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Iimori M, Sonomura K, Ueyama Y, Oobayashi Y, Adachi H, Nakayama M. Minimal Change Nephrotic Syndrome Secondary to Methotrexate-associated Hodgkin Lymphoma. Intern Med 2024; 63:1771-1776. [PMID: 37926543 PMCID: PMC11239266 DOI: 10.2169/internalmedicine.2572-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/20/2023] [Indexed: 11/07/2023] Open
Abstract
The patient was a 64-year-old man who had been receiving methotrexate (MTX) for rheumatoid arthritis for 8 years. Computed tomography (CT) obtained one month prior to admission revealed numerous enlarged lymph nodes. Lower leg edema appeared two weeks prior to admission. Severe proteinuria was confirmed, and the patient was admitted. A renal biopsy revealed minimal changes in glomeruli. CT on day 14 revealed shrinking lymph nodes, and the patient was diagnosed with Hodgkin lymphoma by a neck lymph node biopsy. This is the first report of secondary minimal change nephrotic syndrome caused by an MTX-associated lymphoproliferative disorder.
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Affiliation(s)
- Misa Iimori
- Department of Nephrology, Japanese Red Cross Kyoto Daiichi Hospital, Japan
| | | | - Yuichi Ueyama
- Department of Nephrology, Japanese Red Cross Kyoto Daiichi Hospital, Japan
| | - Yuki Oobayashi
- Department of Nephrology, Japanese Red Cross Kyoto Daiichi Hospital, Japan
| | - Hiroya Adachi
- Department of Nephrology, Matsushita Memorial Hospital, Japan
| | - Mayuka Nakayama
- Department of Nephrology, Japanese Red Cross Kyoto Daiichi Hospital, Japan
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Hayashi I, Toida M. A Rare Case of Other Iatrogenic Immunodeficiency-Associated Lymphoproliferative Disorders With Multiple Oral Mucosal Lesions During Methotrexate Therapy. Cureus 2024; 16:e58995. [PMID: 38800284 PMCID: PMC11127638 DOI: 10.7759/cureus.58995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 05/29/2024] Open
Abstract
As of the most recent WHO classification of immunodeficiency diseases, lymphoproliferative disorders that occur during treatment with immunosuppressive drugs are classified as "other iatrogenic immunodeficiency-associated lymphoproliferative disorders (OIIA-LPDs)" other than post-transplant lymphoproliferative disorders. Most patients with OIIA-LPD have rheumatoid arthritis as the underlying disease. Research indicates that approximately half of people diagnosed with OIIA-LPD see a remission of their lesion after stopping treatment with methotrexate (MTX), a drug used in rheumatoid arthritis treatment. Hereby, we present the case of an 81-year-old woman with rheumatoid arthritis who developed OIIA-LPD at the bilateral lingual margins. The patient had been receiving MTX for the preceding 10 years. After determining that OIIA-LPD was MTX-related, the patient underwent MTX withdrawal and was treated conservatively. The lesion resolved one month after MTX withdrawal. This case report confirms immunosuppressive drug withdrawal as a potentially effective treatment for multiple OIIA-LPDs of the oral mucosa.
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Affiliation(s)
- Itsuki Hayashi
- Department of Oral and Maxillofacial Surgery, Sugita Genpaku Memorial Obama Public Hospital, Obama, JPN
| | - Makoto Toida
- Department of Oral and Maxillofacial Surgery, Sugita Genpaku Memorial Obama Public Hospital, Obama, JPN
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Hatayama Y, Sugiyama H, Murakami D, Oura H, Shima Y, Shirato M, Nishino T, Nakazawa T, Suehiro K, Arai M. Primary Hepatic Other Iatrogenic Immunodeficiency-Associated Lymphoproliferative Disorders After Methotrexate Therapy. J Med Cases 2023; 14:282-288. [PMID: 37692367 PMCID: PMC10482596 DOI: 10.14740/jmc4135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/07/2023] [Indexed: 09/12/2023] Open
Abstract
Prior reports described cases of lymphoproliferative diseases occurring after methotrexate (MTX) administration, which are called methotrexate-associated lymphoproliferative disorders (MTX-LPDs). It has become clear that these lymphoproliferative diseases also occur following treatment with other immunosuppressive drugs, and they have been termed as other iatrogenic immunodeficiency-associated lymphoproliferative disorders (OIIA-LPDs). In most of these cases, the duration of immunosuppressive drugs is very long, on the order of years. In the present study, we evaluated the development of lymphoproliferative disease despite the short duration of immunosuppressive treatment and determined the tumor doubling time. A 71-year-old woman was diagnosed with adult-onset Still's disease. The patient was administered prednisone 30 mg per day starting on February 25, 2022 and MTX 6 mg per week starting 2 weeks later. Because she was a hepatitis B virus (HBV) carrier, nucleic acid analog therapy was also started to prevent HBV activation. Eight weeks later, biweekly tocilizumab was started. After 5 months of MTX administration, a solitary liver tumor measuring 37 × 32 mm2 was detected. Three months later, repeat computed tomography revealed that the liver tumor had grown rapidly to 7 cm in diameter. We considered the possibility of OIIA-LPDs and stopped MTX therapy. Biopsy specimens of the liver tumor exhibited lymphocyte proliferation, which was consistent with OIIA-LPDs. The doubling time for tumor growth was 33 days. Despite withdrawing MTX for 6 weeks, the tumor continued to grow, and thus, the patient was referred to the hematology unit. In previously reported cases of MTX-LPDs of hepatic origin, the average duration of MTX administration was 7.3 (2 - 13) years. This report describes a primary hepatic OIIA-LPDs-associated tumor that rapidly increased in size after an extremely short period of MTX administration.
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Affiliation(s)
- Yasuki Hatayama
- Department of Gastroenterology, Tokyo Women’s Medical University Yachiyo Medical Center, Chiba 276-8523, Japan
| | - Harutoshi Sugiyama
- Department of Gastroenterology, Tokyo Women’s Medical University Yachiyo Medical Center, Chiba 276-8523, Japan
| | - Daisuke Murakami
- Department of Gastroenterology, Tokyo Women’s Medical University Yachiyo Medical Center, Chiba 276-8523, Japan
| | - Hirotaka Oura
- Department of Gastroenterology, Tokyo Women’s Medical University Yachiyo Medical Center, Chiba 276-8523, Japan
| | - Yukiko Shima
- Department of Gastroenterology, Tokyo Women’s Medical University Yachiyo Medical Center, Chiba 276-8523, Japan
| | - Miho Shirato
- Department of Gastroenterology, Tokyo Women’s Medical University Yachiyo Medical Center, Chiba 276-8523, Japan
| | - Takayoshi Nishino
- Department of Gastroenterology, Tokyo Women’s Medical University Yachiyo Medical Center, Chiba 276-8523, Japan
| | - Tadao Nakazawa
- Department of Pathology, Tokyo Women’s Medical University Yachiyo Medical Center, Chiba 276-8523, Japan
| | - Kenichi Suehiro
- Center for Rheumatic Diseases, Chibaken Saiseikai Narashino Hospital, Chiba 275-8580, Japan
| | - Makoto Arai
- Department of Gastroenterology, Tokyo Women’s Medical University Yachiyo Medical Center, Chiba 276-8523, Japan
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Omameuda T, Miyato H, Sata N, Lefor AK. Primary hepatic methotrexate-associated lymphoproliferative disorder associated with Epstein-Barr virus reactivation and accompanied by spontaneous necrosis: A case report. Medicine (Baltimore) 2022; 101:e31993. [PMID: 36451467 PMCID: PMC9705001 DOI: 10.1097/md.0000000000031993] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
RATIONALE Methotrexate-associated lymphoproliferative disorder (MTX-LPD) is a major complication of methotrexate (MTX) therapy that can develop in patients with rheumatoid arthritis (RA), although primary hepatic MTX-LPD is extremely rare. Discontinuation of MTX results in remission in half of the patients with MTX-LPDs and is one treatment approach. PATIENT CONCERN A 64-year-old Japanese woman suffering from rheumatoid arthritis treated with MTX presented with upper abdominal pain. DIAGNOSIS Pathological evaluation showed that the tumor contained geographic necrosis and proliferation of large atypical lymphocytes strongly positive for cluster of differentiation 20 (CD20) antigen with immunohistochemical staining and Epstein-Barr Virus-encoded RNA transcript by in situ hybridization. The tumor was finally diagnosed as a primary hepatic MTX-associated Epstein-Barr Virus positive B-cell LPD. INTERVENTIONS Left hepatic lobectomy was performed for diagnosis and therapy. OUTCOMES No sighs of recurrence were observed for 2 years. LESSONS This patient demonstrated that MTX-LPD could arise in the liver, although it is rare. If liver tumors arise in patients taking MTX, examination of sIL-2R, Epstein-Barr virus-VCA IgG and EBNA might support the diagnosis of MTX-LPD. In this case, the primary hepatic MTX-LPD became necrotic without discontinuation of MTX. It is generally believed that withdrawal of MTX restores antitumor immunity resulting in tumor necrosis. This case indicates that spontaneous regression might occur without any treatment in some patients treated for RA with MTX-LPD. The relationship between MTX-LPD and spontaneous necrosis is unclear and further data is required to characterize the types of patients that will develop spontaneous regression without intervention.
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Affiliation(s)
- Takahiko Omameuda
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
- * Correspondence: Takahiko Omameuda, Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi-ken 329-0498, Japan (e-mail: )
| | - Hideyo Miyato
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Naohiro Sata
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Alan Kawarai Lefor
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
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Watanabe T, Teratani Y. Unusual manifestation of methotrexate-associated lymphoproliferative disorder as a palatal mass. BMJ Case Rep 2022; 15:e250616. [PMID: 36175042 PMCID: PMC9528599 DOI: 10.1136/bcr-2022-250616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Methotrexate-associated lymphoproliferative disorder (MTX-LPD) can occur in the oral cavity, and only a few cases with palatal involvement have been reported. Chemotherapy may be needed if there is no remission after the withdrawal of MTX. We report a case of MTX-LPD presenting with a swelling of the palate that required chemotherapy. A woman in her 70s with rheumatoid arthritis reported a swelling on the left side of the palate. Her condition was diagnosed as Epstein-Barr virus-negative diffuse large B-cell lymphoma (MTX-LPD). Since the mass did not remit after MTX withdrawal, she underwent five courses of chemotherapy. Currently, the patient is in complete remission. In patients on MTX who develop a swelling on the palate, MTX-LPD should be included among the differential diagnostic possibilities. Diagnosis and treatment of MTX-LPD call for consultation with a haematologist. If the mass fails to regress following withdrawal of MTX, appropriate chemotherapy is indicated.
