Predicting factors of malignancy in dermatomyositis and polymyositis: a case-control study

The incidence and associations of malignancy in a large cohort of patients with biopsy-determined idiopathic inflammatory myositis

The South Australian (SA) myositis database has registered all patients with biopsy-proven inflammatory myositis in SA from 1980 to 2009. We determined the incidence and associations of malignancy in myositis by linking this database with the SA cancer registry. Standardized incidence ratios (SIR) for malignancy were determined using the total SA population over the same time period, stratified by age and gender. The SIR for cancer in the myositis population (n = 373) was 1.39, p = 0.047. There was a trend towards an increased SIR in dermatomyositis but no increased risk of malignancy in polymyositis or inclusion body myositis. Malignancies of the lung and prostate were the commonest and 28 % of malignancies occurred within one year of IIM diagnosis. The odds of developing cancer were significantly raised in the presence of a shawl sign, male gender, and in patients with overlap syndrome or rheumatoid arthritis whilst myalgia was a significant protective factor. HLA-A28 allele was overrepresented in patients with malignancy (11 vs 2 %, p = 0.006). Patients in SA with myositis are at modestly increased risk for malignancy. We report clinical and genetic risk factors allowing the identification of patients at greatest risk for malignancy.

Mortality factors in idiopathic inflammatory myopathy: focusing on malignancy and interstitial lung disease

OBJECTIVES

The objective of this study was to assess the incidence and common types of concomitant malignancies and to define predictive factors of death in Korean patients with idiopathic inflammatory myopathy (IIM).

METHODS

From January 1989 to May 2011, 162 patients were diagnosed with IIM at a university hospital in Korea. The medical records were retrospectively reviewed. The clinical findings of the patients were compared for malignancy, and the prognostic factors predicting death were analyzed.

RESULTS

Malignancies were found in 17 patients (10.5 %), all of whom had a significantly lower frequency of interstitial lung disease (ILD) and an older age at onset. The main causes of death were ILD and malignancy. Older age at diagnosis, presence of malignancy, rapidly progressive ILD and minimal creatinine phosphokinase (CPK) elevation were independent risk factors for death.

CONCLUSIONS

Malignancy was one of the most serious risk factor for death in our patients with IIM. Early discovery of malignancy is important, and an extensive investigation for common malignancies in each region should be done at diagnosis and for a minimum of 2 years thereafter. As minimally elevated CPK levels in ILD patients may be associated with fatal ILD, an early evaluation and a more aggressive treatment of ILD should be considered in these patients.

Myositis-related interstitial lung disease and antisynthetase syndrome

In patients with myositis, the lung is commonly involved, and the presence of anti-aminoacyl-tRNA synthetase (anti-ARS) antibodies marks the presence or predicts the development of interstitial lung disease (ILD). A distinct clinical entity-antisynthetase syndrome-is characterized by the presence of anti-ARS antibodies, myositis, ILD, fever, arthritis, Raynaud's phenomenon, and mechanic's hands. The most common anti-ARS antibody is anti-Jo-1. More recently described anti-ARS antibodies might confer a phenotype that is distinct from that of anti-Jo-1-positive patients and is characterized by a lower incidence of myositis and a higher incidence of ILD. Among patients with antisynthetase syndrome-related ILD, the response to immunosuppressive medications is generally, but not universally, favorable.

Paraneoplastic myalgias and myositis

There are several key observations on paraneoplastic myopathies: The risk of cancer associated with DM is very high, whereas risk of cancer associated with PM is mildly increased Most cancers develop within one year of the onset of myositis, although the risk remains high up to 5 years after diagnosis. The most common cancers associated with DM are adenocarcinoma, including lung, ovary, cervical, stomach, pancreas, colorectal and lymphoma, whereas PM is associated with a high risk of lymphoma. The clinical course of myopathy is closely linked with the course of cancer. Certain clinical features are associated with CAM including severe treatment resistant skin manifestations, severe muscle weakness, respiratory muscle weakness, and dysphagia, while some clinical features are protective such as arthritis, Raynaud, and ILD. Screening should be based on age, gender, ethnicity, and the geographic area of the patient; however, certain high-risk patients may require more extensive screening including tumor markers and thoracoabdominal–pelvic CT scans. Certain autoantibodies including anti-p155 and the absence of more common autoantibodies are associated with a higher risk of CAM, while the presence of antisynthetase autoantibodies lowers the risk for CAM. Although the pathogenesis of CAM is unclear, a plausible hypothesis is that immune responses generated against antigens commonly targeted in myositis are related to antitumor responses in affected individuals.

