Malignancies in systemic lupus erythematosus

Weaning Maintenance Therapy in Lupus Nephritis: For Whom, When, and How?

Lupus nephritis (LN) is one of the main determinants of the severity of systemic lupus erythematosus (SLE). LN flares can lead to organ damage with chronic kidney disease (CKD) or even end-stage kidney disease (ESKD) and impair patients' survival. The "treat-to-target" strategy, which aims at obtaining and maintaining remission or low disease activity of SLE to alleviate symptoms and prevent organ damage, also refers to the control of residual activity in the kidney. But damage in SLE can also come from treatments, and toxicities related to long-term use of treatments should be prevented. This may contribute to the frequent nonadherence in patients with SLE. The de-escalation or even weaning of treatments whenever possible, or "think-to-untreat" (T2U) strategy, is to be considered in patients with LN. This possibility of treatment weaning in LN was explored in retrospective cohorts, on the basis of long-term clinical remission. It was also proposed prospectively with a kidney-biopsy-based approach, combining clinical and pathologic remission to secure treatment weaning. The WIN-Lupus trial was the first randomized controlled trial comparing the continuation to the discontinuation of maintenance immunosuppressive therapy (IST) after 2 to 3 years in patients with LN in remission. It showed a higher risk of severe SLE flares in patients who discontinued treatment, but also a possibility of weaning without flare in some patients, who need to be better identified. We propose here a narrative review of the available literature on the weaning of treatment in LN and discuss how to secure a T2U strategy.

Critical evaluation of cancer risks in glomerular disease

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The increased cancer incidence in patients with glomerular disease can be secondary to an intrinsic immune dysfunction associated with the disease or/and extrinsic factors, especially immunosuppressants.

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Paraneoplastic glomerulopathy is sometimes misdiagnosed as primary glomerulopathy.

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The treatment for paraneoplastic glomerulopathy is different from primary glomerular disease.

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In membranous nephropathy, serum circulating autoantibodies against PLA2R and THSD7A, immunohistochemical tissue markers for glomerular PLA2R, THSD7A and specific types of immunoglobulin G (IgG) may be used for identifying underlying malignancies.

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A scheme of screening of cancers frequently reported in the setting of glomerular disease is important.

The increased cancer incidence in patients with glomerular disease can be secondary to an intrinsic immune dysfunction associated with the disease or/and extrinsic factors, especially immunosuppressants. The treatment for paraneoplastic glomerulopathy is different from primary glomerular disease. Immunosuppressive therapy often used for primary glomerulopathy may aggravate concomitant cancers in patients with paraneoplastic glomerulopathy. In membranous nephropathy (MN), measurement of serum circulating autoantibodies against podocyte transmembrane glycoprotein M-type phospholipase A2 receptor (PLA2R) and thrombospondin type 1 domain-containing 7A (THSD7A), immunohistochemical staining of kidney tissue for glomerular PLA2R, THSD7A, neural epidermal growth factor-like 1 protein (NELL-1) and specific types of immunoglobulin G (IgG) may be useful adjuncts when screening for underlying malignancies. This review addresses overall cancer risks in individuals with glomerular diseases and employment of biomarkers available for MN. We propose a scheme of screening of cancers frequently reported in the setting of glomerular disease.

The five major autoimmune diseases increase the risk of cancer: epidemiological data from a large-scale cohort study in China

Background

Cancer incidence and mortality have received critical attention during the long‐term management of morbidities in patients with autoimmune diseases (AIDs). This study aimed to investigate and compare the risk of cancer associated with five major AIDs in a large‐scale Chinese cohort.

Methods

A total of 8,120 AID patients consecutively admitted to a national tertiary referral center in China were included and followed‐up for 38,726.55 patient‐years, including those with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), Sjögren's syndrome (SS), systemic scleroderma (SSc), and idiopathic inflammatory myositis (IIM). Demographic data, cancer incidence, predilecting sites and cancer onset time were recorded and compared among the five AIDs.

Results

Four hundred and thirty (5.3%) patients developed cancer. Their median age was 57.5 years and AID duration was 79.8 months. The estimated total standardized incidence ratio (SIR) of cancer in AIDs patients was 3.37, with the highest SIR observed in IIM (4.31), followed by RA (3.99), SSc (3.77), SS (2.88) and SLE (2.58). The increased SIR of cancers in AID patients showed a female predominance (female vs. male: 3.59 vs. 2.77) and younger patient involvement (age <50 vs. ≥50 years: 4.88 vs. 3.04). Patients with SLE had increased SIRs for developing hematologic malignancies and solid tumors located in the urinary bladder, corpus uteri and cervix uteri. Patients with SS had a significantly high SIR for developing non‐Hodgkin's lymphoma. Within 3 years of IIM diagnosis, 74.6% of the patients developed cancer and they had a high risk of ovarian cancer. RA was associated with a wide distribution of scancers, including non‐Hodgkin's lymphoma, gynecologic, urinary tract, thyroid gland and lung cancers. SSc patients had increased SIRs for developing cervical uterine, lung, and breast cancers.

Conclusion

Patients with five major AIDs in China had an increased risk of developing cancer, with a predominance in women and younger patients, although cancer incidence, predilection sites and cancer onset time may vary greatly in each AID entity.

Hematological malignancies in systemic lupus erythematosus: clinical characteristics, risk factors, and prognosis-a case-control study

BACKGROUND

Systemic lupus erythematosus (SLE) is a chronic and complex multi-system autoimmune disorder. Higher risks of hematological malignancies (HM) were observed in SLE patients, which was associated with higher mortality. The mechanism and risk factors of HM oncogenesis in SLE patients are still under investigation. The aim of this study was to explore clinical characteristics, risk factors, and prognosis of SLE patients with or without HM in the Chinese population.

METHODS

A retrospective, case-controlled study was conducted in 72 SLE patients between January 2013 and December 2020. Clinical and laboratory data were collected and compared between the two groups of patients with HM and those without HM. Logistic regression analysis was performed to determine risk factors of HM oncogenesis. The survival rate was estimated by Kaplan-Meier methods and Cox proportional hazards regression analysis.

