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  • br Patients and methods br Results br Discussion The


    Patients and methods
    Discussion The positivity of serum anti-HBc is the most commonly used marker to confirm the history of HBV infection. Quantification of serum anti-HBc has been explored as a marker of HBV-induced hepatitis and the adaptive immune response against HBV infection as well.[12], [13], [14] Core 4-iodo-SAHA are produced from covalently closed circular DNA (cccDNA), the transcriptional and replicative template of HBV. Therefore, high baseline anti-HBc levels may reflect the amount of residual core antigens produced by replication-competent cccDNAs in hepatocytes. In addition, anti-HBc levels may increase in response to the increase of serum viral naked core antigens released from damaged hepatocytes.[15], [16] The production of anti-HBc may indicate the host immune response to HBV, which is also associated with T cell-mediated hepatitis. The association between the increase of anti-HBc levels and hepatitis flare upon HBV reactivation in our kinetic study may thus suggest a more active immune-related hepatitis in these patients. Low or undetectable anti-HBs at baseline is consistently associated with a higher risk or HBV reactivation.[6], [7], [8], [9] Kusumoto et al. found that patients with anti-HBs levels <10 and 10–100 mIU/ml had HRs of 20.6 and 5.2, respectively, for HBV reactivation, compared with patients with anti-HBs level >100 mIU/ml. This study supports our findings of anti-HBs quantification for the definition of the high-risk group. On the other hand, Seto et al. did not identify a level of anti-HBs as a protective threshold, and thus, recommended a dichotomous readout of anti-HBs positivity to define the high-risk group. The previously reported cutoff value of anti-HBc to differentiate HBsAg-negative individuals into HBV DNA-positive and HBV DNA-negative ones (6.6 IU/ml) was very close to the value that best identify the risk of HBV reactivation in our study (6.41 IU/ml). It implies that an optimal cutoff value of anti-HBc may be defined to allow dichotomous anti-HBc readout for the characterization of the different natural histories of patients with resolved HBV infection. Other virological factors may also help predict HBV reactivation in lymphoma patients with resolved HBV infection. Detectable HBV DNA at baseline, which occurred in <10% of patients with resolved HBV infection, was also associated with a higher risk of HBV reactivation in some studies.[5], [9] A recent report indicated that HBV core-related antigen, which has been shown to correlate with the intrahepatic activity of cccDNA, was associated with an increased risk of HBV reactivation in patients with occult HBV carriers receiving intensified immunosuppressive therapy. It remains undetermined whether these virological markers may also predict HBV-related hepatitis flare or other long-term clinical outcomes. Our findings that patients with high anti-HBc and low anti-HBs at baseline tended to have more frequent and more severe hepatitis flare imply that prophylactic antiviral therapy is most beneficial for this group of patients in terms of clinical-outcome improvement. Its efficacy in improving the patients’ long-term outcome should be validated in future clinical trials. There are several limitations of this study. First, external validation of the cutoff value of anti-HBc/anti-HBs levels to define the high-risk populations is needed for future clinical application. Second, the optimal preventive strategy in patients without the high-risk features remains undefined. The relative benefit of routine prophylactic antiviral therapy vs. regular HBV DNA monitoring for the low-risk population should be studied further. Issues to be considered in the low-risk group may include the optimal duration of prophylactic antiviral therapy, the optimal interval and duration of HBV DNA monitoring, and the cost-effectiveness. Third, although a trend of inferior survival associated with HBV reactivation was found in our study, we did not find HBV-related mortality in our patients, or difference in the causes of death between patients with or without HBV reactivation. Further studies to explore the potential interaction between antiviral and antitumor immunity and its impact on clinical outcome are warranted.[24], [25], [26]