Survival analysis of patients with dermatomyositis and polymyositis: analysis of 192 Chinese cases

To estimate the mortality rate and identify factors predicting survival in patients with polymyositis (PM) and dermatomyositis (DM). The medical records of 192 PM/DM patients who were treated at Chang Gung Memorial Hospital from 1999 through 2008 were retrospectively reviewed. The Taiwan National Death Registry (1999-2008) was used to obtain their survival status. Thirty-one (16.1%) of the 192 patients with PM/DM had an associated malignancy; 41 (21.4%) had interstitial lung disease (ILD). During the follow-up period, 55 (28.6%) patients died and the overall cumulative survival rate was 79.3% at 1 year, 75.7% at 2 years, 69.9% at 5 years, and 66.2% at 10 years. In univariate analysis, older age at PM/DM onset, anemia, thrombocytopenia, leukopenia, diabetes mellitus, ILD, cancer, and non-use of azathioprine were associated with higher mortality (p = 0.0172, 0.0484, <0.0001, 0.0008, 0.0001, 0.0036, 0.0010, and 0.0019, respectively). In multivariate Cox regression analysis, thrombocytopenia (hazard ratio [HR] 4.94, 95% confidence interval [CI] 2.60-9.37, p < 0.0001), diabetes mellitus (HR 2.57, 95% CI 1.38-4.80, p < 0.0001), cancer (HR 2.30, 95% CI 1.26-4.22, p = 0.0030), and ILD (HR 1.98, 95% CI 1.11-3.51, p = 0.0182) were positively associated with mortality. Use of azathioprine (HR 0.35, 95% CI 0.16-0.74, p = 0.0064) was negatively associated with mortality. This study confirmed the high mortality rate (28.6%) in PM/DM patients. Survival time was significantly reduced in patients with thrombocytopenia, diabetes mellitus, ILD, and cancer patients than in those without these conditions.

Malignancy in myositis

Dermatomyositis is associated with an underlying malignancy in about 24% of cases. This association is also true for polymyositis but is less prominent. The malignancy is usually an adenocarcinoma of the ovary, lung, or gastrointestinal tract in Western countries and nasopharyngeal carcinoma in Southeast Asia, Southern China, and Northern Africa. Factors predictive of malignancy in myositis patients include more severe skin and muscle disease and the absence of overlap connective tissue disease features, such as interstitial lung disease. Anti-p155/140 antibodies have a strong predictive value for malignancy in adult patients. Patients with dermatomyositis or polymyositis require an evaluation for occult malignancy at the time of diagnosis and, in some cases, in the event of a subsequent recurrence. This paraneoplastic phenomenon may stem from an immune reaction to antigens expressed in both cancer cells and regenerating fibers in affected muscle.

Idiopathic inflammatory myopathy associated with malignancy: a retrospective cohort of 151 Korean patients with dermatomyositis and polymyositis

OBJECTIVE

To define the standardized incidence ratio (SIR) of malignancy and factors associated with malignancies in Korean patients with dermatomyositis (DM) and polymyositis (PM).

METHODS

The demographic, clinical, and laboratory features of 151 patients diagnosed with DM/PM were compared in patients with and without malignancies.

RESULTS

Malignancies were found in 23 of 98 patients with DM (23.5%) and in 2 of 53 with PM (3.8%). Lung cancer (8 patients) was the most common malignancy. Compared with the period-specific, sex-matched, and age-matched Korean population, the SIR for malignancy in patients with DM was 14.2 (95% CI 9.0-21.3). Univariate analysis showed that factors associated with malignancy included older age (p < 0.001), DM (p = 0.002), dysphagia (p < 0.001), the absence of interstitial lung disease (ILD; p = 0.001), and lower elevations in aspartate aminotransferase (p = 0.005) and lactate dehydrogenase concentrations (p < 0.001). Multivariate analysis showed that factors independently associated with malignancy included older age (per 10 years, OR 2.3, 95% CI 1.6-3.5, p < 0.001), DM (OR 5.9, 95% CI 1.3-26.2, p = 0.020), dysphagia (OR 2.6, 95% CI 1.2-6.6, p = 0.042), and the absence of ILD (OR 0.1, 95% CI 0.01-0.9, p = 0.040).

CONCLUSION

DM was associated with a greater risk of concomitant malignancies, especially lung cancer, than PM. Independent factors associated with malignancies in patients with DM/PM were older age, the presence of dysphagia, and the absence of ILD.

Paraneoplastic muscle disease

In paraneoplastic muscle disease, the malignancy may remotely affect neuromuscular transmission or incite muscle inflammation or necrosis. In several of these diseases, an autoimmune basis for the muscle disease has been established and has become a defining feature. These paraneoplastic muscle diseases may be the first manifestation of a malignancy, and their diagnosis thus demands a vigilant search for an underlying tumor. This article is focused on inflammatory and necrotizing myopathies and disorders of neuromuscular transmission that may arise in the setting of malignancy and are considered paraneoplastic phenomena.