RESULTS

Among 72 SLE patients in this study, fifteen complicated with HM and 57 without HM were identified. The incidence rate of HM was approximately 0.24% with elevated standardized incidence ratios of lymphoma and leukemia (27.559 and 12.708, respectively). Patients with HM were older when diagnosed with SLE, with a higher frequency of infection and splenomegaly, lower levels of hemoglobin and high-density lipoprotein compared with those without HM. Fewer patients with HM expressed positive anti-dsDNA antibody (26.7% vs 66.7%, P = 0.005) or received hydroxychloroquine treatment (40.0% vs 86.0%, P = 0.001). Older age at SLE diagnosis (OR=1.122, 95% CI: 1.037-1.214) was regarded as an independent risk factor of HM oncogenesis. Female (RR= 0.219, 95% CI: 0.070-0.681) and hydroxychloroquine (RR= 0.281, 95% CI: 0.094-0.845) were protective factors of mortality in SLE patients.

CONCLUSIONS

SLE patients with an older age are at an increased risk of HM carcinogenesis. The prognosis of male patients with SLE tends to be poorer whether complicated with HM. The association of antinuclear antibody spectrum, medication, and HM oncogenesis in SLE needs further investigation.

Sustained high expression of multiple APOBEC3 cytidine deaminases in systemic lupus erythematosus

APOBEC3 (A3) enzymes are best known for their role as antiviral restriction factors and as mutagens in cancer. Although four of them, A3A, A3B, A3F and A3G, are induced by type-1-interferon (IFN-I), their role in inflammatory conditions is unknown. We thus investigated the expression of A3, and particularly A3A and A3B because of their ability to edit cellular DNA, in Systemic Lupus Erythematosus (SLE), a chronic inflammatory disease characterized by high IFN-α serum levels. In a cohort of 57 SLE patients, A3A and A3B, but also A3C and A3G, were upregulated ~ 10 to 15-fold (> 1000-fold for A3B) compared to healthy controls, particularly in patients with flares and elevated serum IFN-α levels. Hydroxychloroquine, corticosteroids and immunosuppressive treatment did not reverse A3 levels. The A3AΔ3B polymorphism, which potentiates A3A, was detected in 14.9% of patients and in 10% of controls, and was associated with higher A3A mRNA expression. A3A and A3B mRNA levels, but not A3C or A3G, were correlated positively with dsDNA breaks and negatively with lymphopenia. Exposure of SLE PBMCs to IFN-α in culture induced massive and sustained A3A levels by 4 h and led to massive cell death. Furthermore, the rs2853669 A > G polymorphism in the telomerase reverse transcriptase (TERT) promoter, which disrupts an Ets-TCF-binding site and influences certain cancers, was highly prevalent in SLE patients, possibly contributing to lymphopenia. Taken together, these findings suggest that high baseline A3A and A3B levels may contribute to cell frailty, lymphopenia and to the generation of neoantigens in SLE patients. Targeting A3 expression could be a strategy to reverse cell death and the generation of neoantigens.

TCGA dataset screening for genes implicated in endometrial cancer using RNA-seq profiling

The molecular basis of the mechanism and the potential biomarkers of endometrial cancer (EC) remain to be studied. In the present study, we hypothesized that the comprehensive characterization of transcriptional changes in EC could help achieve this aim. By taking advantage of RNA-seq data from The Cancer Genome Atlas, we determined the profile of differently expressed genes (DEGs) between EC tumor tissues and normal samples. On this basis, we performed Gene Ontology and Kyoto Encyclopedia of Genes and Genomes pathways enrichment analyses. The interacting partners for each of the DEGs were explored and a protein-protein interaction network was constructed. Consequently, 10 hub genes were identified and their association with mortality in EC patients was investigated. The genes, AURKA, CENPA, and KIF2C, were found to be potential biomarkers for EC with a significant prognostic effect. Our work provided a basis for EC studies in both biological and clinical settings.

Eight pillars of oncorheumatology: Crossroads between malignancies and musculoskeletal diseases

ONCORHEUMATOLOGY

RELATIONSHIP BETWEEN MALIGNANCIES AND MUSCULOSKELETAL DISEASES: Oncorheumatology is the meeting point of tumor formation and rheumatic musculoskeletal diseases (RMD). Multiple interactions exist between these two medical specialties. One major field is the topic of malignancies associated with rheumatic diseases, while the other topic covers the development of musculoskeletal disease in cancer patients. Within the first group, secondary malignancies may be associated with rheumatic diseases. Mostly sustained inflammation is responsible for transition into cancer. Tumor-associated antigens (TAA) with adhesive properties are present on tumor cells. These molecules may also be expressed by inflammatory leukocytes and soluble TAA levels may be elevated in RMDs. There has been continuous debate with respect to the possible carcinogenicity of conventional and targeted antirheumatic drugs. Very recent data from registries suggest that neither biologics, nor JAK inhibitors increase cancer risk in arthritis patients. The issue of physiotherapy in rheumatic patients with recent or current cancer has also been controversial. Some modalities, primarily exercise, may be safely applied to patients with RMD and cancer. The second large topic includes paraneoplastic syndromes. Musculoskeletal paraneoplasias are triggered by tumor-derived mediators. These syndromes are sometimes slightly different from the classical RMDs. Various chemotherapies may also be associated with autoimmune side effects. Recently, these immune-related complications have also been observed in cancer patients treated with immune-checkpoint inhibitors. Sex hormone-deprivation therapies, such as aromatase inhibitors and anti-androgens are widely used for the treatment of breast and prostate cancer, respectively. These compounds may induce bone loss and lead to osteoporosis. Finally, primary and secondary malignancies of the musculoskeletal system may also interest rheumatologists. In this review, the clinical, practical aspects of these eight pillars of oncorheumatology will be discussed.

Hematological malignancies in connective tissue diseases

Chronic inflammation has profound tumor-promoting effects. Inflammatory cells are the key players in immunosurveillance against tumors, and immunosuppression is known to increase the risk of tumors. Autoimmune diseases, which manifest as loss of self-tolerance and chronic immune dysregulation, provide a perfect environment for tumor development. Aside from managing the direct inflammatory consequences of autoimmune pathogenesis, cancer risk profiles should be considered as a part of a patient's treatment. In this review, we describe the various associations of malignancies with autoimmune diseases, specifically systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, and Sjögren's syndrome, as well as discuss the mechanisms contributing to the pathogenesis of both disorders.