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Affiliation(s)
- Takuma Watanabe
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yukina Teratani
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Doi K, Muramaki M, Yamamoto T, Katsura D, Fukunaga H, Takahashi K, Matsumoto M, Yamada Y. Epstein‐Barr virus‐related diffuse large B‐cell lymphoma type methotrexate‐associated lymphoproliferative disorders presenting in the adrenal gland. IJU Case Rep 2022; 5:172-174. [PMID: 35509787 PMCID: PMC9057745 DOI: 10.1002/iju5.12429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/02/2022] [Accepted: 02/19/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction Case presentation Conclusion
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Affiliation(s)
- Kazuki Doi
- Department of UrologyHyogo Prefectural Amagasaki General Medical Center Amagasaki‐shi Hyogo Japan
| | - Mototsugu Muramaki
- Department of UrologyHyogo Prefectural Amagasaki General Medical Center Amagasaki‐shi Hyogo Japan
| | - Tetsuro Yamamoto
- Department ofPathology Hyogo Prefectural Amagasaki General Medical Center Amagasaki‐shi Hyogo Japan
| | - Daiki Katsura
- Department of UrologyHyogo Prefectural Amagasaki General Medical Center Amagasaki‐shi Hyogo Japan
| | - Hiroyuki Fukunaga
- Department of UrologyHyogo Prefectural Amagasaki General Medical Center Amagasaki‐shi Hyogo Japan
| | - Kosuke Takahashi
- Department of UrologyHyogo Prefectural Amagasaki General Medical Center Amagasaki‐shi Hyogo Japan
| | - Minori Matsumoto
- Department of UrologyHyogo Prefectural Amagasaki General Medical Center Amagasaki‐shi Hyogo Japan
| | - Yuji Yamada
- Department of UrologyHyogo Prefectural Amagasaki General Medical Center Amagasaki‐shi Hyogo Japan
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Ogawa A, Nakagawa T, Kumaki Y, Hosoya T, Oda G, Mori M, Fujioka T, Kubota K, Onishi I, Uetake H. Spontaneous regression of breast lymphoproliferative disorders after withdrawal of methotrexate in rheumatoid arthritis patients with Epstein–Barr virus infection: a case report and review of the literature. J Med Case Rep 2022; 16:49. [PMID: 35125110 PMCID: PMC8819973 DOI: 10.1186/s13256-022-03274-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 01/13/2022] [Indexed: 11/10/2022] Open
Abstract
Background Lymphoproliferative disorder (LPD) has been shown to occur after treatment with methotrexate (MTX). Currently, MTX-LPD has become widely recognized, but its mechanism and prognostic factors remain unclear. Case presentation We report the first case of Epstein–Barr virus (EBV)-associated MTX-LPD of the breast. A 63-year-old Asian woman with long-term rheumatoid arthritis presented to our facility with intermittent fever. A physical examination revealed a 3-cm lump in her left breast. She had been taking MTX for the past 15 years. Laboratory studies revealed slightly elevated levels of EBV-viral capsid antigen antibody immunoglobulin G and EBV nuclear antibody. Contrast-enhanced computer tomography revealed a mass in the left breast, a subcutaneous nodule in the abdomen, a mass in the left lung, and a nodule in the left retroperitoneum. The definitive diagnosis was consistent with MTX-LPD merging into an EBV-positive, diffuse large B-cell lymphoma. Six months following the withdrawal of MTX, the breast mass had markedly shrunk and the patient remained in good health for 1 year with no evidence of relapse of LPD. Conclusion MTX-LPD rarely occurs in the breast, and it is difficult to diagnose because there have only been six reported cases of breast MTX-LPD reported in the literature. EBV-positive MTX-LPD tends to regress spontaneously after MTX withdrawal, and our case also had similar results. It is important to make an appropriate diagnosis of MTX-LPD of the breast based on imaging and pathology to determine the appropriate treatment protocol for this rare disorder.
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Takada H, Kaneko Y, Nakano K, Tanaka M, Fujii T, Saito K, Sugimoto N, Sasaki S, Saito S, Saito R, Kuramoto N, Harigai M, Suzuki Y. Clinicopathological characteristics of lymphoproliferative disorders in 232 patients with rheumatoid arthritis in Japan: A retrospective, multicenter, descriptive study. Mod Rheumatol 2022; 32:32-40. [PMID: 33705243 DOI: 10.1080/14397595.2021.1899570] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 02/27/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To describe the clinicopathological characteristics of lymphoproliferative disorders (LPDs) in patients with rheumatoid arthritis (RA). METHODS In this multicenter case series, we retrospectively reviewed the medical records of RA patients who were newly diagnosed as having LPDs with or without biopsy confirmation between 2000 and 2017 in eight hospitals in Japan. RESULTS We included 232 patients with LPDs. The median age was 67 years (interquartile range [IQR], 60-73 years), and 77.1% were female. At the time of LPD diagnosis, 94.8% and 62.6% of the patients were methotrexate users and in remission or had low RA disease activity, respectively; lymphadenopathy and extranodal involvement were present in 77.1% and 51.9%, respectively. Major extranodal sites were the lungs and oral/oropharyngeal mucosa. The most common LPD pathological subtype was diffuse large B-cell lymphoma (40.5%), followed by classic Hodgkin lymphoma (10.8%), Epstein-Barr virus-positive mucocutaneous ulcer (7.7%), and reactive lymphoid hyperplasia (6.2%). The clinical and laboratory characteristics varied across the pathological subtypes. CONCLUSION LPD occurred mainly in methotrexate users, while RA disease activity did not seem to be associated with LPD development. Although the clinical manifestations vary among pathological subtypes, manifestations of LPD in patients with RA can include lymphadenopathy, extranodal mass, and mucocutaneous ulcer.
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Affiliation(s)
- Hideto Takada
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kazuhisa Nakano
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Masao Tanaka
- Department of Advanced Medicine for Rheumatic Diseases, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takao Fujii
- Department of Rheumatology and Clinical Immunology, Wakayama Medical University, Wakayama, Japan
| | | | - Naoki Sugimoto
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Shoh Sasaki
- Division of Rheumatology, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Shuntaro Saito
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Rintaro Saito
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Nobuo Kuramoto
- Department of Rheumatology and Clinical Immunology, Wakayama Medical University, Wakayama, Japan
| | - Masayoshi Harigai
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Yasuo Suzuki
- Division of Rheumatology, Tokai University Hachioji Hospital, Tokyo, Japan
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Osaki Y, Kawaratani H, Kachi H, Matsuura K, Tsuji Y, Ozutsumi T, Takagi H, Furukawa M, Sawada Y, Mitoro A, Yamao J, Yoshiji H. Small intestinal follicular lymphoma induced by methotrexate: a case report. BMC Gastroenterol 2021; 21:280. [PMID: 34238226 PMCID: PMC8268449 DOI: 10.1186/s12876-021-01849-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 06/21/2021] [Indexed: 02/07/2023] Open
Abstract
Background Methotrexate-associated lymphoproliferative disorder (MTX-LPD) is a rare but critical complication that develops in patients treated with MTX. Although MTX-LPD has been recently reported, the incidence of follicular lymphoma in the intestine is very low. Case presentation A 73-year-old woman who had been receiving MTX for over 10 years visited our hospital complaining of postprandial abdominal pain and nausea. Upper and lower digestive tract endoscopies did not show any abnormal findings. A patency capsule was stagnated at the proximal part of the ileum with a mild dilation on the oral side. An oral balloon endoscopy revealed shallow ulcerative lesions in the jejunum. She was diagnosed with MTX-LPD based on histopathological findings. The symptoms did not improve with the discontinuation of MTX, and the patient required partial resection of the small intestine. The test result for Epstein-Barr virus-encoded small RNA was negative. She was diagnosed with follicular lymphoma based on the histology findings of a surgical specimen. Postoperative positron emission tomography-computed tomography and bone marrow aspiration did not show any findings of lymphoma. On follow-up, no recurrence was noted four years after the surgery. Conclusions Herein, we report the first case of follicular lymphoma that occurred in the small intestine, negative for Epstein-Barr virus-encoded small RNA. If intestinal symptoms occur during MTX administration, it is important to directly observe by endoscopy and perform histological examination.
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Affiliation(s)
- Yui Osaki
- The Department of Gastroenterology and Metabolism, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Hideto Kawaratani
- The Department of Gastroenterology and Metabolism, Nara Medical University, Kashihara, Nara, 634-8522, Japan.
| | - Hiroki Kachi
- The Department of Gastroenterology and Metabolism, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Kyohei Matsuura
- The Department of Gastroenterology and Metabolism, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Yuki Tsuji
- The Department of Gastroenterology and Metabolism, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Takahiro Ozutsumi
- The Department of Gastroenterology and Metabolism, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Hirotetsu Takagi
- The Department of Gastroenterology and Metabolism, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Masanori Furukawa
- The Department of Gastroenterology and Metabolism, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Yasuhiko Sawada
- The Department of Gastroenterology and Metabolism, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Akira Mitoro
- The Department of Gastroenterology and Metabolism, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Junichi Yamao
- The Department of Gastroenterology and Metabolism, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Hitoshi Yoshiji
- The Department of Gastroenterology and Metabolism, Nara Medical University, Kashihara, Nara, 634-8522, Japan
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Methotrexate-associated lymphoproliferative disorder of the thoracic spine in a patient with rheumatoid arthritis receiving methotrexate: a case report. Skeletal Radiol 2021; 50:2117-2123. [PMID: 33772624 PMCID: PMC8364545 DOI: 10.1007/s00256-021-03764-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 03/18/2021] [Accepted: 03/18/2021] [Indexed: 02/02/2023]
Abstract
Methotrexate-associated lymphoproliferative disorder is recognized as a lymphoma that occurs following methotrexate administration. The lesion of the spine is extremely rare, and only one case of lesion in the lumbar spine has been reported so far. Here, we present a case of methotrexate-associated lymphoproliferative disorder of the thoracic spine in a 54-year-old woman with rheumatoid arthritis. The lesion formed an extra-skeletal tumor mass from lateral to the vertebral body to the paravertebral muscle extending posterior to the epidural space without bone destruction. Magnetic resonance imaging showed low signal intensities on both T1- and T2-weighted images and high signal intensity with short-tau inversion recovery. These radiological findings were similar to those for primary spinal lymphoma. The lesion rapidly paralyzed the patient, forcing her to be treated with posterior spinal decompression. The lesion could not be resected because it adhered to the dura. Following the histopathological diagnosis as methotrexate-associated lymphoproliferative disorder, methotrexate administration was terminated. The remaining mass lesion showed complete regression within 6 months. Methotrexate-associated lymphoproliferative disorder, which could be cured by the discontinuation of methotrexate, should be considered a differential diagnosis in spinal lesion cases showing lymphoma-like appearance with methotrexate treatment to avoid unnecessary treatments.
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11
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Kakiuchi S, Yakushijin K, Takagi I, Rikitake J, Akiyama H, Matsuba H, Hayashi Y, Kajimoto K, Iwata N. Case Report: Composite Angioimmunoblastic T-Cell Lymphoma and Epstein-Barr Virus-Positive B-Cell Lymphoproliferative Disorder as Other Iatrogenic Immunodeficiency-Associated Lymphoproliferative Disorders. Front Med (Lausanne) 2020; 7:625442. [PMID: 33425968 PMCID: PMC7785868 DOI: 10.3389/fmed.2020.625442] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 12/07/2020] [Indexed: 12/02/2022] Open
Abstract
Immunosuppressants are widely used to treat patients with rheumatoid arthritis (RA), and their adverse effects have been known to cause other iatrogenic immunodeficiency-associated lymphoproliferative disorders (OIIA-LPDs). We report a patient with RA who had been treated with methotrexate (MTX) and tacrolimus (TAC) and who developed whole body lymphadenopathy. We simultaneously confirmed angioimmunoblastic T-cell lymphoma (AITL) through a right cervical lymph node biopsy and Epstein-Barr virus-positive B-cell lymphoproliferative disorder (EBV-positive B-LPD) through a bone marrow examination. After cessation of immunosuppressant therapy, both LPDs completely disappeared. Patients with AITL are occasionally reported to develop B-cell lymphoma through reactivation of the EBV, which leads to clonal expansion in the microenvironment. Immunohistochemistry results revealed that both LPD components were positive for EBV-encoded RNA. Moreover, in this patient, the plasma EBV DNA level was found to be high; therefore, EBV infection was a probable etiology. Synchronous coexistence of AITL and B-LPD as an OIIA-LPD has rarely been reported. This case report is the first to discuss the disappearance of both LPDs on withdrawal of immunosuppressants only. AITL occasionally accompany B-LPD; however, this composite lymphoma comprised AITL and B-LPD, and OIIA-LPDs should not be overlooked.