[Dermatomyositis: assessment and follow-up of 20 patients]

BACKGROUND

Dermatomyositis is an idiopathic inflammatory myopathy that mainly affects the skin and skeletal muscle. An estimated 15% to 25% of patients have underlying tumors and some forms are exclusively cutaneous. The factors that predict disease course and prognosis in these patients have not been clearly identified. Here we report our experience through the description and analysis of a series of patients.

MATERIAL AND METHODS

This was a retrospective study of 20 patients with a diagnosis of dermatomyositis undergoing follow-up in the Department of Dermatology at Hospital General Universitario Gregorio Marañón in Madrid, Spain between February 2007 and February 2010. Clinical and histopathological characteristics were assessed alongside the results of laboratory tests and the treatments used.

RESULTS

Nineteen of the 20 patients included in the study were women. The mean age was 61 years (median, 60 years). We identified 11 patients with classic, 3 with amyopathic, 2 with paraneoplastic, 1 with drug-associated, and 1 with juvenile dermatomyositis, and 2 patients had dermatomyositis associated with connective tissue disease. Heliotrope erythema, Gottron papules, and periungual erythema were the most frequent skin lesions. Cutaneous necrosis was present in 2 patients with paraneoplastic dermatomyositis. None of the patients had myositis-specific antibodies. Initial treatment was with systemic corticosteroids in 85% of cases. Eighty percent of patients required 2 or more drugs to achieve disease control.

CONCLUSIONS

Dermatomyositis is a potentially serious disease. Dermatologists can facilitate diagnosis and contribute to the early detection of associated tumors and systemic complications. In most patients, the disease has a good prognosis, although extended periods of treatment may be required. Complications occur most commonly in patients with associated tumors or cardiopulmonary disease.

Incidence and predictive factors for malignancies in 136 Japanese patients with dermatomyositis, polymyositis and clinically amyopathic dermatomyositis

The aim of this study was to define the standardized incidence ratio (SIR) of malignancy and the potential risk factors of concomitant malignancies in patients with inflammatory myopathies, including clinically amyopathic dermatomyositis (CADM). A total of 145 patients diagnosed with either dermatomyositis/polymyositis (DM/PM) or CADM at our institute between 1984 and 2002 were enrolled in the study. The demographic, clinical and laboratory features of the patients at the time of DM/PM or CADM diagnosis were compared between patients with and without malignancies, respectively. Multivariate analysis by logistic regression was used to determine the independent risk factors for the development of malignancies in DM/PM patients. Malignancy was found in 17 of 70 patients with DM (24%), three of 15 patients with CADM (20%), and three of 51 patients with PM (6%). Gastric cancer (8/23) was the most common malignancy. Compared with general population, the SIR of malignancies was 13.8 (range 9.0-21.1). The patients who developed malignancies were older (61.5 vs. 51.1 years; P < 0.005), presented more often with dysphagia (61 vs. 15%; P < 0.0001) and were less likely to have the complication of interstitial lung disease (30 vs. 60%; P < 0.05). These features were independent predictive factors for developing malignancies in multiple logistic regression analysis. The results of our study confirm that CADM in addition to DM was associated with high rates of malignancy among our patient cohort.

A case of nasal-type NK/T cell lymphoma in a patient with dermatomyositis

The association of malignancy with dermatomyositis is well known, and the frequency is reported to be up to 30%. However, cutaneous lymphoma associated with dermatomyositis has rarely been reported. We experienced a case of nasal-type NK/T-cell lymphoma in a 40-year-old woman with a 2-year history of dermatomyositis. To our knowledge, this is the first report of cutaneous involvement of nasal-type NK/T-cell lymphoma developing in a dermatomyositis patient. When skin lesions are resistant to aggressive conventional treatment in dermatomyositis patients, we should consider the possibility of malignancy, especially cutaneous lymphoma.

Cancer risks of dermatomyositis and polymyositis: a nationwide cohort study in Taiwan

Introduction

The association of idiopathic inflammatory myositis (IIM) and malignancies has been reported, but rarely in Asian countries. Our aim was to investigate the risk of cancer among IIM patients without a prior history of malignancies, in Taiwan.

Methods

We conducted a nationwide cohort study of 1,012 patients with dermatomyositis (DM) and 643 patients with polymyositis (PM), but without prior history of malignancies, utilizing the National Health Insurance Database from 1997 to 2007. Standardized incidence ratios (SIRs) of cancers were analyzed.

Results

A total of 95 cancers (9.4%) in DM and 33 cancers (4.4%) in PM were identified. Overall cancer risk was significantly elevated in DM patients (SIR = 5.11, 95% confidence interval [CI] = 5.01 to 5.22) and PM patients (SIR = 2.15, 95% CI = 2.08 to 2.22). Most cancers were detected in the first year of observation. The risk of cancer decreased with observation time, yet remained elevated compared with the general population in both study groups after 5 years of follow-up. DM was associated with sustained elevated risk of cancers in every age group, whereas the risk of cancer in PM was highest in younger patients and decreased with age. DM patients were at the greatest risk of cancers of the nasopharynx, lungs and hematopoietic malignancies.