Targeting Autophagy to Overcome Human Diseases

Autophagy is an evolutionarily conserved cellular process, through which damaged organelles and superfluous proteins are degraded, for maintaining the correct cellular balance during stress insult. It involves formation of double-membrane vesicles, named autophagosomes, that capture cytosolic cargo and deliver it to lysosomes, where the breakdown products are recycled back to cytoplasm. On the basis of degraded cell components, some selective types of autophagy can be identified (mitophagy, ribophagy, reticulophagy, lysophagy, pexophagy, lipophagy, and glycophagy). Dysregulation of autophagy can induce various disease manifestations, such as inflammation, aging, metabolic diseases, neurodegenerative disorders and cancer. The understanding of the molecular mechanism that regulates the different phases of the autophagic process and the role in the development of diseases are only in an early stage. There are still questions that must be answered concerning the functions of the autophagy-related proteins. In this review, we describe the principal cellular and molecular autophagic functions, selective types of autophagy and the main in vitro methods to detect the role of autophagy in the cellular physiology. We also summarize the importance of the autophagic behavior in some diseases to provide a novel insight for target therapies.

Systemic lupus erythematosus is a risk factor for cancer: a nationwide population-based study in Korea

OBJECTIVE

Specific differences in cancer risk have been observed between systemic lupus erythematosus patients and the general population. Although meta-analyses have estimated cancer incidence in systemic lupus erythematosus patients, results have been inconclusive. Hence, we aimed to assess malignancy risk in systemic lupus erythematosus patients, compared to the risk in the general population.

METHODS

Systemic lupus erythematosus patients ( n = 21,016; mean age 41.67 ± 13.14 years; female 90.22%) were selected from the Korean National Health Insurance Service database between 2008 and 2014. Age- and sex-matched controls were randomly sampled in a 5:1 ratio ( n = 105,080).

RESULTS

During the 7 years of follow up, malignancy was detected in 763 (3.63%) systemic lupus erythematosus patients and 2667 (2.54%) controls. Systemic lupus erythematosus patients had a higher risk of malignancy than controls (odds ratio 1.44; 95% confidence interval 1.327-1.559), after multivariate adjustment. Systemic lupus erythematosus patients had a higher odds ratio for developing cervical, thyroid, ovarian, and oral cancer, as well as lymphoma, leukemia, and multiple myeloma than controls. Based on subgroup analysis, male systemic lupus erythematosus patients and patients younger than 40 years showed the highest lymphoma risk.

CONCLUSIONS

Systemic lupus erythematosus might be an independent risk factor for cancer. Therefore, the importance of cancer screening programs should be emphasized in systemic lupus erythematosus patients. Our study is the first large nationwide cohort study for evaluating the risk of cancer in systemic lupus erythematosus patients.

Malignancy in Systemic Lupus Erythematosus (SLE) Patients

Background:

Malignancies are among the leading causes of death in Systemic Lupus Erythematosus (SLE) patients with studies reporting a higher prevalence of malignancy in SLE patients compared to the general population. We wanted to determine the frequency of cancer in a cohort of SLE patients and identify its associated risk factors.

Methods:

Cross-sectional study involving SLE patients attending the nephrology outpatient clinic, Universiti Kebangsaan Malaysia Medical Centre between January and June 2014.

Results:

We recruited 228 patients (207 female, 21 male), aged 40.48 ± 12.86 years with mean SLE duration of 11.65 ± 6.46 years. Majority (87%) had lupus nephritis and were in remission with a median SLEDAI score 2 (0, 14). Majority (89%) were on corticosteroid with either a steroid sparing agent like mycophenolate mofetil (15.4%), azathioprine (36.8%) or ciclosporin (15.4%). One hundred and sixty (70.2%) patients were either receiving or had received intravenous cyclophosphamide with median dose of 5,173.6 ± 3,242.4 mg. Seven female patients were diagnosed with cancer during the course of their SLE with 56 (34-78) years being median age at malignancy and SLE duration of 4 (0-12) years. Majority (5/7) had lupus nephritis and all patients a median dose of prednisolone 10 (2.5, 10) mg with 10 (4-24) years of steroids. Two patients had a family history of cancer with majority developing cancer after the diagnosis of SLE. Two patients received intravenous cyclophosphamide prior to the development of cancer for their SLE compared to overall cohort of 160. Three patients had colorectal cancer, 2 had cervical cancer, 1 had breast cancer, and one patient had germ cell tumour and one thyroid cancer. All patients had their cancer successful treated with no signs of recurrence.

Conclusion:

We found a lower occurrence of cancer in our SLE patients as compared with the reported literature.

Regulators of A20 (TNFAIP3): new drug-able targets in inflammation

Persistent activation of the transcription factor Nuclear factor-κB (NF-κB) is central to the pathogenesis of many inflammatory disorders, including those of the lung such as cystic fibrosis (CF), asthma, and chronic obstructive pulmonary disease (COPD). Despite recent advances in treatment, management of the inflammatory component of these diseases still remains suboptimal. A20 is an endogenous negative regulator of NF-κB signaling, which has been widely described in several autoimmune and inflammatory disorders and more recently in terms of chronic lung disorders. However, the underlying mechanism for the apparent lack of A20 in CF, COPD, and asthma has not been investigated. Transcriptional regulation of A20 is complex and requires coordination of different transcription factors. In this review we examine the existing body of research evidence on the regulation of A20, concentrating on pulmonary inflammation. Special focus is given to the repressor downstream regulatory element antagonist modulator (DREAM) and its nuclear and cytosolic action to regulate inflammation. We provide evidence that would suggest the A20-DREAM axis to be an important player in (airway) inflammatory responses and point to DREAM as a potential future therapeutic target for the modification of phenotypic changes in airway inflammatory disorders. A schematic summary describing the role of DREAM in inflammation with a focus on chronic lung diseases as well as the possible consequences of altered DREAM expression on immune responses is provided.