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Affiliation(s)
- Seiji Kakiuchi
- Department of Hematology, Yodogawa Christian Hospital, Osaka, Japan.,Division of Medical Oncology and Hematology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kimikazu Yakushijin
- Division of Medical Oncology and Hematology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ikumi Takagi
- Department of Hematology, Yodogawa Christian Hospital, Osaka, Japan
| | - Junpei Rikitake
- Department of Hematology, Yodogawa Christian Hospital, Osaka, Japan.,Division of Medical Oncology and Hematology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroaki Akiyama
- Department of Hematology, Yodogawa Christian Hospital, Osaka, Japan
| | - Hiroyuki Matsuba
- Department of Hematology, Yodogawa Christian Hospital, Osaka, Japan
| | - Yoshitake Hayashi
- Division of Molecular Medicine & Medical Genetics, Department of Pathology, Kobe Graduate School of Medicine, Kobe, Japan
| | | | - Nobuko Iwata
- Department of Hematology, Yodogawa Christian Hospital, Osaka, Japan
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Minabe M, Suzuki T, Komatsu M, Hashimoto K, Nomura T. Intraoral localized methotrexate-associated lymphoproliferative disorders concurrent with antiresorptive agent-related osteonecrosis of the jaw: A case report and literature review. Clin Case Rep 2020; 8:2926-2935. [PMID: 33363853 PMCID: PMC7752373 DOI: 10.1002/ccr3.3192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 06/18/2020] [Accepted: 07/05/2020] [Indexed: 11/30/2022] Open
Abstract
Intraoral localized methotrexate-associated lymphoproliferative disorders can cause antiresorptive agent-related osteonecrosis of the jaw associated with infection due to its immunological abnormalities and ulcer formation.
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Affiliation(s)
- Masaki Minabe
- Department of Oral Medicine, Oral and Maxillofacial SurgeryTokyo Dental CollegeIchikawaJapan
| | - Taiki Suzuki
- Department of Oral Medicine, Oral and Maxillofacial SurgeryTokyo Dental CollegeIchikawaJapan
- Division of Oral and Maxillofacial SurgerySUBARU Health Insurance Society Ota Memorial HospitalOtaJapan
| | - Masumi Komatsu
- Department of Oral Medicine, Oral and Maxillofacial SurgeryTokyo Dental CollegeIchikawaJapan
| | - Kazuhiko Hashimoto
- Department of Pathology and Laboratory MedicineTokyo Dental CollegeIchikawa General HospitalIchikawaJapan
| | - Takeshi Nomura
- Department of Oral Medicine, Oral and Maxillofacial SurgeryTokyo Dental CollegeIchikawaJapan
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13
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Lymphopenia at diagnosis predicts survival of patients with immunodeficiency-associated lymphoproliferative disorders. Ann Hematol 2020; 99:1565-1573. [DOI: 10.1007/s00277-020-04084-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 05/12/2020] [Indexed: 12/16/2022]
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14
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Tokuhira M, Tamaru JI, Kizaki M. Clinical management for other iatrogenic immunodeficiency-associated lymphoproliferative disorders. J Clin Exp Hematop 2019; 59:72-92. [PMID: 31257348 PMCID: PMC6661962 DOI: 10.3960/jslrt.19007] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Other iatrogenic immunodeficiency-associated lymphoproliferative disorders (OIIA-LPD), a category of immunodeficiency-associated LPD according to the World Health Organization classification, is associated with immunosuppressive drugs (ISDs). Several factors, including autoimmune disease (AID) activity, Epstein-Barr virus (EBV) infection, ISD usage, and aging, influence the development of OIIA-LPD, resulting in complicated clinical courses and outcomes. Most OIIA-LPD develops in patients with rheumatoid arthritis using methotrexate (MTX-LPD). The management of MTX-LPD is based on the clinical course, i.e., with/without regression, with/without relapse/regrowth event (RRE), LPD subtype, and ISDs for AIDs after LPD development. There are three clinical courses after ISD withdrawal: regressive LPD without relapse/regrowth (R-G), regressive LPD with RRE (R/R-G), and persistent LPD (P-G). The majority of EBV+ diffuse large B-cell lymphomas are classified in R-G, whereas classic Hodgkin lymphoma is generally classified in R/R-G. Polymorphic LPD (P-LPD) in MTX-LPD develops with heterogeneous pathological features similar to monomorphic LPD. Chemotherapy for MTX-LPD is selected according to that for de novo LPD, although the strategy for aggressive P-LPD and non-specific LPD is not well established. The absolute lymphocyte count in the peripheral blood has been suggested as a candidate marker for MTX-LPD development and RRE. Several clinical issues, including correct diagnosis among overlapping clinicopathological features in MTX-LPD and clinical management of LPD by ISDs other than MTX, require further investigation.
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15
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Toyama S, Takatani A, Koga T, Eguchi M, Okamoto M, Tsuji S, Endo Y, Shimizu T, Sumiyoshi R, Igawa T, Kawashiri SY, Iwamoto N, Ichinose K, Tamai M, Nakamura H, Origuchi T, Furuyama M, Tabuchi M, Kobayashi S, Kanetaka K, Hashisako M, Abe K, Niino D, Sato S, Miyazaki Y, Kawakami A. Gastric Perforation due to Iatrogenic Immunodeficiency-associated Lymphoproliferative Disorder during the Treatment of Rheumatoid Arthritis. Intern Med 2019; 58:3331-3336. [PMID: 31327821 PMCID: PMC6911763 DOI: 10.2169/internalmedicine.2782-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 71-year-old woman being treated with methotrexate (MTX) and tacrolimus (TAC) for rheumatoid arthritis (RA) was admitted to our hospital and underwent surgery for gastric perforation and peritonitis. An endoscopic examination six days post-surgery showed an extensive ulcer in the stomach, and a biopsy revealed diffused large B-cell lymphoma. We diagnosed her with immunodeficiency-associated lymphoproliferative disorder (LPD) and discontinued the MTX and TAC. She underwent gastrectomy due to stenosis approximately two months after the first operation, but the histopathological findings of lymphoma had disappeared. LPD should be considered as a potential cause of gastric perforation during RA treatment.
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Affiliation(s)
- Shiho Toyama
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Ayuko Takatani
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Tomohiro Koga
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
- Center for Bioinformatics and Molecular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Mizuna Eguchi
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Momoko Okamoto
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Sosuke Tsuji
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Yushiro Endo
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Toshimasa Shimizu
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
- Clinical Research Center, Nagasaki University Hospital, Japan
| | - Remi Sumiyoshi
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Takashi Igawa
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Shin-Ya Kawashiri
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
- Department of Community Medicine, Unit of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Naoki Iwamoto
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Kunihiro Ichinose
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Mami Tamai
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Hideki Nakamura
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Tomoki Origuchi
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | | | - Maiko Tabuchi
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Shinichiro Kobayashi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Kengo Kanetaka
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | | | - Kuniko Abe
- Department of Pathology, Nagasaki University Hospital, Japan
| | - Daisuke Niino
- Department of Pathology, Nagasaki University Hospital, Japan
| | - Shinya Sato
- Department of Hematology, Nagasaki University Hospital, Japan
| | - Yasushi Miyazaki
- Department of Hematology, Atomic Bomb Disease and Hibakusha Medicine Unit, Atomic Bomb Disease Institute, Nagasaki University, Japan
| | - Atsushi Kawakami
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
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16
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Chatterjee S, Angelov L, Ahluwalia MS, Yeaney GA. Epstein-Barr virus-associated primary central nervous system lymphoma in a patient with diffuse cutaneous systemic sclerosis on long-term mycophenolate mofetil. Joint Bone Spine 2019; 87:163-166. [PMID: 31669807 DOI: 10.1016/j.jbspin.2019.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 10/09/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Epstein Barr virus (EBV)-associated primary central nervous system lymphoma (ePCNSL) is increasingly recognized in immunocompromised subjects, including patients receiving systemic immunosuppressive therapy. Here, we report the first case of primary CNS lymphoma associated with EBV in a patient with diffuse cutaneous systemic sclerosis (dcSSc) receiving long-term mycophenolate mofetil (MMF). CASE REPORT A 51-year-old female with dcSSc had been on MMF 2 grams daily, which was initiated for a rapidly rising modified Rodnan skin score (mRSS), severe pruritus, and progressive joint contractures. She had an impressive response to this therapy with a significant decrease in her mRSS. Her condition remained stable for the next five years, after which she developed worsening headaches for 2-3 weeks, associated with dizziness, gait instability, and left homonymous hemianopia. MRI scan of the brain revealed a solitary 2.4cm peripherally enhancing right parietal lobe mass. Excised tissue from the right parietal lobe mass showed EBV-associated diffuse large B cell lymphoma. She received four cycles of chemotherapy (high dose methotrexate and rituximab). Currently, her condition is being monitored. Her left homonymous hemianopia persists. CONCLUSION Because of a favorable toxicity profile, MMF is increasingly being used as long-term immunomodulatory therapy for a wide variety of autoimmune disorders. Nevertheless, patients on long-term MMF should still undergo regular CNS surveillance, not only for opportunistic infections but also for opportunistic malignancies such as PCNSL. Progressive focal or non-focal neurological deficits should always raise the alarm. Prompt evaluation and management can prevent irreversible neurological sequelae.
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Affiliation(s)
- Soumya Chatterjee
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Staff, Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, Ohio 44195, United States.
| | - Lilyana Angelov
- Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Section of Spinal Radiosurgery and Director of BBTC's Primary CNS Lymphoma Program, Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio 44195, United States
| | - Manmeet S Ahluwalia
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Brain Metastasis Research Program, and the Associate Director, Clinical Trials, Operations in the BBTC, Neurological Institute, Cleveland Clinic, Section Head of NeuroOncology Outcomes, Staff, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio 44195, United States
| | - Gabrielle A Yeaney
- Pathology, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Section Head, Ocular Pathology, Division of Neuropathology, Department of Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio 44195, United States
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17
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Ikeue T, Kawachi H, Yoshida H, Tanaka E, Noguchi S, Fukao A, Terashita S, Tajiri T, Horikawa S, Sugita T. Endobronchial Manifestation of Methotrexate-induced Lymphoproliferative Disorder. Intern Med 2019; 58:1597-1603. [PMID: 30713318 PMCID: PMC6599933 DOI: 10.2169/internalmedicine.2109-18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Lymphoproliferative disorders can occur in patients with autoimmune disorders who undergo long-term methotrexate therapy (MTX-LPD). Although the manifestations of MTX-LPD are diverse, little attention is paid to endobronchial involvement. We herein describe two patients with MTX-LPD who presented with parenchymal pulmonary tumors and endobronchial involvement of LPD; one had lymphomatoid gramulomatosis and the other LPD. The patients had no tumors adjacent to the endobronchial lesions. The endobronchial findings included multiple protruded mucosal lesions covered with white material, which was pathologically consistent with LPD. Recognition of the findings may help in making an earlier diagnosis of MTX-LPD in appropriate settings.