Conclusions

Patients with IIM are at increased risk for cancer and should receive age-appropriate and gender-appropriate malignancy evaluations, with additional assessment for nasopharyngeal, lung and hematologic malignancy following diagnosis, and with continued vigilance for development of cancers in follow-up.

[Dermatomyositis associated with metastatic rectal adenocarcinoma: case report]

INTRODUCTION

Dermatomyositis is an idiopathic inflammatory myopathy with characteristic cutaneous changes. The disease belongs to paraneoplastic dermatosis. Association of dermatomyositis with malignant conditions has been described in various studies. We present a patient with paraneoplastic dermatomyositis associated with metastatic rectal adenocarcinoma.

CASE REPORT

A 66-year-old man was hospitalized in our Institute due to skin changes and myopathy in October 2006. According to the medical documents and history, he underwent surgery because of rectal adenocarcinoma in April 2006. Skin changes appeared 5 months before, while aggravation occurred 6 months after the surgery. The diagnosis of dermatomyositis was based on: characteristic clinical picture; the elevated serum level of following enzymes: creatinine kinase, lactate dehydrogenase; the presence of anti-Mi 2 antibodies in serum; electromyographic finding; and by histology of the muscle biopsy. Paraneoplastic nature of dermatomyositis was confirmed by computer tomography of the abdomen which revealed multiple deposits in the liver, by explorative laparotomy showing peritoneal dissemination and histopathological analysis that verified metastatic adenocarcinoma of the rectum. The oncological consulting team suggested chemotherapy which was not carried out because of the rapid lethal outcome.

CONCLUSION

We report a case of paraneoplastic dermatomyositis associated with metastatic rectal adenocarcinoma and lethal outcome, and suggest a comprehensive evaluation of patients with dermatomyositis older than 50 years in order to exclude or verify the occult malignancy.

Juvenile dermatomyositis as a paraneoplastic phenomenon: an update

Approximately 33% of adult patients with dermatomyositis develop malignancy with up to 42% presenting after the diagnosis has been made; careful evaluation for malignancy is often undertaken at the time of dermatomyositis diagnosis. This phenomenon has rarely been noted in pediatric patients and extensive workup for malignancy is not indicated in pediatric patients. In 1993, 6 cases were reported in which juvenile dermatomyositis/polymyositis (JDM/PM) appeared to be part of a paraneoplastic phenomenon. Our objective was to update the literature for reported cases of malignancy associated with JDM/PM; we reviewed the literature over the last 15 years and located 6 additional cases. In 9 of 12 reported patients an unusual physical finding such as splenomegaly or lymphadenopathy was noted at the time of diagnosis, and in the entire group, the malignancy occurred within a mean of 12 months. It is less likely that JDM/PM in pediatric patients is a paraneoplastic phenomenon as it is in adult patients. However, if the physical examination at the time of diagnosis of JDM/PM is atypical the presence of malignancy must be considered and a more in-depth evaluation to rule out malignancy should be performed prior to the initiation of treatment.

Paraneoplastic myopathy

PURPOSE OF REVIEW

It has been recognized for some time now, that compared with the normal population, patients with idiopathic inflammatory myopathies (IIM) live with an increased risk of developing malignancy. In the majority of these patients, cancer-associated myositis appears to have some paraneoplastic features. The aim of the present review is to describe new data that explain the connection between myositis and malignant diseases, as well as to highlight its value in the current management of these patients.

RECENT FINDINGS

Antigen expressions and patterns shared by regenerating muscle and cancers raise questions about whether myositis cases without clinically observable cancer may represent a fully successful antitumor immune response with bystander damage to regenerating muscle. The discovery of anti-155/140 autoantibody may aid in the better diagnosis of adult IIM patients with a higher risk of malignancy. It also may help the better understanding of paraneoplastic myositis.

SUMMARY

Cancer-associated myositis differs from primary myositis in many aspects. Prognosis and life-expectancy are determined by the underlying malignancy. Therefore, patient-specific examinations for detection of an underlying cancer are important in the management of patients. Recent clinical findings and new possibilities in immunoserological testing may result in the elaboration of an evidence-based recommendation for cancer screening programs in patients with IIM in the future.

Malignancy is associated with dermatomyositis but not polymyositis in Northern New England, USA

OBJECTIVE

To retrospectively evaluate the association of idiopathic inflammatory myopathy (IIM) and malignancy in patients seen at 1 academic center over a 23-year period.