Evaluation of the risk of cervical cancer in patients with Multiple Sclerosis treated with cytotoxic agents: A cohort study

Background: Since most patients with relapsing-remitting multiple sclerosis (RRMS) are women, the present study aimed to determine whether treatment of patients with MS by cytotoxic agents is associated with an increased risk of cervical dysplasia. Cancer screening is often neglected in the chronic diseases such as MS, so more attention in this field was needed. Decreasing morbidity and mortality due to cervical cancer is the most important goal of screening in female MS patients especially in child bearing age. Thus, it can be said that this is the first study which investigated this important issue. Methods: A total of 129 individuals participated in this cohort study. They were assigned into 3 groups including 43 patients with MS who were treated with cytotoxic drugs, 43 patients with MS on immunomodulators, and 43 normal healthy controls. Pap smears were performed following standard methods and the results obtained from the three groups were compared by statistical analysis. Demographic data, Expanded Disability Status Scale (EDSS), and Pap smear changes were analyzed by SPSS software. Results: The most commonly detected abnormality in all examined patients and healthy controls was inflammation. Five patients with MS who were treated with cytotoxic agents revealed benign cellular changes (BCC) in their Pap smear that were statistically significant in comparison with other groups (P = 0.03). Patients who took Mitoxantrone presented BCC more than other groups [Odds ratio (OR) = 9.44, 95% confidence interval (CI): 1.46-60.70]. There was no significant difference between mean duration of MS diagnosis (P = 0.12), mean duration of previous MS treatments (P = 0.25), and mean duration of current MS treatments (P = 0.21) in patients with BCC compared to normal healthy controls or inflammatory change. Conclusion: According to the results of present study, BCC is more frequently observed in patients with MS who were treated with cytotoxic agents with immunosuppressive effect. Since BCC is a 'premalignant condition', the authors suggest that mandatory annual Pap smear should be performed for patients with MS who are treated with cytotoxic agents irrespective of their age in order to detect early signs of malignancy.

Description of Malignancy Rates in Childhood- and Adult-Onset Systemic Lupus Erythematous by Proportional Meta-analysis

OBJECTIVE

Describe malignancy rates in childhood onset and adult onset systemic lupus erythematous (SLE) by proportional meta-analysis.

METHODS

Two reviewers screened data from PubMed (1966-2015), EMBASE (1980-2015), and LILACS (1982-2015) for SLE-associated malignancy. Proportional meta-analysis with a random-effects model and 95% confidence intervals (CIs) were calculated according to SLE onset age and mean follow-up time. Statistical difference was defined by 95% CI overlap.

RESULTS

Overall the malignancy rate reported in 30 case series with 96,578 subjects was 3.4% (95% CI, 0.0260-0.0442; I = 97.6%; P < 0.0001). The malignancy rate was 4.2% (95% CI, 0.0318-0.0531; I = 98%; P < 0.0001) in 25 adult-onset SLE series, compared with 0.5% (95% CI, 0.0003-0.0154; I = 62.6%; P = 0.03) in 5 childhood-onset SLE series. Overall, in those with less than 5 years' follow-up, the malignancy rate was 2.8% (95% CI, 0.013-0.047; I = 91%; P < 0.0001) compared with 3.6% (95% CI, 0.0226-0.0531; I = 98.3%; P < 0.0001) in those with more than 5 years' follow-up, which was not significant, with 95% CI overlap.

CONCLUSIONS

The meta-analysis indicated lower malignancy rates in pediatric-onset SLE compared with adult-onset SLE, but accrued data from childhood-onset SLE are still needed.

Impact of autoimmune diseases on outcome of patients with early breast cancer

Our aim was to analyze the impact of a concurrent autoimmune disease on outcome of patients with early breast cancer. We reviewed medical charts of patients with a diagnosis of autoimmune diseases (AD) among a population of 17.153 cases. We categorized ADs as endocrine, rheumatic, systemic, neurological diseases and vasculitis. For each patient in the study group, we matched 2 patients. The events to determine overall survival (OS) and disease free survival (DFS) were identified from follow-up data. We identified 279 (1.62%) patients with early breast cancer and concurrent ADs. The median follow-up was 7.0 years. The 10-year OS rate was 86% (95% CI, 80% to 91%) in the study group and 90% (95% CI, 86% to 93%) for the control group (p = 0.011). In patients with ER positive/HER2 negative subtype a worse OS was observed in the study group when compared to the control group (p = 0.0046); this difference remained statistically significant when the analysis was restricted to breast cancer mortality (p = 0.045). The 10-year DFS rate was 69% (95% CI, 61% to 76%) in the study group and 72% (95% CI, 66% to 77%) for the control group (p = 0.22). Autoimmunity at diagnosis of early breast cancer is associated with worse survival.

No association between the risk of breast cancer and systemic lupus erythematosus: evidence from a meta-analysis

Several studies have estimated breast cancer risk in patients with systemic lupus erythematosus (SLE) relative to the general population. However, the results have been inconclusive. Therefore, we conducted a meta-analysis to ascertain a more comprehensive conclusion. A systematic literature search of electronic databases including PubMed, Web of Science, Embase, Cochrane Library, and Scopus was conducted to identify eligible studies using multiple search strategies. Based on the degree of heterogeneity, a random-effect model was chosen to calculate the pooled standardized incidence rate (SIR) with 95% confidence interval (CI), to estimate the strength of association between SLE and breast cancer incidence risk. A total of 18 eligible studies including 110,720 patients with SLE were enrolled in this meta-analysis. The combined results showed no significant association between SLE and breast cancer incidence (SIRs = 1.012 (95% CI, 0.797-1.284)). Subgroup analysis by study type, ethnicity, follow-up years, sample size, and SLE diagnostic criteria also showed no altered risk for breast cancer incidence (the summary risk estimate of each subgroup ranged from 0.82 to 1.40 with no statistical significance). This meta-analysis suggests no direct association between SLE and risk of breast cancer incidence.

Exploring the interplay between autoimmunity and cancer to find the target therapeutic hotspots

Autoimmunity arises when highly active immune responses are developed against the tissues or substances of one's own body. It is one of the most prevalent disorders among the old-age population with prospects increasing with age. The major cause of autoimmunity and associated diseases is the dysregulation of host immune surveillance. Impaired repairment of immune system and apoptosis regulation can be seen as major landmarks in autoimmune disorders such as the mutation of p53 gene which results in rheumatoid arthritis, bowel disease which consequently lead to tissue destruction, inflammation and dysfunctioning of body organs. Cytokines mediated apoptosis and proliferation of cells plays a regulatory role in cell cycle and further in cancer development. Anti-TNF therapy, Treg therapy and stem cell therapy have been used for autoimmune diseases, however, with the increase in the use of immunomodulatory therapies and their development for autoimmune diseases and cancer, the understanding of human immune system tends to become an increasing requirement. Hence, the findings associated with the relationship between autoimmune diseases and cancer may prove to be beneficial for the improvement in the health of suffering patients. Here in, we are eliciting the underlying mechanisms which result in autoimmune disorders causing the onset of cancer, exploration of interactome to find the pathways which are mutual to both, and recognition of hotspots which might play important role in autoimmunity mediated therapeutics with different therapies such as anti-TNF therapy, Treg therapy and stem cell therapy.