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Affiliation(s)
- Tatsuyoshi Ikeue
- Department of Respiratory Medicine, Japanese Red Cross Wakayama Medical Center, Japan
| | - Hiroaki Kawachi
- Department of Respiratory Medicine, Japanese Red Cross Wakayama Medical Center, Japan
| | - Hiroshi Yoshida
- Department of Respiratory Medicine, Japanese Red Cross Wakayama Medical Center, Japan
| | - Eiichiro Tanaka
- Department of Respiratory Medicine, Japanese Red Cross Wakayama Medical Center, Japan
| | - Susumu Noguchi
- Department of Respiratory Medicine, Japanese Red Cross Wakayama Medical Center, Japan
| | - Akari Fukao
- Department of Respiratory Medicine, Japanese Red Cross Wakayama Medical Center, Japan
| | - Satoshi Terashita
- Department of Respiratory Medicine, Japanese Red Cross Wakayama Medical Center, Japan
| | - Tomoko Tajiri
- Department of Respiratory Medicine, Japanese Red Cross Wakayama Medical Center, Japan
| | - Sadao Horikawa
- Department of Respiratory Medicine, Japanese Red Cross Wakayama Medical Center, Japan
| | - Takakazu Sugita
- Department of Respiratory Medicine, Japanese Red Cross Wakayama Medical Center, Japan
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18
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Lee M, Nguyen KA, Kaplan R. Methotrexate-induced iatrogenic immunodeficiency-associated lymphoproliferative disorder causing hypercalcaemia. BMJ Case Rep 2019; 12:12/5/e226633. [PMID: 31154343 DOI: 10.1136/bcr-2018-226633] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Hypercalcaemia is a rare but potentially life-threatening consequence of malignancies. Solid cancers, such as lymphomas, increase serum calcium primarily through parathyroid hormone-related protein or ectopic production of 1alpha-hydroxylase. We present a case of 56-year-old woman with Sjogren's syndrome and psoriasis in the setting of chronic methotrexate (MTX) use who developed worsening hypercalcaemia and symptoms suggestive of lymphoma. Pathology results diagnosed her with MTX-induced iatrogenic immunodeficiency-associated lymphoproliferative disorder (LPD). This case reminds clinicians that chronic MTX use is associated with LPDs and can ultimately lead to hypercalcaemia. The patient's MTX and other immunosuppressive medications were stopped, and her calcium corrected with fluids and calcitonin. At her 8-month follow-up postdischarge, the patient was asymptomatic with normal laboratory results and in partial clinical remission.
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Affiliation(s)
- Monica Lee
- Internal Medicine, Irvine School of Medicine, University of California, Irvine, California, USA
| | - Khoa Anh Nguyen
- Internal Medicine, Irvine School of Medicine, University of California, Irvine, California, USA
| | - Robert Kaplan
- Internal Medicine, Irvine School of Medicine, University of California, Irvine, California, USA
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19
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Tokuhira M, Saito S, Suzuki K, Higashi M, Momose S, Shimizu T, Mori T, Kimura Y, Amano K, Okamoto S, Takeuchi T, Tamaru JI, Kizaki M. Clinicopathological features of clinical methotrexate-related lymphoproliferative disorders. Leuk Lymphoma 2019; 60:2508-2515. [DOI: 10.1080/10428194.2019.1585841] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Michihide Tokuhira
- Department of Hematology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Shuntaro Saito
- Department of Medicine, Division of Rheumatology, Keio University School of Medicine, Tokyo, Japan
| | - Katsuya Suzuki
- Department of Medicine, Division of Rheumatology, Keio University School of Medicine, Tokyo, Japan
| | - Morihiro Higashi
- Department of Pathology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Shuju Momose
- Department of Pathology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Takayuki Shimizu
- Department of Medicine, Division of Hematology, Keio University School of Medicine, Tokyo, Japan
| | - Takehiko Mori
- Department of Medicine, Division of Hematology, Keio University School of Medicine, Tokyo, Japan
| | - Yuta Kimura
- Department of Hematology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Koichi Amano
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Shinichiro Okamoto
- Department of Medicine, Division of Hematology, Keio University School of Medicine, Tokyo, Japan
| | - Tsutomu Takeuchi
- Department of Medicine, Division of Rheumatology, Keio University School of Medicine, Tokyo, Japan
| | - Jun-Ichi Tamaru
- Department of Pathology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Masahiro Kizaki
- Department of Hematology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
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20
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Matsubayashi RN, Iwasaki H, Iwakuma N, Momosaki S. Methotrexate (MTX)-associated malignant lymphoma of the bilateral breast: imaging features in comparison to other nipple-areolar tumors. Clin Imaging 2019; 53:120-125. [DOI: 10.1016/j.clinimag.2018.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 09/06/2018] [Accepted: 10/02/2018] [Indexed: 11/28/2022]
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21
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Other immunomodulatory agent-related lymphoproliferative diseases: a single-center series of 72 biopsy-confirmed cases. Mod Pathol 2018; 31:1457-1469. [PMID: 29765143 DOI: 10.1038/s41379-018-0054-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 03/12/2018] [Accepted: 03/24/2018] [Indexed: 02/08/2023]
Abstract
Ongoing development of new drugs, as well as novel indications in the treatment of autoimmune diseases leads to the increasing use of immunomodulatory and immunosuppressive drugs. Immunomodulatory agent-related lymphoproliferative disorders are a known and potentially life threatening complication of chronic administration of these drugs, but are less well characterized compared with post-transplant lymphoproliferative disorders. The heterogeneous drug targets, various underlying disease indications, different drug combinations used and relatively low incidence render data collection and interpretation difficult. In this retrospective paper, we describe the clinicopathological characteristics of a larger single-center series of 72 immunomodulatory agent-related lymphoproliferative disorder cases. We divided the cases according to the therapy, administered in the year preceding diagnosis of a lymphoproliferative disorder, in an immunosuppressive drug, an immunomodulatory drug and a combination of immunosuppressive and immunomodulatory drugs group. We observed differences in "time to lymphoproliferative disorder development" with a shorter time for all the immunomodulatory drug-related cases combined (immunomodulatory and immunomodulatory + immunosuppressive = immunomodulatory-all) vs immunosuppressive-only (p = 0.0031). The proportion of malignant cases in patients receiving immunomodulatory therapy was, however, also significantly lower when compared with the immunosuppressive treated cases (43 vs 88%; p = 0.0184). The immunomodulatory/suppressive agent-related lymphoproliferative disorders were less often associated with the Epstein-Barr virus (EBV) (31 vs 66%; p = 1.829e-05) and the lymphoproliferative disorders incidence in the first year after immunomodulatory/immunosuppressive therapy initiation was lower (18 vs 41%; p = 0.04151)-compared with a published series of 140 post-transplant lymphoproliferative disorder cases from the same center. However, a similar histopathological spectrum from nondestructive, to polymorphic and monomorphic lesions as in post-transplant lymphoproliferative disorders is observed. With increasing use of immunosuppressive and especially immunomodulatory therapy, a higher incidence of immunomodulatory/suppressive agent-related lymphoproliferative disorders is to be expected. Life-long awareness for development of immunomodulatory/suppressive agent-related lymphoproliferative disorders with clinical follow-up and timely biopsies of suspicious lesions is required since these lymphoproliferative disorders arise both early after therapy initiation and many years later. Histopathological confirmation and correct classification is necessary to guide therapy and EBV ISH should be a part of routine pathological diagnostics.
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22
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Hatano T, Ohishi M, Yoshimoto G, Yamauchi M, Maekawa A, Yamamoto H, Oda Y, Endo M, Bekki H, Matsunobu T, Nakashima Y, Okazaki K, Fukushi JI, Oyamada A, Iwamoto Y. Methotrexate-Related Lymphoproliferative Disorder Presenting with Severe Swelling of the Elbow Joint: A Case Report. JBJS Case Connect 2018; 7:e65. [PMID: 29252894 DOI: 10.2106/jbjs.cc.17.00002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A patient with rheumatoid arthritis (RA) who was being treated with methotrexate (MTX) therapy presented with severe swelling of the left elbow. Magnetic resonance imaging showed a tumor-like lesion around the elbow joint. Fluorodeoxyglucose positron emission tomography indicated multiple lesions in the lung and the lymph nodes. An open biopsy of a cervical lymph node was performed, and MTX-related lymphoproliferative disorder (MTX-LPD) was diagnosed. After cessation of the MTX therapy, the elbow swelling regressed, and the patient was in remission of MTX-LPD. CONCLUSION MTX-LPD should be considered in the differential diagnosis when a patient with RA develops severe joint swelling while on MTX therapy.
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Affiliation(s)
- Takashi Hatano
- Departments of Orthopaedic Surgery (T.H., M.O., M.E., T.M., Y.N., K.O., J.-i.F., A.O., and Y.I.), Hematology and Oncology (G.Y.), and Otorhinolaryngology (M.Y.), Kyushu University Hospital, Fukuoka, Japan
| | - Masanobu Ohishi
- Departments of Orthopaedic Surgery (T.H., M.O., M.E., T.M., Y.N., K.O., J.-i.F., A.O., and Y.I.), Hematology and Oncology (G.Y.), and Otorhinolaryngology (M.Y.), Kyushu University Hospital, Fukuoka, Japan
| | - Goichi Yoshimoto
- Departments of Orthopaedic Surgery (T.H., M.O., M.E., T.M., Y.N., K.O., J.-i.F., A.O., and Y.I.), Hematology and Oncology (G.Y.), and Otorhinolaryngology (M.Y.), Kyushu University Hospital, Fukuoka, Japan
| | - Moriyasu Yamauchi
- Departments of Orthopaedic Surgery (T.H., M.O., M.E., T.M., Y.N., K.O., J.-i.F., A.O., and Y.I.), Hematology and Oncology (G.Y.), and Otorhinolaryngology (M.Y.), Kyushu University Hospital, Fukuoka, Japan
| | - Akira Maekawa
- Departments of Anatomic Pathology and Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hidetaka Yamamoto
- Departments of Anatomic Pathology and Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshinao Oda
- Departments of Anatomic Pathology and Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Makoto Endo
- Departments of Orthopaedic Surgery (T.H., M.O., M.E., T.M., Y.N., K.O., J.-i.F., A.O., and Y.I.), Hematology and Oncology (G.Y.), and Otorhinolaryngology (M.Y.), Kyushu University Hospital, Fukuoka, Japan
| | - Hirofumi Bekki
- Departments of Anatomic Pathology and Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoya Matsunobu
- Departments of Orthopaedic Surgery (T.H., M.O., M.E., T.M., Y.N., K.O., J.-i.F., A.O., and Y.I.), Hematology and Oncology (G.Y.), and Otorhinolaryngology (M.Y.), Kyushu University Hospital, Fukuoka, Japan
| | - Yasuharu Nakashima
- Departments of Orthopaedic Surgery (T.H., M.O., M.E., T.M., Y.N., K.O., J.-i.F., A.O., and Y.I.), Hematology and Oncology (G.Y.), and Otorhinolaryngology (M.Y.), Kyushu University Hospital, Fukuoka, Japan
| | - Ken Okazaki
- Departments of Orthopaedic Surgery (T.H., M.O., M.E., T.M., Y.N., K.O., J.-i.F., A.O., and Y.I.), Hematology and Oncology (G.Y.), and Otorhinolaryngology (M.Y.), Kyushu University Hospital, Fukuoka, Japan
| | - Jun-Ichi Fukushi
- Departments of Orthopaedic Surgery (T.H., M.O., M.E., T.M., Y.N., K.O., J.-i.F., A.O., and Y.I.), Hematology and Oncology (G.Y.), and Otorhinolaryngology (M.Y.), Kyushu University Hospital, Fukuoka, Japan
| | - Akiko Oyamada
- Departments of Orthopaedic Surgery (T.H., M.O., M.E., T.M., Y.N., K.O., J.-i.F., A.O., and Y.I.), Hematology and Oncology (G.Y.), and Otorhinolaryngology (M.Y.), Kyushu University Hospital, Fukuoka, Japan
| | - Yukihide Iwamoto
- Departments of Orthopaedic Surgery (T.H., M.O., M.E., T.M., Y.N., K.O., J.-i.F., A.O., and Y.I.), Hematology and Oncology (G.Y.), and Otorhinolaryngology (M.Y.), Kyushu University Hospital, Fukuoka, Japan
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23
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Hashimoto K, Akagi M. Lymphoproliferative disorder in an elderly rheumatoid arthritis patient after longterm oral methotrexate administration: A case report. Mol Clin Oncol 2018; 9:293-296. [PMID: 30155252 DOI: 10.3892/mco.2018.1675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 07/18/2018] [Indexed: 02/07/2023] Open
Abstract
Methotrexate-associated lymphoproliferative disorder (MTX-LPD) is frequently reported in the literature; however, its pathophysiology has not been fully elucidated to date. We herein describe a case of MTX-LPD that occurred after long-term treatment with oral MTX in a 67-year-old Japanese woman with rheumatoid arthritis (RA) who presented with generalized lymphadenopathy of the neck. The patient had been diagnosed with RA 24 years earlier, and had been on oral MTX for 20 years. The patient noticed a mass on her neck, which prompted a visit to our hospital. The mass was confirmed as diffuse large B-cell lymphoma by biopsy. MTX treatment was discontinued, which resulted in a reduction in the size of the mass and improvement of the patient's symptoms. Therefore, clinicians must be aware of MTX-LPD as a differential diagnosis for patients with rheumatological conditions on long-term MTX therapy presenting with signs and symptoms suggestive of lymphoma.
