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Hepatitis B Testing Urged for Non-Hodgkin's Lymphoma Treatment: Presented at NCCN

HOLLYWOOD, Fla -- March 16, 2009 -- Before initiating treatment for non-Hodgkin's lymphoma, doctors need to determine if the patient has been infected with hepatitis B virus, especially if treatment will be with rituximab-based therapy, according to a presentation here at the National Comprehensive Cancer Network (NCCN) 14th Annual Conference: Clinical Practice Guidelines & Quality Cancer Care.

"Hepatitis B virus can reactivate with immunosuppression," explained presenter Andrew Zelenetz, MD, PhD, Lymphoma Service, Memorial-Sloan Kettering Cancer Center, New York, New York.

Rituximab depletes B cells in patients with B-cell lymphoma, possibly compromising the immune system and allowing the virus to emerge and reactivate, Dr. Zelenetz said in a presentation on March 13.

If patients are found to be positive for the hepatitis B virus -- as determined by hepatitis B surface antigen, core antibody, e-antigen, and/or viral load -- then the treating physician should consult with a hepatologist, he advised. "This is important because more than 5% of patients with acute hepatitis B virus reactivation will die of liver failure," Dr. Zelenetz said.

The US Food and Drug Administration mandated a black box warning regarding rituximab therapy after cases of fulminant hepatitis were reported. The risk of reactivation persists for as long as 6 months following treatment.

The lymphoma algorithm is designed to guide treatment practice among the 21 institutions that make up the NCCN, including Memorial-Sloan Kettering, which releases treatment guidelines that have become standard-of-care for many institutions worldwide.

Dr. Zelenetz said that hepatitis B testing was added to the guidelines as part of the essential work-up for patients.

Other constituents of that work-up include a physical examination with attention to node-bearing areas, including Waldeyer's ring, and with attention to the size of the liver and spleen; the patient's performance status; a chest-abdominal-pelvic computer-assisted tomography (CT) scan; bone marrow and aspirate test to document clinical stage; and pregnancy testing in women of childbearing age if chemotherapy is considered.

"Positron emission tomography [PET] is not an essential part of the work-up," he said, "although PET has been useful in some cases." Also useful in selected cases are hepatitis C testing, discussion of fertility issues and sperm banking, PET-computed tomography scans, neck CT scans, and echocardiogram.

Dr. Zelenetz said the risk of reactivation is higher among young men, in patients with higher hepatitis B virus DNA before treatment, and in patients with prolonged or deep immunosuppression.

[Presentation title: NCCN Non-Hodgkin's Lymphoma Guidelines Update.]