Autoimmune Phenomena in Patients with Solid Tumors

INTRODUCTION

Autoimmune disorders have been documented in solid tumors and malignant hematological disorders. They are very common and well studied in lymphomas which are associated with immune imbalance. They are less common in solid tumors and are categorized as paraneoplastic syndromes with unclear pathogenesis.

AIM

The aim of the present study was to find the frequency of autoimmune phenomena in solid tumors of various origin, location and status of the tumor.

PATIENTS AND METHODS

Between 2000 and 2014 we studied 1083 patients with solid tumors that were diagnosed and treated in St George University Hospital, Plovdiv.

RESULTS

We found higher incidence of these phenomena in prostate and ovarian carcinomas (9.01% and 5.6%, respectively) than in other solid tumors. Their distribution by type of autoimmune disease showed that vasculitis, polyneuritis and autoimmune hemolytic anemia have the highest frequency of all. Immune thrombocytopenia, seronegative arthritis, psoriasis, polymyositis are less commonly documented. The autoimmune paraneoplastic phenomena manifest themselves metachronously, less commonly synchronously, with the tumor. In most cases, their clinical manifestation is a progressive disease or metastatic malignant disorder which respond favourably to therapy.

CONCLUSION

Paraneoplastic autoimmune phenomena are found very commonly in prostate and ovarian carcinomas. They occur in the course of the evolvement of neoplasm and can regress with medicamentous or surgical treatment of the malignoma.

Interleukin-1β as emerging therapeutic target in hematological malignancies and potentially in their complications

Interleukin-1β (IL-1β) is a pleiotropic cytokine that exerts multiple roles in both physiological and pathological conditions. It is produced by different cell subsets, and drives a wide range of inflammatory responses in numerous target cells. Enhanced IL-1β signaling is a common event in patients of hematological malignancies. Recent body of evidence obtained in preclinical models shows the pathogenic role of these alterations, and the promising therapeutic value of IL-1 targeting. In this review, we further highlight a potential contribution of IL-1β linking to complications and autoimmune disease that should be investigated in future studies. Hence, drugs that target IL-1 may be helpful to improve outcome or reduce morbidity in patients. Some of them are FDA-approved, and used efficiently against autoimmune diseases, like IL-1 receptor antagonist. In the clinic, however, this agent seems to have limited properties. Current improved drugs will allow to determine the true potential of IL-1 and IL-1β targeting as therapy in hematological malignancies and their related complications.

Novel risk factors related to cancer in scleroderma

OBJECTIVE

Emerging data have shown an increased risk of malignancy among patients diagnosed with systemic sclerosis (SSc) so identification of risk factors linking both disorders might have prognostic implications. The aim of this study was to assess the clinical and treatment-related risk factors for cancer in a single-center cohort of patients with SSc.

METHODS

Demographic, clinical, capillaroscopic, immunological and treatment-related data from 432 consecutive SSc patients were retrospectively analyzed. Variables that reached significant association in the univariate analysis were entered into a logistic regression in order to identify independent risk factors for cancer.

RESULTS

Malignancy was diagnosed in 53 patients (12.2%). Fifty-eight neoplasms were identified, among which breast (n=15), lung (n=10) and hematologic (n=9) malignancies were the most prevalent. In 19 patients the diagnosis of both scleroderma and tumour was made in <3years apart. Cancer significantly decreased the probability of survival (OR=2.61; 95%CI 1.46-4.69; p=0.001). No association with age, sex, smoking, cutaneous subset or RNA polymerase-III antibodies was found. However, risk of cancer was directly associated with the presence of anti-PM/Scl antibodies (OR=3.90; 95%CI 1.31-11.61; p=0.014), and inversely related to aspirin use (OR=0.33; 95%CI 0.12-0.90; p=0.031), which remained as independent risk factors for cancer on multivariate analysis.

CONCLUSIONS

PM/Scl antibodies seem to be associated with a higher risk of cancer in scleroderma. In contrast, the use of aspirin is related to a lower risk of cancer in our series. More studies are needed to ascertain the role of anti PM/Scl antibodies and aspirin in the development of malignancy among patients with SSc.

Neoplasia in Turner syndrome. The importance of clinical and screening practices during follow-up

AIM OF THE STUDY

Turmer syndrome (TS) patients show increased morbidity due to metabolic, autoimmune and cardiovascular disorders. A risk of neoplasia is also reported. Here, we review the prevalence of neoplasia in a cohort of Turner patients.

METHODS

We retrospectively evaluated 87 TS women. Follow-up included periodic ultrasound of the neck, abdominal and pelvic organs, dermatologic evaluation and fecal occult blood test. Karyotype was 45,X in 46 patients. During follow-up, 63 girls were treated with growth hormone, 65 with estro-progestin replacement therapy and 20 with L-thyroxine. Autoimmune diseases were present in 29 TS.

RESULTS

A total of 17 neoplasms in 14 out of 87 patients were found. Six skin neoplasia, 3 central nervous system tumors, 3 gonadal neoplasia, 2 breast tumors, 1 hepatocarcinoma, 1 carcinoma of the pancreas and 1 follicular thyroid cancer were detected. Age at tumor diagnosis was higher in 45,X pts than in those with other karyotypes (p = 0.003). Adenomioma gallbladdder (AG) was detected in 15.3% of the patients, with a lower age in girls at diagnosis with an associated neoplasia in comparison with TS without tumors (p = 0.017). No correlation between genetic make up, treatment, associated autoimmune diseases and neoplastia was found.

CONCLUSION

In our TS population an increased neoplasia prevalence was reported. A high prevalence of AG was also noted and it might be indicative of a predisposition to neoplasia. Further studies are needed to define the overall risk for neoplasia, and to determine the role of the loss of the X-chromosome and hormonal therapies.

Systemic lupus erythematosus and malignancies risk

OBJECTIVE

To evaluate the risk of site-specific and overall malignancies after SLE and explore the potential influencing factors.

METHODS

We searched electronic databases for articles that assessed the risk of malignancies after SLE through February 2015. We extracted the incidence rates (IRs) and corresponding 95 % confidence intervals (CIs). We used random effects models to calculate the pooled IRs and assessed the impact of study designs, region, gender, age and duration of follow-up.