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Affiliation(s)
- Kazuhiko Hashimoto
- Department of Orthopedic Surgery, Kindai University Hospital, Osaka-Sayama, Osaka 589-8511, Japan
| | - Masao Akagi
- Department of Orthopedic Surgery, Kindai University Hospital, Osaka-Sayama, Osaka 589-8511, Japan
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24
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Takajo I, Umekita K, Ikei Y, Oshima K, Okayama A. Adult T-cell Leukemia/Lymphoma as a Methotrexate-associated Lymphoproliferative Disorder in a Patient with Rheumatoid Arthritis. Intern Med 2018; 57:2071-2075. [PMID: 29491299 PMCID: PMC6096007 DOI: 10.2169/internalmedicine.0308-17] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The patient was a 74-year-old Japanese woman with rheumatoid arthritis (RA) who developed generalized lymphadenopathy with elevated levels of lactase dehydrogenase (LD), and soluble IL-2 receptor (sIL-2R). She was found to be positive for anti-human T-cell leukemia virus type 1 (HTLV-1) antibodies. Her symptoms and laboratory abnormalities spontaneously regressed after the cessation of methotrexate (MTX), suggesting that she had an MTX-associated lymphoproliferative disorder; however, her lymphadenopathy appeared again approximately 14 months later with LD and sIL-2R elevation. A histopathological analysis and Southern blotting of a lymph node biopsy specimen for HTLV-1 provirus supported the diagnosis of adult T-cell leukemia/lymphoma (ATL) (lymphoma type). These data confirmed that an HTLV-1 positive RA patient may develop ATL.
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Affiliation(s)
- Ichiro Takajo
- Department of Rheumatology, Infectious Diseases and Laboratory Medicine, Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
- Youkikai Ikei Hospital, Japan
| | - Kunihiko Umekita
- Department of Rheumatology, Infectious Diseases and Laboratory Medicine, Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | | | | | - Akihiko Okayama
- Department of Rheumatology, Infectious Diseases and Laboratory Medicine, Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
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Suzuki E, Kanno T, Kimura S, Irie T, Odajima H, Migita K. Methotrexate-associated lymphoproliferative disorder complicated by severe acute respiratory failure and ileal perforation:a case report. Fukushima J Med Sci 2018; 64:82-88. [PMID: 29925726 DOI: 10.5387/fms.2017-23] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Lymphoproliferative disorder (LPD) is a potentially severe adverse effect of methotrexate (MTX) administration in patients with rheumatoid arthritis (RA). We report a case of MTX-associated LPD (MTX-LPD) in a patient with RA who developed severe pulmonary failure complicated by perforation of the terminal ileum. A 61-year-old woman with RA receiving MTX complained of dyspnea and abdominal pain. She was diagnosed with intestinal perforation and peritonitis, and underwent immediate abdominal surgery. Pathological examinations of the specimen obtained from the resected ileum and a bone marrow aspirate revealed diffuse large B-cell lymphoma. Steroid therapy failed to improve her respiratory failure, but her condition improved after abdominal surgery and suspension of MTX. MTX-LPD can result in multiple life-threatening conditions; however, the symptoms are highly variable. RA patients receiving MTX should thus be monitored carefully, and MTX administration should be stopped immediately on suspicion of MTX-LPD.
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Affiliation(s)
- Eiji Suzuki
- Department of Rheumatology, Ohta-Nishinouchi Hospital
| | - Takashi Kanno
- Department of Rheumatology, Ohta-Nishinouchi Hospital
| | | | - Takumi Irie
- Department of Surgery, Ohta-Nishinouchi Hospital
| | | | - Kiyoshi Migita
- Department of Rheumatology, Fukushima Medical University School of Medicine
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Oebisu N, Hoshi M, Ieguchi M, Iwai T, Tanaka S, Osawa M, Nakamura H. Lymphoproliferative disorder with pathological fracture of the femur in a patient with rheumatoid arthritis treated with methotrexate: A case report. Mol Clin Oncol 2018; 9:187-191. [PMID: 30101019 DOI: 10.3892/mco.2018.1654] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 06/08/2018] [Indexed: 11/06/2022] Open
Abstract
Methotrexate (MTX) is the key drug for the treatment of rheumatoid arthritis (RA). MTX-treated RA has been associated with the development of lymphoproliferative disorders (LPDs). Notably, the hyperimmune state of RA itself or the immunosuppressive state induced by MTX administration may contribute to development of LPD. Furthermore, Epstein-Barr virus (EBV) has been indicated to contribute to the development of MTX-LPD. MTX-associated LPD (MTX-LPD) may affect nodal or extranodal sites, including the gastrointestinal tract, skin, lungs, kidneys, and soft tissues, at an almost equal frequency. However, it is rare for MTX-LPD to manifest as multiple bone tumors with a pathological fracture. The present study reported the case of a 46-year-old Japanese woman with RA who had complications of EBV-positive MTX-LPD during an approximate 5-year course of MTX therapy. The present study indicated a rare case in which the LPD had spread to multiple bones in a patient with a pathologic fracture. Notably, the LPD was subclassified as diffuse large B-cell lymphoma (DLBCL).
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Affiliation(s)
- Naoto Oebisu
- Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Osaka 545-8585, Japan
| | - Manabu Hoshi
- Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Osaka 545-8585, Japan
| | - Makoto Ieguchi
- Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Osaka 545-8585, Japan
| | - Tadashi Iwai
- Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Osaka 545-8585, Japan
| | - Sayaka Tanaka
- Department of Diagnostic Pathology, Osaka City University Graduate School of Medicine, Osaka, Osaka 545-8585, Japan
| | - Masahiko Osawa
- Department of Diagnostic Pathology, Osaka City University Graduate School of Medicine, Osaka, Osaka 545-8585, Japan
| | - Hiroaki Nakamura
- Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Osaka 545-8585, Japan
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Tokuhira M, Saito S, Okuyama A, Suzuki K, Higashi M, Momose S, Shimizu T, Mori T, Anan-Nemoto T, Amano K, Okamoto S, Takeuchi T, Tamaru JI, Kizaki M. Clinicopathologic investigation of methotrexate-induced lymphoproliferative disorders, with a focus on regression. Leuk Lymphoma 2017; 59:1143-1152. [DOI: 10.1080/10428194.2017.1369073] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Michihide Tokuhira
- Department of Hematology, Saitama Medical Center, Saitama Medical University, Kawagoe Saitama, Japan
| | - Shuntaro Saito
- Department of Hematology, Saitama Medical Center, Saitama Medical University, Kawagoe Saitama, Japan
- Division of Rheumatology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Ayumi Okuyama
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University, Kawagoe Saitama, Japan
| | - Katsuya Suzuki
- Division of Rheumatology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Morihiro Higashi
- Department of Pathology, Saitama Medical Center, Saitama Medical University, Kawagoe Saitama, Japan
| | - Shuji Momose
- Department of Pathology, Saitama Medical Center, Saitama Medical University, Kawagoe Saitama, Japan
| | - Takayuki Shimizu
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takehiko Mori
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tomoe Anan-Nemoto
- Department of Hematology, Saitama Medical Center, Saitama Medical University, Kawagoe Saitama, Japan
| | - Koichi Amano
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University, Kawagoe Saitama, Japan
| | - Shinichiro Okamoto
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Jun-Ichi Tamaru
- Department of Pathology, Saitama Medical Center, Saitama Medical University, Kawagoe Saitama, Japan
| | - Masahiro Kizaki
- Department of Hematology, Saitama Medical Center, Saitama Medical University, Kawagoe Saitama, Japan
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Klein A, Reinhard H, Mueller AM, Horneff G. Spontaneous regression of Epstein-Barr virus-associated lymphoproliferative disorder in a juvenile idiopathic arthritis patient after the discontinuation of methotrexate and etanercept. Eur J Rheumatol 2017. [PMID: 28638688 DOI: 10.5152/eurjrheum.2016.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A case of a 16-year-old female with polyarticular juvenile idiopathic arthritis (JIA) since the age of 4 years is reported here. This patient also suffered from multiple congenital anomalies. On long-term treatment with oral methotrexate (MTX) and etanercept, multiple subcutaneous nodules were detected, which were accompanied by increased lactate dehydrogenase and uric acid levels. A biopsy of the largest nodule revealed Epstein-Barr (EB) virus-positive diffuse large B-cell lymphoma (DLBCL). The patient was classified as clinical stage IIIA due to a mediastinal lesion. Immunosuppressive treatment was discontinued immediately, which led to regression of the remaining nodules and normalization of the lactate dehydrogenase levels. The patient was considered to have an iatrogenic lymphoproliferative disorder classified as "other iatrogenic immunodeficiency-associated lymphoproliferative disorders" by the World health organization (WHO). To our knowledge, this is the first case report of a JIA patient with EBV-positive DLBCL following the administration of etanercept and methotrexate and spontaneous regression of lymphoproliferation after the discontinuation of antirheumatic treatment.