METHODS

Patients were identified using the International Classification of Diseases, 9th edition (ICD-9) codes and diagnoses, then confirmed by chart review. Population cancer statistics obtained from the US Centers for Disease Control for Vermont and New Hampshire were used for comparison.

RESULTS

Chart review confirmed IIM in 198 of 483 patients initially identified by ICD-9 codes. Within 5 years of diagnosis with IIM, malignancy developed in 32 patients (16.2%), 24 of whom (75%) had dermatomyositis (DM). Malignancy and DM developed within 1 year in 75%. The cancer risk associated with DM was much greater than the risk associated with other IIM. The most frequent tumor types were breast, lung, pancreas, and colon. DM patients with cancer were more frequently male and >or= 45 years of age than those without cancer. There were no cases of interstitial lung disease among patients with cancer and any form of IIM. The incidence of cancer was increased in patients with DM compared to age- and sex-matched population controls, both over a 5-year interval surrounding the diagnosis of DM and over the lifetime interval following diagnosis.

CONCLUSION

The risk of cancer in IIM is concentrated among patients with DM. The association between DM and cancer was enhanced by its temporal relationship (< 1 year) in 87.5% of these cases. Patients with malignancy-associated DM were more frequently male and over age 45 and less likely to have interstitial lung disease.

A case of erythrodermic dermatomyositis associated with gastric cancer

Erythroderma is an unusual cutaneous finding associated with dermatomyositis. There are only five cases of erythrodermic dermatomyositis reported in the English literature. We treated a case of erythrodermic dermatomyositis associated with a Bormann type 1 gastric cancer. The patient had a generalized, erythematous scaly eruption consistent with erythroderma and Gottron's papules as well as a heliotrope rash; these are the hallmark skin manifestations of dermatomyositis.

[Myopathies and malignancy]

There is a greater risk of developing cancer among patients with inflammatory myositis, specifically dermatomyositis. This relationship was first described in 1916 by Sterz and has been corroborated in population based studies. This chapter describes clinical and serological characteristics of patients with myositis and cancer, as well as the most common malignancies and diagnostic and prognostic considerations in this group of patients.

Paraneoplastic dermatological manifestation of gastrointestinal malignancies

Numerous dermatological disorders have been associated with underlining malignancies of the gastrointestinal (GI) tract. Such cutaneous manifestations might have an important diagnostic value if they are the sole expressions of otherwise asymptomatic carcinomas. The recognition of some typical paraneoplastic dermatologic disorders can lead to the prompt diagnosis of the underlying malignancy, timely administration of therapy, and ultimately, better prognosis. In this review we discuss the most common paraneoplastic dermatological syndromes from the perspective of the practicing gastroenterologist. We also outline a comprehensive practical approach for the evaluation for occult malignancy in patients presenting with cutaneous findings potentially associated with GI cancers.

[Dermatomyositis]

Dermatomyositis is a form of idiopathic inflammatory myopathy that involves skeletal muscle and skin. The objectives of this review are to briefly describe the cutaneous manifestations of the disease, to raise some questions still debated about amyopathic dermatomyositis, and to reflect current knowledge of an interesting aspect in dermatomyositis as it is the risk to develop malignancy. Although clear evidence for a significant dermatomyositis-cancer association exists, optimal clinical or biological factors that predict an association with cancer have not been identified. Recently, some specific autoantibodies in dermatomyositis have been shown to be associated with internal malignancy. They open up the possibility to have available serological markers for detecting cancer-associated myositis in the near future.

[Polymyositis and dermatomyositis in adults. Tunisian multicentre study]

INTRODUCTION

To study the clinical features and the outcome of polymyositis (PM) and dermatomyositis (DM) in Tunisia.

METHODS

Retrospective multicentre study conducted by the Tunisian Society of Internal Medicine. Adult patients with confirmed and probable PM and DM, according to the Bohan and Peter's criteria, were included in the study and followed-up between 1987 and 2005.

RESULTS

Twenty cases of PM and 50 cases of DM were included. Female/male sex-ratio was 2.5. The mean age at diagnosis was 40.7 years. Muscle weakness concerned girdle muscles in 94.3% and pharyngeal muscles in 42.8% of the patients. Interstitial lung disease and heart involvement occurred respectively in 35.7 and 20%. Eyelid erythema, peri-ungual erythema and Gottron's sign occurred in respectively 86, 50 and 36% of the cases of DM. Malignant disease was found in 12.8% of the patients (mainly gynecological and nasopharyngeal cancers). All patients received high dose corticosteroids with additional immunosuppressive drugs in 40% of the cases. The outcome was stabilization or partial improvement in 71.5% of the cases. Death occurred in 20% and was caused by respiratory failure, sepsis and cardiac failure.

CONCLUSION

The particularities of PM and DM in Tunisia are the preponderance of DM, early onset of the disease and high frequency of the nasopharyngeal cancer.

