in patients with resolved HBV infection, 1,4,5 but a standard management according to the risk of HBV reactivation has not been established as yet. We hope that the additional information can help readers regarding the optimal interval and sensitivity of the HBV DNA monitoring assay. In addition, if the reappearance of HBsAg and viral mutations related to viral replication are good predictive markers for severe hepatitis resulting from HBV reactivation, we can recommend that antiviral treatment should be started immediately for those patients with HBV reactivation.
Reply:We thank Dr. Kusumoto and his colleagues for their comments on our study. 1 Management of chemotherapy-induced hepatitis B virus (HBV) reactivation in lymphoma patients with resolved HBV infection is a challenging issue in endemic areas because 50%-60% of the general population in those areas have resolved HBV infection, and the clinical courses of HBV reactivation in this patient population vary greatly. Dr. Kusumoto pointed out several important points that warrant further investigation.With increasing sensitivity of the HBV DNA tests, chemotherapy-induced HBV reactivation can be detected in about 20% of lymphoma patients who receive rituximab/CHOP chemotherapy and can be detected earlier (median, 11.8 weeks earlier than the less-sensitive assay). 1,2 However, in our study, most of the additional HBV reactivations detected by the more-sensitive assay were asymptomatic. Only 1 patient had a hepatitis flare, which resolved spontaneously. It is difficult to analyze whether earlier use of antiviral therapy by a more-sensitive assay can further reduce the number of HBV-related hepatitis flares, given the small number of patients. Therefore, the clinical benefit of HBV reactivation detected by the more-sensitive assay for pre-emptive antivirals remains to be established.Reappearance of hepatitis B surface antigen (HBsAg), which can be measured conveniently in the clinic by chemiluminescent immunoassay, such as the Abbott Architect assay (Abbott Laboratories, Abbott Park, IL), was found, in our study, to be significantly associated with HBV-related hepatitis flares. The sensitivity of HBsAg tests currently used in the clinic can be as low as 0.05 IU/mL. Most of the patients were found to be HBsAg 1 at the time of hepatitis flare. Therefore an assay for HBsAg during the chemotherapy course is strongly advocated, in addition to HBV DNA. Whether HBsAg assay is useful, and more cost-effective for managing HBV reactivations in lymphoma patients, warrants a prospective study. Finally, we agree with Dr. Kusumoto that persistence of HBsAg positivity for more than 6 months may negatively influence long-term outcome, and long-term follow-up of patients with reappearance of HBsAg is ongoing.Dr. Kusumoto pointed out the potential importance of viral factors, including the HBV replication levels and the presence of precore/basal core promoter mutations, in the development of severe hepatitis flare. Because the majority of the patients did not have detectable HBV...