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Affiliation(s)
- Ariane Klein
- Department of General Pediatrics, Asklepios Clinic Sankt Augustin, Sankt Augustin, Germany
| | - Harald Reinhard
- Department of General Pediatrics, Asklepios Clinic Sankt Augustin, Sankt Augustin, Germany
| | - Annette M Mueller
- Center of Pediatric Pathology, MVZ Venusberg, University Clinic Bonn, Bonn, Germany
| | - Gerd Horneff
- Department of General Pediatrics, Asklepios Clinic Sankt Augustin, Sankt Augustin, Germany
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Gion Y, Iwaki N, Takata K, Takeuchi M, Nishida K, Orita Y, Tachibana T, Yoshino T, Sato Y. Clinicopathological analysis of methotrexate-associated lymphoproliferative disorders: Comparison of diffuse large B-cell lymphoma and classical Hodgkin lymphoma types. Cancer Sci 2017; 108:1271-1280. [PMID: 28380678 PMCID: PMC5480080 DOI: 10.1111/cas.13249] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 03/10/2017] [Accepted: 03/29/2017] [Indexed: 12/03/2022] Open
Abstract
Patients with rheumatoid arthritis often develop methotrexate‐associated lymphoproliferative disorders (MTX‐LPD) during MTX treatment. MTX‐LPD occasionally regresses spontaneously after simply discontinuing MTX treatment. In patients without spontaneous regression, additional chemotherapy is required to avoid disease progression. However, the differences between spontaneous and non‐spontaneous regression have yet to be elucidated. To clarify the factors important for spontaneous regression, we analyzed the clinicopathological features of 51 patients with rheumatoid arthritis who developed MTX‐LPD (diffuse large B‐cell lymphoma [DLBCL]‐type [n = 34] and classical Hodgkin lymphoma [CHL]‐type [n = 17]). We examined the interval from MTX discontinuation to the administration of additional chemotherapy. The majority of DLBCL‐type MTX‐LPD patients (81%) exhibited remission with MTX discontinuation alone. In contrast, the majority of CHL‐type MTX‐LPD patients (76%) required additional chemotherapy. This difference was statistically significant (P = 0.001). However, overall survival was not significantly different between DLBCL‐type and CHL‐type (91% vs 94%, respectively; P > 0.05). Thus, the morphological differences in the pathological findings of MTX‐LPD may be a factor for spontaneous or non‐spontaneous regression after discontinuation of MTX.
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Affiliation(s)
- Yuka Gion
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Noriko Iwaki
- Department of Cellular Transplantation Biology (Hematology/Oncology and Respiratory Medicine), Division of Cancer Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Katsuyoshi Takata
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Mai Takeuchi
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Keiichiro Nishida
- Department of Human Morphology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yorihisa Orita
- Department of Otolaryngology Head and Neck Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | | | - Tadashi Yoshino
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yasuharu Sato
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.,Division of Pathophysiology, Okayama University Graduate School of Health Sciences, Okayama, Japan
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Tokuhira M, Tabayashi T, Tanaka Y, Takahashi Y, Kimura Y, Tomikawa T, Anan-Nemoto T, Momose S, Higashi M, Okuyama A, Watanabe R, Amano K, Tamaru JI, Kizaki M. The aggressive clinical courses of Hodgkin lymphoma primarily diagnosed as methotrexate-induced non-specific lymphoproliferative disorder in patients with rheumatoid arthritis. J Clin Exp Hematop 2017; 56:165-169. [PMID: 28331131 DOI: 10.3960/jslrt.56.165] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Recently, attention has been focused on methotrexate-induced lymphoproliferative disease (MTX-LPD), and atypical phenotypes are occasionally documented. We encountered two patients with rheumatoid arthritis (RA) who were diagnosed with non-specific LPD (LPD-nos). Biopsy samples were not obtained during the initial examination when the LPD development was discovered, and the patients achieved a complete response after MTX cessation (case 1) or steroid pulse therapy (case 2). However, the tumors flared up 1.5 years later, and LPD-nos was determined following biopsies of the lymph node (LN, case 1) and liver (case 2). Prednisolone was subsequently administered instead of chemotherapy; however, multiple masses, including in the spine (case 1), and severe icterus with liver dysfunction (case 2) were exacerbated within a few months. Although the re-biopsy of LN proved the presence of HL and radiation followed by aggressive chemotherapy rescued the patient (case 1), the superficially accessible biopsy site was not found, and autopsy finally revealed HL (case 2). In both cases, the underlying pathogenesis along with the B symptoms and laboratory abnormalities suggested MTX-LPD, HL in particular. Therefore, even if the pathological diagnosis does not confirm the specific LPD subtype, the administration of aggressive chemotherapy should be considered if the LPD activity flares severely.
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Affiliation(s)
- Michihide Tokuhira
- Department of Hematology, Saitama Medical Center, Saitama Medical University
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Composite Cutaneous Lymphoma (Iatrogenic Immunodeficiency-Associated Lymphoproliferative Disorder) in a Patient with Rheumatoid Arthritis Treated with Methotrexate: Staging and Evaluation of Response to Therapy with 18F-FDG PET/CT. Nucl Med Mol Imaging 2016; 51:261-265. [PMID: 28878854 DOI: 10.1007/s13139-016-0463-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 12/03/2016] [Accepted: 12/07/2016] [Indexed: 10/20/2022] Open
Abstract
A 67 year old woman with a 10 year history of rheumatoid arthritis (RA) treated with methotrexate and prednisone, presented with a 2 year history of worsening multiple cutaneous plaques of variable appearance. Two distinct skin lesions were biopsied to reveal a composite cutaneous lymphoma, possibly caused by long term methotrexate therapy. An [18F] fluoro-2-deoxy-D-glucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) was performed to stage the malignancy, and was later repeated to evaluate response to chemotherapy, which guided subsequent management. We present the PET/CT imaging findings of this very rare iatrogenic (methotrexate induced) immunodeficiency-associated lymphoproliferative disorder.
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Matsumoto R, Numata K, Doba N, Hara K, Chuma M, Fukuda H, Nozaki A, Tanaka K, Ishii Y, Maeda S. A case of multiple hepatic lesions associated with methotrexate-associated lymphoproliferative disorder. J Med Ultrason (2001) 2016; 43:545-51. [PMID: 27577564 DOI: 10.1007/s10396-016-0740-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 08/05/2016] [Indexed: 12/14/2022]
Abstract
Patients receiving methotrexate (MTX) for the treatment of autoimmune disease are at a high risk of developing lymphoproliferative disorders (LPD), the so-called methotrexate-associated lymphoproliferative disorders (MTX-LPD). We recently performed abdominal ultrasonography (US) in a patient with rheumatoid arthritis (RA) who had developed hepatic dysfunction during the course of MTX therapy; the examination revealed multiple well-demarcated hepatic tumors with slightly irregular borders, the largest one measuring 9 cm in diameter. In view of the finding of portal and hepatic veins perforating the tumor, we suspected a diagnosis of malignant lymphoma and performed a hepatic tumor biopsy. Histopathological examination of the biopsy specimens revealed a diagnosis of diffuse large B-cell lymphoma, and we made a final diagnosis of MTX-LPD. MTX treatment was discontinued, which resulted in rapid resolution of the lesions. Resolution of MTX-LPD can be obtained just by discontinuation of MTX treatment. In patients receiving MTX therapy who are found to have hepatic tumors perforated by the portal vein and/or hepatic vein on abdominal US, it is advisable to perform hepatic tumor biopsy to facilitate differential diagnosis of MTX-LPD and enable a definite diagnosis.
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Affiliation(s)
- Ruby Matsumoto
- Gastroenterological Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan.,Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Kazushi Numata
- Gastroenterological Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan.
| | - Nobutaka Doba
- Gastroenterological Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Koji Hara
- Gastroenterological Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Makoto Chuma
- Gastroenterological Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Hiroyuki Fukuda
- Gastroenterological Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Akito Nozaki
- Gastroenterological Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Katsuaki Tanaka
- Gastroenterological Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Yoshimi Ishii
- Department of Hematology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Shin Maeda
- Division of Gastroenterology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
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Kondo K, Nakamura S, Takahashi M, Kaneko T, Horie N, Shimoyama T. Methotrexate-related lymphoproliferative disorder of the oral region in patients with rheumatoid arthritis. JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY MEDICINE AND PATHOLOGY 2016. [DOI: 10.1016/j.ajoms.2015.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Affiliation(s)
- Kenta Watanabe
- Department of Otolaryngology (Watanabe), Toranomon Hospital; Department of Hematology (Kajiwara), Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Koichi Kajiwara
- Department of Otolaryngology (Watanabe), Toranomon Hospital; Department of Hematology (Kajiwara), Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
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Fantò M, Peragallo MS, Pietrosanti M, Di Rosa R, Picchianti Diamanti A, Salemi S, D'Amelio R. Risk of malignancy in patients with rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis under immunosuppressive therapy: a single-center experience. Intern Emerg Med 2016; 11:31-40. [PMID: 26099279 DOI: 10.1007/s11739-015-1270-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 06/01/2015] [Indexed: 12/19/2022]
Abstract
Systemic inflammatory rheumatic diseases are associated with an increased risk of malignancy, in particular of lymphoproliferative disorders. Chronic inflammation, due to the disease itself, generates a microenvironment able to promote cancer development, but it is still controversial whether immunosuppressive therapy may contribute to carcinogenesis. The aim of the study was to evaluate the risk of malignancy in 399 patients affected by rheumatoid arthritis (RA), psoriatic arthritis and ankylosing spondylitis, all treated with either tumor necrosis factor α-inhibitors plus disease-modifying anti-rheumatic drugs (DMARDs) or DMARDs alone. The risk of malignancy in this cohort of patients, observed in the period between 2005 and 2011 at S. Andrea Hospital-Sapienza University of Rome, was compared with that of the general Italian population, matched for age, sex, and area of residence. Fourteen (3.5%) malignancies, five of which were hematologic, have been observed. The overall cancer risk was not significantly increased in comparison to the general population, whereas the risk of hematologic malignancies appeared significantly higher in RA patients (SIR 4.94, 95% CI 1.35-12.64), particularly in female gender (SIR 6.9, 0.95% CI 1.88-17.66). No significant association between therapy and malignancy was demonstrated in RA patients.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antirheumatic Agents/therapeutic use
- Arthritis, Psoriatic/complications
- Arthritis, Psoriatic/drug therapy
- Arthritis, Psoriatic/pathology
- Arthritis, Rheumatoid/complications
- Arthritis, Rheumatoid/drug therapy
- Arthritis, Rheumatoid/pathology
- Female
- Humans
- Immunosuppressive Agents/therapeutic use
- Incidence
- Male
- Middle Aged
- Neoplasms/epidemiology
- Neoplasms/pathology
- Retrospective Studies
- Spondylitis, Ankylosing/complications
- Spondylitis, Ankylosing/drug therapy
- Spondylitis, Ankylosing/pathology
- Tumor Necrosis Factor-alpha/antagonists & inhibitors
- Young Adult
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Affiliation(s)
- Marta Fantò
- Unit of Allergy and Immuno-Rheumatology, S. Andrea Hospital, Sapienza University of Rome, Rome, Italy.
| | | | - Mario Pietrosanti
- Unit of Allergy and Immuno-Rheumatology, S. Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Roberta Di Rosa
- Unit of Allergy and Immuno-Rheumatology, S. Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | | | - Simonetta Salemi
- Unit of Allergy and Immuno-Rheumatology, S. Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Raffaele D'Amelio
- Unit of Allergy and Immuno-Rheumatology, S. Andrea Hospital, Sapienza University of Rome, Rome, Italy.