Defining cancer risk in dermatomyositis. Part II. Assessing diagnostic usefulness of myositis serology

In part 1 of this review, we examined the evidence behind the association between idiopathic inflammatory myopathies (IIM) and cancers. In view of the well-recognized association between cancer and myositis (hence the term cancer-associated myositis, or CAM), clinicians responsible for the management of patients with myositis must make important decisions regarding how intensively they undertake searches for malignancy. Clinicians must also decide how often such searches are repeated, and again how intensively, to optimize both cancer detection and treatment, and thus patient survival. As the risks of CAM are greatest in dermatomyositis, this is an issue of obvious importance to dermatologists. In this second of two reviews, we examine the role of autoantibodies as potential predictors of cancer risk in patients with IIM.

Interstitial lung disease in polymyositis and dermatomyositis

The aim of the study was to estimate the prevalence, characteristics, and prognostic factors of interstitial lung disease (ILD) in patients with polymyositis (PM) and dermatomyositis (DM). The medical records of 151 PM/DM patients treated at Chang Gung Memorial Hospital between January, 2000 and June, 2007 were retrospectively reviewed. Thirty of 151 (19.9%) PM/DM patients had developed ILD. Older age at PM/DM onset, anti-Jo-1 antibody, and arthritis/arthralgia were associated with the presence of ILD (p = 0.004, p = 0.008, and p = 0.026, respectively). Anti-Jo-1 was initially excluded from the multivariate analysis because only 80 patients underwent the test. An older age at onset above 45 years (odds ratio 3.28, 95% confidence interval (CI) 1.15-9.34, p = 0.026) and arthritis/arthralgia at onset (odds ratio (OR) 2.57, 95% CI 1.09-6.08, p = 0.032) were the two independent risk factors for developing ILD. If anti-Jo-1 was included in the multivariate analysis (n = 80), then an older age at onset above 45 years (OR 7.30, 95% CI 1.70-31.40, p = 0.008) and anti-Jo-1 positive (OR 7.89, 95% CI 1.18-52.87, p = 0.033) were associated with ILD, while arthritis/arthralgia was no longer significant (OR 2.64, 95% CI 0.70-10.01, p = 0.153). Of the 30 ILD patients, 16 (53.3%) died. The survival time was significantly shorter in ILD patients than in patients without ILD (p < 0.001). Poor survival in ILD patients was associated with male gender (p = 0.039), a Hamman-Rich-like presentation (p = 0.039), and a clinical diagnosis of acute interstitial pneumonia (p = 0.007).

Malignancies associated with dermatomyositis and polymyositis in Taiwan: a nationwide population-based study

BACKGROUND

Previous studies showed that idiopathic inflammatory myopathies (IIM) carried an increased risk of cancers. However, no large-scale study of IIM has been conducted in the Chinese population.

OBJECTIVES

We sought to delineate the association of IIM and various cancer types from a nationwide database in Taiwan.

METHODS

We analysed the published national data from records of National Health Insurance claims. Cases of dermatomyositis (DM) and polymyositis (PM) from 2000 to 2005 and cancers registered in the catastrophic illness profile from 1997 to 2006 were collected. A nationally representative cohort of 1,000,000 enrollees was included for comparison.

RESULTS

In total, 136 patients (12.8%) among 1059 cases of DM and 46 persons (7.0%) among 661 cases of PM carried internal malignancies. Patients with DM tended to have cancers of nasopharynx, lung and breast. On the other hand, patients with PM tended to have breast, uterine cervix and lung cancers. Compared with the general population, DM gave a 10-fold increased risk for cancers, in which a 66-fold increased risk for nasopharyngeal carcinoma and a 31-fold increased risk for lung cancer were the two most significant. For patients with PM, a 6-fold increased risk for cancer was observed. Juvenile DM had a 16-fold increased risk for haematopoietic or lymphoid malignancy. Two thirds of comorbid malignancies were detected shortly after the diagnoses of IIM, within a mean of 1-2 years. Overall, younger patients with IIM carried the highest risk for malignancies, especially those in their twenties and thirties.

CONCLUSIONS

This is the first large-scale study to report the associated malignancies and the cancer risk of IIM in Taiwan.

Defining cancer risk in dermatomyositis. Part I

The idiopathic inflammatory myopathies (IIMs) comprise polymyositis, myositis overlapping with another connective tissue disease, dermatomyositis (DM) and inclusion-body myositis (IBM). IIMs are characterized by the presence of proximal muscle weakness, increased levels of muscle-specific enzymes, specific electromyographic abnormalities, and the presence of inflammatory cell infiltrates in skeletal muscle. Clinical, serological and histological criteria can be used to define individual IIM subtypes. In the first of this two-part review series, we examine the evidence for the existence of cancer-associated myositis (CAM), and in part 2, we discuss recent discoveries that provide insight into identification of patients with DM, who may be most at risk of developing CAM.

