Reactivation of Hepatitis B Virus in Cancer Patients receiving Chemotherapy

Durai Manavalan, V M (2011) Reactivation of Hepatitis B Virus in Cancer Patients receiving Chemotherapy. Masters thesis, Madras Medical College, Chennai.


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INTRODUCTION: Nearly one third of the world's population have been infected with hepatitis B and the virus is endemic in many Asian countries. In India 4-4.75 per cent carry the virus. Hepatitis B, the cause of serum hepatits,is the most versatile of hepatotropic viruses. HBV can produce (1) Acute hepatitis, (2) Chronic non progressive hepatitis, (3) Progressive chronic disease ending in cirrhosis, (4) Fulminant hepatitis with massive liver necrosis, (5) An asymptomatic carrier state. HBV is present in the blood for the last stages of incubation period of 30-180 days and during the active episodes of acute and chronic hepetits and is present in all physiological and pathological body fluids with the exception of stools. HBV is a hardy virus and can withstand extremes of temperature and humidity. Thus although blood and body fluids are the primary vehicles of transmission, virus may also spread by contact with body secretions such as semen, saliva, sweat, tears, breast milk and pathological effusions. Tansfusions, blood products, dialysis, needle stick accidents among the health care workers, intravenous drug abuse and sexual constitute the primary risk categories for HBV infection. In one third of the patient source of infection is unknown. AIM OF THE STUDY: In this study 1. To determine the hepatitis B virus carrier state in patients receiving chemotherapy. 2. To determine the incidence of reactivation of chronic carrier HBsAg positive patients who underwent chemotherapy. 3. To assess the possibility of follow up of the carrier patients with serological and liver function tests for reactivation of Hepatitis B virus. SUBJECTS AND METHODS: Inclusion criteria: 1. Among the patients reported at medical oncology department, • Pathogically confirmed malignancy either by FNAC or biopsy histopathology report. • patients with hepatocellular carcinoma- confirmed by image guided FNAC or USG/ CT imaging suggestive of HCC with elevated S.AFP. • patients with malignancy planned for chemotherapy: - neoadjuvant chemotherapy, -adjuvant chemotherapy, - palliative chemotherapy- for metastatic and recurrent lesions. 2. Performance status ECOG- 2{zubrod score}. 3. complete hemogram with in normal limits. WBC Tc- > 1,500cells/mm3, Platelets >1,00,000cells/mm3, Hemoglobin> 10gm% (or corrected with packed cell transfusion). 4. Renal function: Blood urea : < 40 mg%, S. Creatinine: < 1.2mg%, 5 Liver function test: Total bilirubin <2 mg%, SGOT/SGPT: < 1.5 times the upper limit of normal, S.ALP : < 1.5 times the upper limit of normal, Cardiac function ECHO: ejection fraction > 60%, ECG: within normal limits. 6. Age > 18 yrs. 7. Viral markers : HBs Ag positive. 8. Signed specific consent form prior to study. EXCLUSION CRITERIA: 1. known case of HBs antigen positive without proof of malignancy 2. patients with proof of malignancy and HBs antigen positivity but not on chemotherapy as per the study protocol. 3. known case of HBs antigen positive patients already on T.Lamivudine prophylaxis. 4. previous or present history of other immunesuppressive drugs patients already on steroids for other comorbid medical conditions and as a treatment of malignancy except dexamethasone used as antiemetic prophylaxis and treatment. • patients already on T.cyclophosphamide, azathioprine, cyclosporine, etc. 5. patients with history of autoimmune disorders are excluded. 6. patients with history of uncontrolled diabetes mellitus, and history. of congestive cardiac failure, chronic kidney disease. 7. patients with decompensated liver disease. • Total bilirubin > 2 mg%, • Elevated SGOT/SGPT > 1.5x UNL, • Elevated ALP > 1.5x UNL, • Low albumin < 4gm%, • Albumin / globulin ratio reversal (imaging suggested of cirrhosis with coexisting liver sol suggestive of hepatocellular carcinoma and elevated tumor markers with normal LFT are included in the study). 8. coexisting viral infections such as human immune deficiency virus are excluded. 9. patients with history of jaundice within 6 months previous to chemotherapy are excluded. 10. patients with coexisting HCV antibodies positive are excluded. 11. previous history of chemotherapy and radiotherapy. 12. previous history of malignancy treated surgically other than included in the study (patients with history of malignancy previously treated with surgery only but not with chemotherapy or radiotherapy now with metastatic or recurrent disease and planned for 1st line chemotherapy are included in the sudy). 13. performance status > 3. 14. patients with evidence of malignancy planned for chemotherapy with HBs antigen positive patients but with anti HBc positive patients, HBe antigen positive and HBV DNA positive are excluded from the study. 15 patients with severe and active comorbid medical and surgical conditions. 16. pregnant and nursing mothers. 17 age < 18 yrs and > 65 yrs. 18. patients requiring dose modification due to renal or hepatic dysfunction are excluded from the study. RESULTS : Between June 2009 and December 2010 all the patients registered at medical oncology opd GGH were evaluated for the serological status. All the patients underwent serology tests ELISA for HIV, ELISA for HBs AG and ELISA for Anti HCV antibodies. Totally 1850 patients were examined among them 62 patients were found to be HBS antigen positive. The HBS antigen positive patients are about 3.35% of the total patients underwent serological tests. There were about 20 female patients and 42 male patients were diagnosed as hepatitis b antigen positive .Among the 62 patients one patient had coexisting HIV infection and not included in the study, one patient had coexisting HCV antibodies positive and hence not included in the study. Among the 60 patients only 43 patients had met the eligibility criteria for the study and included in the study. Those 17 patients who do not met the criteria for the study 11 patients presented with jaundice and 3 patients had chronic renal disease and 2 patients had congestive cardiac failure and not included in the study. One patient had rheumatoid arthritis and already on steroids and excluded. Among the 11 patients with jaundice 8 patients were diagnosed as hepatocellular carcinoma and 2 were carcinoma stomach with liver secondaries and one with carcinoma pancreas with liver secondaries. CONCLUSION: From the Study, we concluded that, 1. The overall incidence of chronic HBs antigen carrier state is about 3.35%. 2. The incidence of reactivation of Hepatitis B virus in chronic HBs antigen patients receiving chemotherapy is 21% as we concluded from the study. 3. Patients who are on adriamycin based chemotherapy for the solid malignancies also had increased incidence of reactivation of hepatits B virus in HBs antigen chronic carriers. 4. Since patients with solid malignancy in chronic carrier HBs antigen state had high incidence of reactivation, we suggest that those patients should be treated with prophylactic Lamivudine.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Reactivation ; Hepatitis B Virus ; Cancer Patients ; Chemotherapy.
Subjects: MEDICAL > Medical Oncology
Depositing User: Kambaraman B
Date Deposited: 09 May 2018 17:39
Last Modified: 09 May 2018 17:39

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