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Komiya A, Matsui T, Horie K, Fukuda H, Iwata K, Tsuno H, Ogihara H, Ikenaka T, Kawakami M, Furukawa H, Hashimoto A, Hirai K, Tohma S. Neutrophil CD64 is upregulated in RA patients with lymphoma but not in other solid cancers. Mod Rheumatol 2015; 26:216-23. [PMID: 26381527 DOI: 10.3109/14397595.2015.1078986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate the utility of quantifying CD64 expression on neutrophils in rheumatoid arthritis patients with malignancy, especially its diagnostic role in lymphoma. METHODS We used flow cytometry to quantify CD64 expression on neutrophils from patients diagnosed with malignancy during the follow-up period prior to initiating treatment. RESULTS Neutrophils from 18 patients with lymphoma expressed significantly higher levels of CD64 (9635.6 ± 2123.7 molecules/cell) than those from 32 patients with other solid cancers (carcinoma) (1250.5 ± 91.1 molecules/cell) (p < 0.001). When the cutoff value was set at 2060 molecules/cell, the sensitivity and specificity of CD64 for diagnosing lymphoma was 88.9% and 94.4%, respectively. CONCLUSIONS The quantitative measurement of neutrophil CD64 by flow cytometry may be useful as a subsidiary diagnostic marker in patients with suspected lymphoma. Although neutrophil CD64 is currently a well-known marker of infection, it is necessary to bear in mind that lymphoma is also a candidate in differential diagnosis when CD64 expression on neutrophils is upregulated.
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Affiliation(s)
- Akiko Komiya
- a Department of Clinical Laboratory , Sagamihara National Hospital, National Hospital Organization , Kanagawa , Japan
| | - Toshihiro Matsui
- b Department of Rheumatology , Sagamihara National Hospital, National Hospital Organization , Kanagawa , Japan
| | - Koichiro Horie
- b Department of Rheumatology , Sagamihara National Hospital, National Hospital Organization , Kanagawa , Japan
| | - Hidefumi Fukuda
- b Department of Rheumatology , Sagamihara National Hospital, National Hospital Organization , Kanagawa , Japan
| | - Kanako Iwata
- c Department of Rheumatology , Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, National Hospital Organization , Kanagawa , Japan
| | - Hirotaka Tsuno
- b Department of Rheumatology , Sagamihara National Hospital, National Hospital Organization , Kanagawa , Japan
| | - Hideki Ogihara
- b Department of Rheumatology , Sagamihara National Hospital, National Hospital Organization , Kanagawa , Japan
| | - Tatsuoh Ikenaka
- d Department of Rehabilitation , Sagamihara National Hospital, National Hospital Organization , Kanagawa , Japan , and
| | - Misato Kawakami
- b Department of Rheumatology , Sagamihara National Hospital, National Hospital Organization , Kanagawa , Japan
| | - Hiroshi Furukawa
- c Department of Rheumatology , Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, National Hospital Organization , Kanagawa , Japan
| | - Atsushi Hashimoto
- b Department of Rheumatology , Sagamihara National Hospital, National Hospital Organization , Kanagawa , Japan
| | - Kotaro Hirai
- e Department of Urology , Sagamihara National Hospital, National Hospital Organization , Kanagawa , Japan
| | - Shigeto Tohma
- c Department of Rheumatology , Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, National Hospital Organization , Kanagawa , Japan
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Miyashita M, Koike T, Aizawa H, Kurita H. Reversible methotrexate-associated lymphoproliferative disorder (MTX-LPD) associated with Epstein–Barr virus in a patient with rheumatoid arthritis. JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY, MEDICINE, AND PATHOLOGY 2015. [DOI: 10.1016/j.ajoms.2014.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Ohkura Y, Shindoh J, Haruta S, Kaji D, Ota Y, Fujii T, Hashimoto M, Watanabe G, Matsuda M. Primary Adrenal Lymphoma Possibly Associated With Epstein-Barr Virus Reactivation Due to Immunosuppression Under Methotrexate Therapy. Medicine (Baltimore) 2015; 94:e1270. [PMID: 26252293 PMCID: PMC4616607 DOI: 10.1097/md.0000000000001270] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Primary adrenal lymphoproliferative disorder (LPD) is an extremely rare disease that is widely known to be associated with methotrexate (MTX) use in patients with rheumatoid arthritis (RA).A 70-year-old man was incidentally found to have a tumor at the dorsal part of the liver in a medical check-up. He had a history of RA treated with MTX. Abdominal ultrasonography demonstrated a low echoic mass (30 mm in diameter) at the dorsal part of the liver, located close to the inferior vena cava. Preoperative differential diagnoses included intrahepatic cholangiocarcinoma, adrenal tumor, and hepatic malignant lymphoma, but no definitive diagnosis was reached. On exploratory laparotomy, the tumor seemed to be derived from the right adrenal gland and adhered tightly to segment 7 of the liver. Therefore, right adrenectomy with partial resection of segment 7 of the liver was performed. Pathological findings revealed diffuse inflammatory cell infiltration with a population of small atypical lymphoid cells, with positive immunohistochemical evidence for Epstein-Barr virus (EBV). Final diagnosis was primary adrenal iatrogenic EBV-positive LPD, classified as "other iatrogenic immunodeficiency-associated LPDs: Hodgkin-like lesions."In this report, we described the possibility of the spontaneous healing of MTX-associated LPD (MTX-LPD) before treatment and the importance of doubting MTX-LPD and doing immunostaining to necrotic tissue. To our knowledge, this is the first reported case of MTX-related EBV-positive LPD, Hodgkin-like lesion, of the unilateral adrenal gland in patient with RA.
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Affiliation(s)
- Yu Ohkura
- From the Department of Gastroenterological Surgery, Hepato Pancreato Billiary Surgery Unit (YO, JS, SH, MH, GW, MM) and Departments of Hematology (DK) and Pathology (YO, TF), Toranomon Hospital, Tokyo, Japan; and Isetan Mitsukoshi Ltd., Nihonbashi Mitsukoshi Main Store, Tokyo, Japan (MM)
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Inui Y, Matsuoka H, Yakushijin K, Okamura A, Shimada T, Yano S, Takeuchi M, Ito M, Murayama T, Yamamoto K, Itoh T, Aiba K, Minami H. Methotrexate-associated lymphoproliferative disorders: management by watchful waiting and observation of early lymphocyte recovery after methotrexate withdrawal. Leuk Lymphoma 2015; 56:3045-51. [PMID: 25721751 DOI: 10.3109/10428194.2015.1022769] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
No optimum treatment of iatrogenic immunodeficiency-associated lymphoproliferative disorders due to methotrexate in patients with rheumatoid arthritis (MTX-LPD) has yet been established, although MTX withdrawal is known to have a substantial effect on tumor regression. Here, we retrospectively analyzed 20 cases of MTX-LPD. Tumor shrinkage occurred in 18 of 20 cases, but only following MTX withdrawal. This tumor regression ratio was considerably better than in previous reports, and appeared due to longer "watchful waiting." Lymphocyte recovery at 2 weeks after MTX withdrawal was significantly higher in cases with tumor regression in 1 month than in those without tumor regression (p = 0.001). Median time to maximal efficacy after MTX cessation in cases without chemotherapy was 12 weeks (range 2-76). In conclusion, watchful waiting for a longer period after MTX cessation with observation of early lymphocyte recovery and uninterrupted continuation of other anti-rheumatoid drugs may be an acceptable management plan for MTX-LPD.
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Affiliation(s)
- Yumiko Inui
- a Division of Medical Oncology/Hematology, Department of Medicine , Kobe University Graduate School of Medicine , Kobe , Japan
| | - Hiroshi Matsuoka
- a Division of Medical Oncology/Hematology, Department of Medicine , Kobe University Graduate School of Medicine , Kobe , Japan
| | - Kimikazu Yakushijin
- a Division of Medical Oncology/Hematology, Department of Medicine , Kobe University Graduate School of Medicine , Kobe , Japan
| | - Atsuo Okamura
- a Division of Medical Oncology/Hematology, Department of Medicine , Kobe University Graduate School of Medicine , Kobe , Japan
| | - Takaki Shimada
- b Division of Clinical Oncology and Hematology, Jikei University School of Medicine , Tokyo , Japan
| | - Shingo Yano
- b Division of Clinical Oncology and Hematology, Jikei University School of Medicine , Tokyo , Japan
| | - Mai Takeuchi
- c Department of Pathology , Kobe University Graduate School of Medicine , Kobe , Japan
| | - Mitsuhiro Ito
- d Laboratory of Hematology, Division of Medical Biophysics, Kobe University Graduate School of Health Sciences , Kobe , Japan
| | - Tohru Murayama
- a Division of Medical Oncology/Hematology, Department of Medicine , Kobe University Graduate School of Medicine , Kobe , Japan.,e Hematology Division, Department of Medicine , Hyogo Cancer Center , Hyogo , Japan
| | - Katsuya Yamamoto
- a Division of Medical Oncology/Hematology, Department of Medicine , Kobe University Graduate School of Medicine , Kobe , Japan
| | - Tomoo Itoh
- c Department of Pathology , Kobe University Graduate School of Medicine , Kobe , Japan
| | - Keisuke Aiba
- b Division of Clinical Oncology and Hematology, Jikei University School of Medicine , Tokyo , Japan
| | - Hironobu Minami
- a Division of Medical Oncology/Hematology, Department of Medicine , Kobe University Graduate School of Medicine , Kobe , Japan
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Kawahara A, Tsukada J, Yamaguchi T, Katsuragi T, Higashi T. Reversible methotrexate-associated lymphoma of the liver in rheumatoid arthritis: a unique case of primary hepatic lymphoma. Biomark Res 2015; 3:10. [PMID: 25964853 PMCID: PMC4426646 DOI: 10.1186/s40364-015-0035-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 04/28/2015] [Indexed: 12/14/2022] Open
Abstract
Primary hepatic lymphoma (PHL) is an extremely rare disease, frequently associated with viruses such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immune deficiency virus (HIV). On the other hand, an increased risk of lymphoproliferative disorders (LPD) has been demonstrated in patients treated with immunosuppressive drugs such as methotrexate (MTX) for rheumatoid arthritis (RA). The role of Epstein-Barr virus (EBV) has been discussed in the pathogenesis of the immunodeficiency-associated LPDs. We here describe a RA patient, who developed PHL during RA treatment. The patient was a 64 year-old Japanese male with a 2-year history of RA, who had been treated with MTX at weekly dose of 8–14 mg for 2 years and infliximab (IFX) for 7 months. He presented with a 2 month history of generalized malaise, right hypochondrium pain and fever. Contrast-enhanced computed tomography (CECT) of the abdomen showed multiple irregular and nodular liver masses with a maximum of 13 cm in diameter on the right liver. Biopsy specimens demonstrated CD20-positve diffuse large B-cell lymphoma (DLBCL), but EBV was not identified by EBV-encoded RNA in situ hybridization. Serology for HBV, HCV, human T-cell leukemia virus I (HTLV-I), and HIV was negative. His symptoms disappeared following discontinuation of RA treatment including MTX. A drastic regression of the tumor masses was further obtained without cytotoxic chemotherapy. In addition, although the patient had no past history of liver dysfunction before MTX therapy, persistent elevation of liver enzymes has been observed during MTX treatment. These findings show a causative role of MTX in the development of reversible PHL in the patient.