Factors associated with underlying malignancy in a retrospective cohort of 121 patients with dermatomyositis

Demographic, clinical, and laboratory features that predict underlying malignancy in patients with dermatomyositis (DM) are poorly known. We conducted a retrospective study in all adult patients with a definite (n = 75) or probable (n = 32) diagnosis of DM according to Bohan and Peter criteria or with amyopathic DM (n = 14) who were referred to 2 departments during a 13-year period. The diagnosis of malignancy-associated DM was retained if DM occurred in a context of recently diagnosed malignancy or if a malignancy was diagnosed during the 5 years following the diagnosis of DM. The Kaplan-Meier method was used to assess the cumulative incidence rates of underlying malignancy during the first 5 years of DM. Factors associated with malignancy in patients with DM were identified by Cox proportional hazards models. During the study period, 121 patients fulfilled the inclusion criteria (median age, 52 yr; range, 19-77 yr; women: 70%). For 29 of them, the diagnosis of malignancy-associated DM was retained. The cumulative incidence rate of malignancy was 21 +/- 4% and 28 +/- 5%, 1 year and 5 years after the diagnosis of DM, respectively. The median duration of follow-up of the 92 patients with no malignancy diagnosed was 36 months (range, 1-140 mo). In multivariate analysis, independent factors associated with an underlying malignancy in patients with DM were an age at diagnosis >52 years (hazard ratio [HR], 7.24; 95% confidence interval [CI], 2.35-22.31), a rapid onset of skin and/or muscular symptoms (HR, 3.11; 95% CI, 1.07-9.02), the presence of skin necrosis (HR, 3.84; 95% CI, 1.00-14.85) or periungual erythema (HR, 3.93; 95% CI, 1.16-13.24), and a low baseline level of complement factor C4 (HR, 2.74; 95% CI, 1.11-6.75). Lastly, low baseline lymphocyte count (<1500/mm(3)) was a protective factor of malignancy (HR, 0.33; 95% CI, 0.14-0.80). Taken together, these data may help physicians focus on a group of patients who might benefit from extensive evaluation for malignancy.

Lymphoma arising from a calcinotic lesion in a patient with juvenile dermatomyositis

Approximately one-third of adult patients with dermatomyositis develop malignancy, usually within 1 year of diagnosis of dermatomyositis. This phenomenon is not seen in patients with juvenile dermatomyositis. We are reporting a case of B-cell lymphoma arising from a calcinotic lesion in a 14-year-old girl who had been diagnosed with juvenile dermatomyositis 3 years prior. Our review of the literature revealed only one other case of malignancy arising from an area of calcinosis.

Malignancy in the setting of the anti-synthetase syndrome

Malignancy and interstitial lung disease (ILD) are 2 conditions associated with dermatomyositis (DM) that are responsible for a significant portion of the morbidity and mortality related to this disease; however, they rarely occur in the same patient. The antisynthetase syndrome consists of several characteristics, including ILD, arthritis, Raynaud phenomenon, "mechanic's hands," and positive antibodies to tRNA synthetases, which have each been negatively associated with cancer. When patients with DM present with such characteristics, clinicians may be falsely reassured that a thorough malignancy screen is unnecessary. We describe a patient who presented with the antisynthetase syndrome and was subsequently found to have colon cancer. Removal of the cancer led to resolution of the myositis and lung disease, but the patient's rash and arthritis persisted and ultimately required immunosuppressive therapy. We provide a review of the literature describing the concurrence of both this syndrome and ILD alone, with malignancy. We conclude that a thorough and expedited age-appropriate malignancy work up is indicated in all patients with a new diagnosis of DM, despite the presence of disease characteristics that are usually not associated with cancer.

Systemic lupus erythematosus and dermatomyositis with symptomatic bilateral sacroiliitis: an unusual and interesting association

Systemic lupus erythematosus (SLE) is a multisystem autoimmune connective-tissue disease with a complex phenotype and varying disease course. Although SLE often causes a polyarticular synovitis, there are only a few case reports of abnormalities of the synovial lined sacroiliac joints. We report a case with an overlap syndrome of SLE and dermatomyositis who subsequently developed bilateral symptomatic sacroiliitis. We conclude that sacroiliitis, although rare, can occur in patients with active SLE as a manifestation of the disease per se.

