Dermatomyositis associated with malignancy. 12 case reports

Malignancy in a retrospective cohort of 17 patients with Dermatomyositis or Polymyositis in southern Tunisia

INTRODUCTION

The prognosis of dermatomyositis (DM)/ polymyositis (PM) in adults is partly related to their association with neoplasia. The aim of our study was to report the epidemiologic, clinical, paraclinical, therapeutic and evolutionary aspects of DM associated with malignancy in patients from Sfax, south eastern of Tunisia.

METHODS

A retrospective cohort study of patients with DM or PM admitted in Dermatology and Internal Medicine Departments of Hedi Chaker University Hospital of Sfax between 1996 and 2015. Cases of DM or PM associated with malignancy were retained.

RESULTS

Seventeen cases (13.5%) of DM or PM associated with malignancy were noted. Fourteen patients had DM and 3 patients had PM. The Sex ratio M / F was 0.3 and the mean age at diagnosis was 56.5 years. In DM patients, malignancy preceded the myositis in 64.2% of cases. In PM patients, only one patient was known to have breast cancer and the myositis revealed the cancer for 2 others. Treatment consisted of corticosteroids associated with methotrexate in 4 cases. Outcome was fatal in 5 cases (29.4%), due to the underlying cancer in 3 cases. Swallowing disorders related to DM/PM were responsible for death in 2 cases.

CONCLUSION

There are no specific clinical or biological features in paraneoplastic DM. In our series, breast neoplasm represented the first cancer associated with DM. Cancers of nasopharynx, colon and urinary tract had the second position.

Inflammatory Myopathies with Cutaneous Involvement: from Diagnosis to Therapy

The group of idiopathic inflammatory myopathies (IIM) include various disorders of skeletal muscles with or without skin involvement. The most common types are dermatomyositis (DM), polymyositis (PM), inclusion body myositis (IBM) and necrotizing autoimmune myopathy (NAM). Dermatomyositis subdivides into various clinical forms such as juvenile, amyopathic or paraneoplastic dermatomyositis, scleromyositis, overlap or anti-synthetase syndromes, etc.

Recently, numerous new antibodies defining the characteristic clinical phenotype have been described as anti-MDA5 antibodies associated with interstitial lung disease and amyopathic dermatomyositis or anti-TIF1γ antibodies as markers for paraneoplastic dermatomyositis. Moreover, new clinical entities as drug-induced dermatomyositis are presumed, since some medications may induce, or trigger inflammatory myopathies.

Knowledge of the complex methods and techniques required to diagnose the disease is of great importance in clinical practice. The variety of clinical variants needs diagnosis because of the differing prognosis and therapeutic modalities.

Idiopathic Inflammatory Myopathies and Malignancy: a Comprehensive Review

The idiopathic inflammatory myopathies (IIMs) are a heterogeneous group of autoimmune diseases (collectively known as myositis) affecting the skeletal muscles as well as other organ systems such as skin, lungs, and joints. The primary forms of myositis include polymyositis (PM), dermatomyositis (PM), and immune-mediated necrotizing myopathy (IMNM). Patients with these diseases experience progressive proximal muscle weakness, have characteristic muscle biopsy findings, and produce autoantibodies that are associated with unique clinical features. One distinguishing feature of these patients is that they are also known to have an increased risk of cancer. Since the first description of the association in 1916, it has been extensively reported in the medical literature. However, there have been significant variations between the different studies with regard to the degree of cancer risk in patients with IIM. These discrepancies can, in part, be attributed to differences in the definition of malignancy-associated myositis used in different studies. In recent years, significant advances have been made in defining specific features of IIM that are associated with the development of malignancy. One of these has been myositis-specific antibodies (MSAs), which are linked to distinct clinical phenotypes and categorize patients into groups with more homogeneous features. Indeed, patients with certain MSAs seem to be at particularly increased risk of malignancy. This review attempts a systematic evaluation of research regarding the association between malignancy and myositis.

Carcinoma of unknown primary and paraneoplastic dermatomyositis

Dermatomyositis is known to be associated with neoplastic disorders, however the presentation of carcinoma of unknown primary as dermatomyositis is rare. We describe a case index of 50-year-old female who presented with enlarged inguinal lymph nodes accompanied with symmetric proximal muscle weakness and erythematous plaques. Conventional basic work-up did not reveal the diagnosis, however, positron emission tomography-computed tomography and re-staining of the pathology specimen suggested the ovaries as the primary site. Chemotherapy including carboplatin paclitaxel and bevacizumab led to complete response of disease and improvement in the dermatomyositis. The present case emphasizes the importance of a thorough directed evaluation for the underlying cancer in patients with carcinoma of unknown primary presenting as dermatomyositis. We further provide an up-to-date detailed review of published data describing these clinical entities.

