The Straw that Broke the Oncogenic Back: Occurrence of Large B Cell Lymphoma after Hepatitis C Treatment

Abstract

Purpose: The risk of hepatocellular carcinoma with chronic hepatitis C virus (HCV) infection is well recognized while the association between HCV and B-cell non-Hodgkin's lymphoma (NHL) is under appreciated. Lymphoma is thought to arise from chronic B-cell stimulation resulting in malignant monoclonal proliferation. Case series suggest that treatment of HCV infection may lead to regression of lymphoma in select patients. However, there is also a concern for the development of malignancy as a secondary outcome to interferon therapy. We present a patient who developed large B-Cell lymphoma shortly after initiation of HCV treatment. A 60-year-old man with treatment naïve, genotype 1b chronic HCV infection (baseline viral load 7.7 million IU) was referred to our institution for treatment. He contracted the virus in 1969 after blood transfusion for a bleeding duodenal ulcer. There were no radiographic or clinical signs of cirrhosis, portal hypertension, or decompensation. He had no lymphadenopathy on physical exam. After a four week lead-in with pegylated interferon alpha and ribavirin, boceprevir was added. He was interferon responsive, evidenced by a 4-log decline in viral load at treatment week 4. Shortly thereafter, he developed a sore throat and painless swelling in the left neck. On exam, a palpable 3 cm lymph node was identified. CT of the neck showed a level 2A lymph node measuring 3.6 cm with associated tracheal deviation and a smaller level 2B lymph node measuring 1.5 cm. The patient underwent ultrasound guided FNA biopsy, which confirmed a diffuse large B cell lymphoma. Due to the rapid presentation, all HCV therapy was discontinued and he was started on R-CHOP (rituximab-cyclophosphamide, doxorubicin, vincristine, and prednisone). Treatment was complicated by mild transaminitis but led to complete regression of his lymphoma. Reattempt at HCV treatment is planned. While antiviral therapy may lead to regression of lymphoma in some patients with chronic HCV infection, the immunostimulating properties of interferon seem to have unmasked an occult lymphoma in our patient. Clinicians need to be aware of the important association between HCV infection and NHL and this potential complication of antiviral therapy.