Dermatomiosite

Dermatomiosite é doença idiopática inflamatória crônica que afeta a musculatura estriada, a pele e outros órgãos. Apresenta critérios diagnósticos definidos por Bohan & Peter, podendo os pacientes ser classificados em cinco grupos: dermatomiosite juvenil, dermatomiosite primária idiopática, dermatomiosites amiopáticas, dermatomiosite associada a neoplasias e dermatomiosite associada a outras doenças do tecido conectivo. O sexo feminino é mais afetado, e a idade média do diagnóstico é 40 anos. Manifestações cutâneas são observadas em todos os pacientes. Das alterações sistêmicas, a manifestação muscular mais freqüente é a perda de força proximal, e a manifestação pulmonar mais comum é a pneumopatia intersticial. Podem ser observadas neoplasias durante o seguimento da doença, sendo mais freqüentes nos pacientes acima de 60 anos. A desidrogenase lática é a enzima muscular alterada na maioria dos casos. Para diagnóstico da dermatomiosite, pode ser realizado exame anatomopatológico de biópsia cutânea e biópsia muscular, além de eletroneuromiografia. Os corticóides são a terapia mais utilizada. As causas de óbito mais freqüentes são a neoplasia maligna, a septicemia e a infecção pulmonar.

Musculoskeletal syndromes associated with malignancy (excluding hypertrophic osteoarthropathy)

PURPOSE OF REVIEW

To examine recent data about the association between rheumatic disorders and cancer. This article focuses on paraneoplastic rheumatic disorders, which usually precede by a short period of time the diagnosis of malignancy, and on malignant transformation, which occurs late in the course of rheumatic disorders. Evidence of causality between malignancies and rheumatic disorders was reviewed based on statistical indicators (standardized incidence ratios and odds ratios) and by applying Bradford Hill's criteria of causality.

RECENT FINDINGS

Firm epidemiological evidence was found attesting that dermatomyositis and polymyostis may present as paraneoplastic syndromes. Several other musculoskeletal disorders may be present akin to paraneoplastic syndrome, based on clinicians' impressions, but with scarce epidemiological evidence supporting a causal determinism. In contrast, robust evidence has accumulated on the role of longstanding rheumatoid arthritis, Sjögren's syndrome and systemic sclerosis as premalignant conditions. Evidence that systemic lupus erythematosus may evolve into lymphoma is equivocal.

SUMMARY

The link between malignancies and rheumatic disorders may impact on clinical practice. First, paraneoplastic rheumatic syndromes can provide the clinician with hints for earlier diagnosis of occult cancer. Second, the risk of malignant transformation during the course of rheumatic disorders may motivate the search for strategies aimed at prevention.

Paraneoplastic myopathy: response to intravenous immunoglobulin

Necrotizing myopathy is an unusual and severe form of paraneoplastic myopathy in which inflammation is minimal or absent. We report two cases of necrotizing myopathy which demonstrated significant response to intravenous immunoglobulin (IVIG) (one in spite of tumor progression). A third case represents the first association of anti-signal recognition particle (anti-SRP) syndrome with large-cell lung cancer. These cases highlight the role of histopathologic diagnosis in directing the treatment of paraneoplastic myopathy, and the role for IVIG in treatment of the syndrome.

Adult clinically amyopathic dermatomyositis with rapid progressive interstitial lung disease: a retrospective cohort study

The aim of the study was to investigate the characteristics of adult clinically amyopathic dermatomyositis (CADM) with rapid progressive interstitial lung disease (ILD). Hospitalized patients with dermatomyositis (DM) and polymyositis (PM) between 1998 and 2005 in the Shanghai Renji Hospital were retrospectively studied. One hundred and forty-five patients were classified into CADM, classic DM or PM according to the modified Sontheimer's definition or Bohan-Peter's classification criteria. They were further stratified based on the presence or absence of clinical ILD. The Kaplan-Meier survival analysis and COX regression were performed. The predictive factors for ILD and other clinical properties of CADM-ILD were explored. The presence of clinical ILD was a significant risk factor for the poor outcome of DM/PM (OR = 4.237, CI 95%: 1.239-14.49, p = 0.021). Other risk factors are the presence of rashes and elevated urea nitrogen. Patients with DM/PM complicated by ILD had different clinical courses. Patients with CADM-ILD showed a rapidly progressive pattern with 6-month survival rate of 40.8%. The DM-ILD manifested a progressive pattern with a 5-year survival rate of 54%, while PM-ILD was chronic with 5- and 10-year survival rate of 72.4% and 60.3%, respectively. Better preserved muscle strength, elevated erythrocyte sedimentation rate, and hypoalbuminemia may herald ILD in DM/PM. Patients with CADM-ILD who later died had lower PO(2), higher lactate dehydrogenase, and prominent arthritis/arthralgia compared with those who survived. The presence of antinuclear antibody seems to be protective. Rapid progressive CADM-ILD is refractory to conventional treatment. ILD is a common complication in over 40% of our hospitalized DM/PM cohort and is also a prominent prognostic indicator. CADM is a special phenotype of DM/PM. CADM-ILD, which is usually rapidly progressive and fatal, requires further investigation.