Dermatomyositis: analysis of 109 patients surveyed at the Hospital das Clínicas (HCFMUSP), São Paulo, Brazil

BACKGROUND

Dermatomyositis affects striated muscles, skin and other organs.

OBJECTIVE

To characterize the disease from January 1992 to December 2002, assessing its classification, cutaneous and systemic manifestations, and also laboratory results, therapeutic and prognostic findings compared to those in the literature.

METHODS

Data were obtained from medical records of 109 patients who were classified into five groups: 23 juvenile dermatomyositis; 59 primary idiopathic dermatomyositis; 6 amyopathic dermatomyositis; 7 dermatomyositis associated with neoplasms and 14 dermatomyositis associated with other connective tissue diseases.

RESULTS

Sixty patients were classified as "definite" diagnosis; 33 as "possible"; four as "probable" and 12 and as amyopathic. The average age at diagnosis was 36 years. Cutaneous manifestations occurred in all patients; the most frequent symptom was loss of proximal muscle strength; the most common pulmonary disorder was interstitial lung disease, and gastritis was the most prevalent digestive manifestation. Tumors were documented in 6.42% of cases. Lactate dehydrogenase was the muscle enzyme most frequently elevated in the majority of cases. Skin biopsies were performed in 68 patients; muscle biopsies in 53; and electroneuromyographies in 58 patients. The most commonly used treatment was corticotherapy and the mortality rate was 14.7%.

CONCLUSION

in this sample, the disease appeared in younger individuals, was more frequent in women and the association with cancer was small.

Paraneoplastic muscle disease

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

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

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

Paraneoplastic dermatological manifestation of gastrointestinal malignancies

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

Dermatomiosite

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

Polymyositis and dermatomyositis associated with malignancy: a 30-year retrospective study

BACKGROUND

Polymyositis and dermatomyositis in association with malignancy are paraneoplastic syndromes, but the incidence, treatment and factors that predict associated cancer and its prognosis all remain unclear.

PATIENTS AND METHOD

During the 30-year period 1969-99, we treated 64 patients who had polymyositis (including two with cancer) and 28 patients who had dermatomyositis (including 10 with cancer). We compared the clinical findings of the patients who had cancer with the findings of those who did not have cancer.

RESULTS

The risk of cancer is significantly higher in dermatomyositis and somewhat higher in polymyositis. An increased cancer risk was found in male patients with dermatomyositis who were older than 50 years. Cancer was diagnosed within 4 years before or after the diagnosis of polymyositis or dermatomyositis, and usually within 1 year. An operation was not possible in many of the patients with cancer because of the advanced stage of the disease.

CONCLUSION

Our findings suggest that early discovery of malignancy is critical in cases of polymyositis and dermatomyositis.

Malignancy in patients with inflammatory myopathy

The most recent evidence from population-based cohort studies confirms the association between malignancy and dermatomyositis and polymyositis. These studies show an even stronger association between polymyositis and malignancy than previous studies, suggesting less misclassification. This is particularly true of one study that used pathologic criteria to distinguish between myositis subtypes. Recent data also confirm that the association for dermatomyositis and polymyositis is not purely caused by diagnostic suspicion or surveillance bias. More data are still required to determine individual cancer risks, although it appears that ovarian and lung cancer are associated with dermatomyositis while lung cancer and non-Hodgkin's lymphoma are associated with polymyositis. An association between malignant disease and inclusion body myositis has also been verified for the first time. Of interest, too, is the increasing number of reports documenting cases in which the clinical course of the myositis mirrors that of the cancer, supporting the notion that in some instances, myositis is a paraneoplastic disorder.

Paraneoplastic dermatoses

Skin manifestations of systemic disease and malignancy are protean. The recognition of a potentially paraneoplastic dermatosis as such must prompt an investigation for occult malignancy. Lack of familiarity with cutaneous clues of internal malignancy may delay diagnosis and treatment of cancer. It is important to consider a paraneoplastic process in the differential diagnosis of a number of eruptive and treatment-resistant dermatoses. These dermatoses may be the first sign of an occult neoplasm. Their recognition may assist in cancer detection and the swift induction of appropriate therapy.