy. HBsAg-negative/anti-HBc-positive

patients should be closely observed for signs of HBV reactiva-tion through the regular monitoring of ALT. Prophylaxislamivudine is recommended for OBI before chemotherapy.

A wider study on large number of patients is recommended.Also, HBV full genome amplification and sequencing are rec-ommended in further research to identify the most susceptible

HBV genome for HBV reactivation.

Authors’ contributions

* Concept, design, definition of intellectual content, data

analysis, statistical analysis and manuscript preparation:Tamer A. Elbedewy.

* Literature search, manuscript review and manuscript

editing: Tamer A. Elbedewy, Hossam Eldin A. Elashtokhy,Enaam S. Rabee, Gamal E. Kheder.

* Data acquisition, Clinical studies: Tamer A. Elbedewy,

Hossam Eldin A. Elashtokhy.* Experimental studies: Enaam S. Rabee, Gamal E. Kheder.* All authors have been read and approved the final versionof the manuscript.

Conflict of interest

The authors report no conflict of interest.

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