RESULTS

Eighteen studies were included, giving a pooled IR of 1.44 (95 % CI 1.23-1.69). Europeans, Americans and Asians showed a IR of 1.56 (95 % CI 1.07-2.28), 1.18 (95 % CI 1.01-1.39) and 1.62 (95 % CI 1.38-1.89), respectively. Males and females (eight studies) demonstrated a IR of 1.34 (95 % CI 1.07-1.67) and 1.51 (95 % CI 1.20-1.90), respectively. Prospective and retrospective studies showed a IR of 1.55 (95 % CI 0.97-2.47) and 1.44 (95 % CI 1.21-1.73), respectively. An increment of 10 years of age conferred a decrease in IR of 0.6. An increment of 5 years of SLE duration conferred a decrease in IR of 2.5. An increased IR of malignancies was observed in NHL, vagina/vulva, hematology, head/neck, leukemia, thyroid, liver/gallbladder, kidney, anal, cervix, esophagus, lung and pancreas. A decreased IR of malignancies was observed in ovary and colon/rectum.

CONCLUSIONS

SLE patients had an increased risk of developing overall malignancies, particularly among Asians and females. Age and SLE duration are inversely associated with the risk of overall malignancies. SLE patients showed a different role in the onset of various site-specific malignancies.

Predisposition to Cervical Atypia in Systemic Lupus Erythematosus: A Clinical and Cytopathological Study

Introduction. Systemic lupus erythematosus (SLE) is a complex disease with variable presentations, course, and prognosis. The female genital tract may be a potential target organ in SLE since cervical inflammation may be associated with disease activity. An increase in cervical dysplasia, a precursor of cervical cancer, has been reported in females with SLE. Aim of the Work. This work aimed to study the prevalence of abnormal cervicovaginal smears in patients with systemic lupus erythematosus (SLE) and to correlate abnormal smear findings with exposure to infection with human papilloma virus (HPV) in SLE patients. Patients and Methods. Thirty-two patients with SLE, fulfilling the 1997 revised criteria for the classification of SLE, were included in this study. They were subjected to full history taking, clinical examination, laboratory investigations, and cervicovaginal smearing. Twenty healthy subjects not known to suffer from any rheumatological disease were used as controls, and they were subjected to cervicovaginal smearing. Results. Four out of 32 SLE patients showed abnormal Pap smears (12.5%) compared to none showing any cervical changes in the control group (0%). Among these 4 patients, 3 were having ASCU and one was having LSIL (HPV). Conclusion. Cervicovaginal smearing is an easy, economic, safe, repeatable, and noninvasive technique for screening and early detection of cervical neoplastic lesions in SLE.

Polymyalgia Rheumatica and its Association with Cancer

OBJECTIVE

Polymyalgia rheumatica (PMR) is a common rheumatologic disease in the elderly population. Studies on the relationship between PMR and cancer have yielded mixed results and have been limited by multiple factors. This study examined the association between PMR and development of cancer in a community cohort.

METHODS

A population-based cohort of 359 patients with PMR diagnosed between 1/1/1970 and 12/31/1999 and followed to 12/31/2013 was assembled along with a comparison cohort of 357 subjects. Records of the PMR and comparator subjects were reviewed for details concerning diagnosis of cancer. The cumulative incidence of malignancy in patients with and without PMR, adjusted for the competing risk of death, was estimated and compared using methods of Gray. Cox proportional hazards models were used to assess the trends in malignancy over time.

RESULTS

There was no significant difference in the prevalence of malignancy prior to PMR incidence date/index date between the two groups with prior malignancies in 41 (11%) of patients with PMR, and 50 (14%) of non-PMR subjects (p-value=0.31). As well, there was no difference in the cumulative incidence of malignancy at 10 years following PMR incidence between patients with PMR and non-PMR subjects (cumulative incidence at 10 years ± SE: PMR 13.8 ± 2.0, control 13.1 ± 2.0; p-value=0.89).

CONCLUSION

There is no increased risk of malignancy in patients who are diagnosed with PMR when compared to subjects without PMR in this population-based cohort.

Systemic lupus erythematous and malignancy risk: a meta-analysis

Background

Pilot studies have estimated cancer incidence in patients with systemic lupus erythematous (SLE). However, the results have been inconclusive. To ascertain the correlation between SLE and malignancy more comprehensively and precisely, we conducted a meta-analysis.

Methods

PubMed, the Cochrane Library and Embase databases through June 2014, were searched to identify observational studies evaluating the association between SLE and malignancy. The outcomes from these studies were measured as relative risks (RRs). A random or fixed effects model was chosen to calculate the pooled RR according to heterogeneity test. Between-study heterogeneity was assessed by estimating I² index. Publication bias was assessed by Egger’s test.

Results

A total of 16 papers, including 59,662 SLE patients, were suitable for the meta-analysis. Of these papers, 15 reported RRs for overall malignancy, 12 for non-Hodgkin lymphoma (NHL) and lung cancer, 7 for bladder cancer, 6 for Hodgkin lymphoma (HL) and leukemia, 5 for skin melanoma, and liver and thyroid cancers, 4 for multiple myeloma (MM), and esophageal and vaginal/vulvar cancers and 3 for laryngeal and non-melanoma skin cancers. The pooled RRs were 1.28 (95% CI, 1.17–1.41) for overall cancer, 5.40 (95% CI, 3.75–7.77) for NHL, 3.26(95% CI, 2.17–4.88) for HL, 2.01(95% CI, 1.61–2.52) for leukemia, 1.45(95% CI, 1.04–2.03) for MM, 4.19(95% CI, 1.98–8.87) for laryngeal cancer, 1.59 (95% CI, 1.44–1.76) for lung cancer, 1.86(95% CI, 1.21–2.88) for esophageal cancer, 3.21(95% CI, 1.70–6.05) for liver cancer, 3.67(95% CI, 2.80–4.81) for vaginal/vulvar cancer, 2.11(95% CI, 1.12–3.99) for bladder cancer, 1.51(95% CI, 1.12–2.03) for non-melanoma skin cancer, 1.78(95% CI, 1.35–2.33) for thyroid cancer, and 0.65(95% CI, 0.50–0.85) for skin melanoma. Only the meta-analyses of overall malignancy, NHL, and liver and bladder cancers produced substantial heterogeneity (I², 57.6% vs 74.3% vs 67.7% vs 82.3%). No apparent publication bias was detected except for NHL studies.

Conclusions

Our data support an association between SLE and malignancy, not only demonstrating an increased risk for NHL, HL, leukemia, and some non-hematologic malignancies, including laryngeal, lung, liver, vaginal/vulvar, and thyroid malignancies, but also a reduced risk for skin melanoma. Although an increased risk of MM, and esophageal, bladder and non-melanoma skin cancers was identified from the accumulated data in these studies, this observation requires confirmation.