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Affiliation(s)
- Ai Kawahara
- Hematology, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8556 Japan
| | - Junichi Tsukada
- Hematology, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8556 Japan
| | - Takahiro Yamaguchi
- Hematology, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8556 Japan
| | - Takefumi Katsuragi
- Hematology, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8556 Japan
| | - Takehiro Higashi
- Hematology, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8556 Japan
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Yamada K, Oshiro Y, Okamura S, Fujisaki T, Kondo S, Nakayama Y, Suematsu E, Tamura K, Takeshita M. Clinicopathological characteristics and rituximab addition to cytotoxic therapies in patients with rheumatoid arthritis and methotrexate-associated large B lymphoproliferative disorders. Histopathology 2015; 67:70-80. [DOI: 10.1111/his.12627] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 11/24/2014] [Indexed: 12/18/2022]
Affiliation(s)
- Kozue Yamada
- Department of Pathology; Faculty of Medicine; Fukuoka University; Fukuoka Japan
| | - Yumi Oshiro
- Department of Pathology; Matsuyama Red Cross Hospital; Matsuyama Japan
| | - Seiichi Okamura
- Department of Internal Medicine; Clinical Research Center; National Hospital Organization Kyushu Medical Center; Fukuoka Japan
| | - Tomoaki Fujisaki
- Department of Hematology; Matsuyama Red Cross Hospital; Matsuyama Japan
| | - Seiji Kondo
- Department of Internal Medicine; Clinical Research Center; National Hospital Organization Kyushu Medical Center; Fukuoka Japan
| | - Yoshifuku Nakayama
- Department of Pathology; Clinical Research Center; National Hospital Organization Kyushu Medical Center; Fukuoka Japan
| | - Eiichi Suematsu
- Department of Internal Medicine; Clinical Research Center; National Hospital Organization Kyushu Medical Center; Fukuoka Japan
| | - Kazuo Tamura
- Division of Medical Oncology, Hematology and Infectious Disease; Department of Internal Medicine; Faculty of Medicine; Fukuoka University; Fukuoka Japan
| | - Morishige Takeshita
- Department of Pathology; Faculty of Medicine; Fukuoka University; Fukuoka Japan
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Miyagawa K, Shibata M, Noguchi H, Hayashi T, Oe S, Hiura M, Abe S, Harada M. Methotrexate-related primary hepatic lymphoma in a patient with rheumatoid arthritis. Intern Med 2015; 54:401-5. [PMID: 25748956 DOI: 10.2169/internalmedicine.54.3361] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
A 56-year-old woman with rheumatoid arthritis treated with methotrexate (MTX) was admitted to our hospital due to multiple liver tumors. Contrast-enhanced computed tomography (CT) revealed multiple hypovascular masses, and 18F-fluorodeoxyglucose positron emission tomography CT showed diffuse abnormal accumulation in the liver only. We therefore made a diagnosis of MTX-related primary hepatic lymphoma (MTX-PHL) exhibiting features of diffuse large B-cell lymphoma. Although MTX has been reported to increase the risk of lymphoproliferative disorders, MTX-PHL has not been reported previously. The present case is the first case in which MTX appears to have been involved in the development of PHL.
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Affiliation(s)
- Koichiro Miyagawa
- The Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
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Primary hepatic lymphoma in a patient with rheumatoid arthritis treated with methotrexate. Case Rep Hematol 2014; 2014:460574. [PMID: 25610674 PMCID: PMC4290657 DOI: 10.1155/2014/460574] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 12/12/2014] [Indexed: 12/13/2022] Open
Abstract
Primary hepatic lymphoma (PHL) has rarely been reported in patients with immunosuppression. We herein describe a case of Epstein-Barr virus- (EBV-) positive PHL in a 67-year-old Japanese woman receiving methotrexate (MTX) treatment for rheumatoid arthritis (RA). The patient, who had been receiving MTX therapy for more than 6 years, presented with low-grade fever and abdominal pain. Initial laboratory tests showed mildly elevated liver enzymes with normal levels of alpha-fetoprotein and carcinoembryonic antigen, and computed tomography scans revealed multiple hepatic tumors with no lymph-node swelling. Examination of liver specimens obtained via ultrasonography-guided needle biopsy indicated EBV-positive diffuse large B cell lymphoma; therefore, she was diagnosed with PHL. MTX was discontinued, and she was carefully monitored thereafter owing to the prolonged history of MTX administration for RA. Rapid progression of PHL was observed; therefore 10 days after the PHL diagnosis, she received 6 cycles of R-THP-COP (rituximab, cyclophosphamide, pirarubicin, vincristine, and prednisolone) therapy and achieved complete remission for more than 1 year. Although MTX-associated lymphoproliferative disorders often show remission after withdrawal of MTX, early diagnosis and treatment are essential for PHL in patients with RA treated with MTX, because of the aggressive nature of the disease.
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44
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Tokuhira M, Kizaki M. [Recent progress of diagnosis and treatment for immune-mediated hematological diseases. Topics: IV. Recent topics; 3. Methotrexate related malignant lymphoma]. ACTA ACUST UNITED AC 2014; 103:1660-8. [PMID: 25154262 DOI: 10.2169/naika.103.1660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Singh BK, Antony PT, Verma SK, Basu D, Negi VS. Anaplastic large cell lymphoma in a patient with systemic onset juvenile arthritis: case report and review of literature. Int J Rheum Dis 2014; 17:573-7. [PMID: 24698355 DOI: 10.1111/1756-185x.12361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The association of malignancy with autoimmune rheumatic diseases has been a subject of investigation. It has been shown that there is increased risk of malignancies, mainly non-Hodgkin lymphoma, in patients with autoimmune disorders. There is scarcity of data about malignancy in juvenile idiopathic arthritis (JIA). We report the occurrence of anaplastic large cell lymphoma in a patient with systemic onset juvenile idiopathic arthritis treated with low dose methotrexate (MTX). A relationship between MTX treatment and the occurrence of lymphoma in autoimmune diseases has been suggested. The hypothesis that MTX has a role in the aetiology of lymphoproliferative disorders is supported by the observation of spontaneous remission of lymphoma in few cases on cessation of MTX therapy. However, systemic onset juvenile idiopathic arthritis patients receiving MTX must be periodically examined for the development of lymphoproliferative disorder especially if the disease is difficult to control or patient develop new symptoms on therapy.
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Affiliation(s)
- Bharat K Singh
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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46
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Koji H, Yazawa T, Nakabayashi K, Fujioka Y, Kamma H, Yamada A. CD8-positive T-cell lymphoproliferative disorder associated with Epstein-Barr virus-infected B-cells in a rheumatoid arthritis patient under methotrexate treatment. Mod Rheumatol 2014; 26:271-5. [PMID: 24386983 DOI: 10.3109/14397595.2013.850613] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
We report a 48-year-old female who developed lymphoproliferative disorder (LPD) during treatment of rheumatoid arthritis (RA) with methotrexate (MTX). She presented with multiple tumors in the cervical lymph nodes (LNs), multiple lung shadows and round shadows in both kidneys with pancytopenia and a high CRP level. The LN showed CD8-positive T-cell LPD associated with Epstein-Barr (EB) virus-infected B-cells. Clonality assays for immunoglobulin (Ig) heavy chain and T-cell receptor gamma (TCRγ) were negative. The cessation of MTX without chemotherapy resulted in the complete disappearance of the tumors and abnormal clinical features. We compared this case with previously published ones and discuss the pathological findings, presuming that the proliferation of CD8 T-cells was a reactive manifestation to reactivated EB virus-infected B-cells.
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Affiliation(s)
- Hitoshi Koji
- a First Department of Internal Medicine , Kyorin University School of Medicine , Mitaka, Tokyo , Japan
| | - Takuya Yazawa
- b Department of Pathology , Kyorin University School of Medicine , Mitaka, Tokyo , Japan
| | - Kimimasa Nakabayashi
- a First Department of Internal Medicine , Kyorin University School of Medicine , Mitaka, Tokyo , Japan
| | - Yasunori Fujioka
- b Department of Pathology , Kyorin University School of Medicine , Mitaka, Tokyo , Japan
| | - Hiroshi Kamma
- b Department of Pathology , Kyorin University School of Medicine , Mitaka, Tokyo , Japan
| | - Akira Yamada
- a First Department of Internal Medicine , Kyorin University School of Medicine , Mitaka, Tokyo , Japan
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Hatachi S, Kunitomi A, Aozasa K, Yagita M. CD8+T-cell lymphoproliferative disorder associated with Epstein–Barr virus in a patient with rheumatoid arthritis during methotrexate therapy. Mod Rheumatol 2014. [DOI: 10.3109/s10165-010-0300-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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48
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Yamakawa N, Fujimoto M, Kawabata D, Terao C, Nishikori M, Nakashima R, Imura Y, Yukawa N, Yoshifuji H, Ohmura K, Fujii T, Kitano T, Kondo T, Yurugi K, Miura Y, Maekawa T, Saji H, Takaori-Kondo A, Matsuda F, Haga H, Mimori T. A clinical, pathological, and genetic characterization of methotrexate-associated lymphoproliferative disorders. J Rheumatol 2013; 41:293-9. [PMID: 24334644 DOI: 10.3899/jrheum.130270] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Methotrexate-associated lymphoproliferative disorders (MTX-LPD) often regress spontaneously during MTX withdrawal, but the prognostic factors remain unclear. The aim of our study was to clarify the clinical, histological, and genetic factors that predict outcomes in patients with MTX-LPD. METHODS Patients with MTX-LPD diagnosed between 2000 and 2012 were analyzed retrospectively regarding their clinical course, site of biopsy, histological typing, Epstein-Barr virus (EBV) in situ hybridization and immunostaining, and HLA type. RESULTS Twenty-one patients, including 20 with rheumatoid arthritis (RA) and 1 with polymyositis, were analyzed. The mean dose of MTX was 6.1 mg/week and the mean duration of treatment was 71.1 months. Clinically, 5 patients were diagnosed with EBV-positive mucocutaneous ulcer (EBVMCU) and had polymorphic histological findings. The proportion of those patients successfully treated solely by withdrawal of MTX was significantly greater than that of those without EBVMCU (75% vs 7.7%, p = 0.015). The HLA-B15:11 haplotype was more frequent in patients with EBV+ RA with MTX-LPD than in healthy Japanese controls (p = 0.0079, Bonferroni's method). EBV latency classification and HLA typing were not associated with the prognosis of MTX-LPD in our cohort. CONCLUSION Our data demonstrate that patients in the EBVMCU, a specific clinical subgroup of MTX-LPD, had a better clinical outcome when MTX was withdrawn than did other patients with MTX-LPD.
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Affiliation(s)
- Noriyuki Yamakawa
- From the Department of Rheumatology and Clinical Immunology, the Department of Diagnostic Pathology, the Center for Genomic Medicine, and the Department of Hematology and Oncology, Kyoto University Graduate School of Medicine; the Department of Transfusion Medicine and Cell Therapy, Kyoto University Hospital; the HLA Foundation Laboratory, Kyoto, Japan
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Spontaneous regression of colonic lymphoma following infliximab and azathioprine withdrawal in patients with Crohn's disease. Inflamm Bowel Dis 2013; 19:E69-70. [PMID: 23399737 DOI: 10.1097/mib.0b013e31827fec81] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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50
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Cho GM, Bae MN, Jung YH, Kang HS, Baek IW, Kim KJ, Cho CS. Spontaneous Remission of Hodgkin's Lymphoma in a Patient with Systemic Lupus Erythematosus after Withdrawal of Methotrexate. JOURNAL OF RHEUMATIC DISEASES 2013. [DOI: 10.4078/jrd.2013.20.4.238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Gu-Min Cho
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Myung-Nam Bae
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young-Hee Jung
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hye-Sun Kang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - In-Woon Baek
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ki-Jo Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chul-Soo Cho
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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