Patients with systemic lupus erythematosus and haematological malignancy at a tertiary care centre: timing, histopathology and therapy

Objectives

Patients with systemic lupus erythematosus (SLE) are at higher risk of haematological malignancies (HMs) than the general population. Most reports have focused on HM diagnosed after SLE, and have excluded concurrent and preceding diagnoses. Information on response to therapy is also limited.

Methods

We identified 13 296 cases of HM and 10 539 potential patients with SLE at our centre; 45 patients were confirmed to have HM and SLE. Our retrospective case series was based on these 45 patients.

Results

Of the 45 patients, 64% were diagnosed with HM ≥1 year after diagnosis with SLE, and 36% with HM before or concurrent with SLE. Of the 29 patients with HM after SLE, 13 had diffuse large B cell lymphoma (DLBCL), 6 indolent lymphoma, 4 leukaemia, 3 Hodgkin's disease, and 1 each Burkitt's lymphoma, T cell lymphoma and multiple myeloma. Eleven patients with DLBCL were treated with cyclophosphamide, hydroxydaunorubicin, oncovin and prednisone (CHOP) or rituximab-CHOP; hydroxydaunorubicin, oncovin and prednisone; only four achieved durable remission. Of the 16 patients diagnosed with HM before or concurrent with SLE, 9 were diagnosed with HM more than 2 years before SLE and tended to be in remission prior to SLE diagnosis. Seven patients were diagnosed with HM and SLE concurrently; in terms of their HM, six achieved remission or stable disease.

Conclusions

In summary, DLBCL was the most common type of lymphoma in patients diagnosed with HM after SLE; these patients presented with advanced-stage disease and had poor outcomes. In contrast, patients diagnosed with HM before or concurrent with SLE had early stage disease and typically achieved remission.

Comorbidities of pediatric systemic lupus erythematosus: A 6-year nationwide population-based study

OBJECTIVE

Systemic lupus erythematous (SLE) is a systemic and complex disease that can involve multiple organs. To clarify the risk of developing associated comorbidities after a diagnosis of SLE in children, we used the National Health Insurance Research Database (NHIRD) in Taiwan to investigate diseases experienced in these patients. This is the first nationwide population-based study of the comorbidities of pediatric SLE patients.

METHODS

The study was based on data from the NHIRD in Taiwan. Children were enrolled who were below the age of 18 years and whose disease corresponded to the International Classification of Disease, Ninth Revision Clinical Modification (ICD-9-CM) diagnostic code of 710.0 (SLE). The comorbidities associated with SLE were defined by the ICD-9-CM codes of diseases that presented after the SLE diagnosis. We analyzed the common diseases in SLE patients and compared the frequency of these diseases between pediatric SLE patients and the non-SLE population.

RESULTS

From January 1, 2003 to December 31, 2008, we enrolled 904 SLE patients (774 females, 130 males). Infection (86.36%) was the most common comorbidity in pediatric SLE. Other comorbidities were musculoskeletal diseases (16.7%), cardiovascular diseases (16.37%), ocular diseases (10.73%), and renal diseases (6.75%). Children with SLE had a higher risk of heart failure, hypertension, osteoporosis, cataracts, glaucoma, dyslipidemia, seizures, encephalopathy, and malignant changes, compared to non-SLE populations.

CONCLUSION

The population-based cohort demonstrated several systemic and/or chronic diseases in pediatric SLE patients in Taiwan. Children with SLE were more susceptible to these diseases, including malignancy, compared to the non-SLE population.

Aseptic necrosis at multiple localisations in a lupus patient with lymphoma

Avascular or aseptic necrosis is a well-defined entity leading to the degradation of cellular elements of the bone. The pathogenesis of osteonecrosis (ON) is still unknown. There are two main types of ON: traumatic or non-traumatic. Several clinical entities could associate with ON, systemic diseases, environmental factors, pregnancy, systemic autoimmune or rheumatic diseases, thrombophilia, corticosteroid therapy, cytotoxic dugs, infections, metabolic and hematologic diseases, etc. Corticosteroids (CS) are still the most frequently used therapeutic options in the early phase and during flares of these diseases. Inflammatory cytokines and antibodies have been described to participate in the pathogenesis of ON. The infiltrative disorders of the bone marrow could also contribute to the development of ON. Hereby, we describe a female patient with NHL followed by SLE in whom ON has developed at least in two localisations. Lupus flare, long-term CS therapy, lymphoma relapse or the presence of antiphospholipid antibodies were excluded. Although the bi-localised ON could be contributed to immunologic factors or trauma, the exact aetiology in this case could not be elucidated.

Immunologic pathomechanism of Hodgkin's lymphoma

Hodgkin's lymphoma is a lymphoid malignancy of the immune system. The pathognomonic Hodgkin and Reed-Sternberg cells (HRS) are derived mainly from monoclonal, preapoptotic B cells, and they carry rearranged, somatically mutated immunoglobulin heavy chains. In an appropriate microenvironment, HRS cells escape from apoptosis by several mechanisms, including single mutations, aberrant signaling pathways. Eventually, weakened immune surveillance leads to uncontrolled, disproportional B cell proliferation. This review summarizes the latest findings on the pathogenesis of Hodgkin lymphoma, with a special emphasis on immunologic processes, and depicts current and future immunotherapeutic regimens, which improve treatment outcomes and reduce late toxicities.

Impact of head and neck malignancies on risk factors and survival in systemic lupus erythematosus

CONCLUSIONS

Systemic lupus erythematosus (SLE) is associated with an increased risk of developing a head and neck malignancy (HNM). A history of SLE did not significantly impact the survival of our study cohort after cancer developed.

OBJECTIVES

To examine the risk and survival rates of HNM in patients with SLE.

METHODS

This was a population-based, retrospective cohort study. We compared patients newly diagnosed with SLE between 2001 and 2008 (n = 8751) with age-matched controls (1:10) (n = 87 510). The incidence of HNMs at the end of 2009 was then determined.

RESULTS

We found a 2.16-fold higher risk of HNMs in patients diagnosed with SLE compared with the risk of first malignancy in the age-matched controls (incidence rate ratio, IRR = 2.16, p < 0.05). The site with the highest incidence of HNMs in SLE patients was the oral cavity (5/11, 45.45%), followed by the nasopharynx (4/11, 36.36%). SLE displayed no synergic effect on the survival of SLE patients with an HNM compared with age-matched controls with a new HNM (p = 0.2446).

Cancer risk in immune-mediated inflammatory diseases (IMID)

Inflammation and cancer have a profound yet ambiguous relationship. Inflammation - especially chronic inflammation - has protumorigenic effects, but inflammatory cells also mediate an immune response against the tumor and immunosuppression is known to increase the risk for certain tumors.This article reviews current literature on the role of inflammation in cancer and the cancer risk in immune-mediated inflammatory diseases (IMIDs). We discuss the effect on cancer risk of different drug classes used in the treatment of IMIDs treatment, including biologicals such as tumor necrosis factor (TNF) inhibitors.Overall cancer incidence and mortality risk are similar to the general population in inflammatory bowel disease (IBD), and slightly increased for rheumatoid arthritis and psoriasis, with risk profiles differing for different tumor types. Increased risk for non-melanoma skin cancer is associated with thiopurine treatment in IBD, with the combination of anti-TNF and methotrexate in rheumatoid arthritis and with PUVA, cyclosporine and anti-TNF treatment in psoriasis. Data on the safety of using biologic or immunosuppressant therapy in IMID patients with a history of cancer are scarce.This review provides clinicians with a solid background to help them in making decisions about treatment of immune-mediated diseases in patients with a tumor history.This article is related to another review article in Molecular Cancer: http://www.molecular-cancer.com/content/12/1/86.

Clinical course, prognosis, and causes of death in mixed connective tissue disease

OBJECTIVE

To study the survival rate and prognostic indicators of mixed connective tissue disease (MCTD) in a Hungarian population.

METHODS

Two hundred eighty patients with MCTD diagnosed between 1979 and 2011 were followed prospectively. Clinical features, autoantibodies, and mortality data were assessed. Prognostic factors for survival were investigated and survival was calculated from the time of the diagnosis by Kaplan-Meier method.

RESULTS

A total of 22 of 280 patients died: the causes of death were pulmonary arterial hypertension (PAH) in 9 patients, thrombotic thrombocytopenic purpura in 3, infections in 3, and cardiovascular events in 7. The 5, 10, and 15-year survival rates after the diagnosis was established were 98%, 96%, and 88%, respectively. The deceased patients were younger at the diagnosis of MCTD compared to patients who survived (35.5 ± 10.4 vs 41.8 ± 10.7 yrs; p < 0.03), while there was no difference in the duration of the disease (p = 0.835). Our cohort study showed that the presence of cardiovascular events (p < 0.0001), esophageal hypomotility (p = 0.04), serositis (p < 0.001), secondary antiphospholipid syndrome (p = 0.039), and malignancy (p < 0.001) was significantly higher in the deceased patients with MCTD. The presence of anticardiolipin (p = 0.019), anti-β2-glycoprotein I (p = 0.002), and antiendothelial cell antibodies (p = 0.002) increased the risk of mortality.

CONCLUSION

Overall, PAH remained the leading cause of death in patients with MCTD. The prevalence of cardiovascular morbidity and mortality, malignancy, and thrombotic events increased during the disease course of MCTD. The presence of antiphospholipid antibodies raised the risk of mortality.

Safety profile of belimumab: pooled data from placebo-controlled phase 2 and 3 studies in patients with systemic lupus erythematosus

Safety data were pooled and analyzed from one phase 2 and two phase 3 double-blind, placebo-controlled, repeat-dose systemic lupus erythematosus (SLE) trials of belimumab 1, 4 (phase 2 only), and 10 mg/kg. Types and rates of adverse events (AEs) were similar across treatment groups. Rates of patients experiencing any serious AE were 16.6%, 19.5%, 13.5%, and 18.0% with placebo, and belimumab 1, 4, and 10 mg/kg, respectively; rates of serious infusion reactions (including hypersensitivity reactions) occurring on the same days as infusions were 0.4%, 0.9%, 0%, and 0.9%, and rates of serious infections were 5.5%, 7.1%, 6.3%, and 5.3%. Malignancy rates/100 patient-years (excluding non-melanoma skin cancer) were 0.29 with placebo vs. 0.20 with all belimumab doses combined; mortality rates/100 patient-years were 0.43 vs. 0.73. These data support the conclusion that belimumab in combination with standard SLE therapy was generally well tolerated in a predominantly autoantibody-positive population with active SLE. ClinicalTrials.gov identifiers: LBSL02: NCT00071487; BLISS-52: NCT00424476; BLISS-76: NCT00410384.

Defective DNA double-strand break repair in pediatric systemic lupus erythematosus

OBJECTIVE

Previous reports of cells from patients with systemic lupus erythematosus (SLE) note that repair of single-strand breaks is delayed, and these lesions may be converted to double-strand breaks (DSBs) at DNA replication forks. We undertook this study to assess the integrity of DSB recognition, signaling, and repair mechanisms in B lymphoblastoid cell lines derived from patients with pediatric SLE.

METHODS

Nine assays were used to interrogate DSB repair and recognition in lymphoblastoid cell lines from patients with pediatric SLE, including the neutral comet assay (NCA), colony survival assay (CSA), irradiation-induced foci formation for γ-H2AX and 53BP1 proteins, kinetics of phosphorylation of structural maintenance of chromosomes protein 1 (SMC1), postirradiation bromodeoxyuridine incorporation to evaluate S phase checkpoint integrity, monoubiquitination of Fanconi protein D2, ATM protein expression, and non-homologous DNA end joining protein expression and function.

RESULTS

Three of the 9 assays revealed abnormal patterns of response to irradiation-induced DNA damage. The NCA and CSA yielded aberrant results in the majority of SLE lymphoblastoid cell lines. Abnormal prolongation of SMC1 phosphorylation was also noted in 2 of 16 SLE lymphoblastoid cell lines.

CONCLUSION

Our data suggest that DSB repair is defective in some lymphoblastoid cell lines from pediatric patients with SLE, especially when assessed by both NCA and CSA. Since these studies are nonspecific, further studies of DNA repair and kinetics are indicated to further delineate the underlying pathogenesis of SLE and possibly identify therapeutic targets.

The age-risk relationship of haematologic malignancies in female patients with systemic lupus erythematosus: a nationwide retrospective cohort study

BACKGROUND

The risks of haematologic malignancies in female patients with systemic lupus erythematosus (SLE) have been observed to be higher in young age groups than in old age groups. However, the age-risk relationship between haematologic malignancies and SLE is poorly defined.

DESIGN AND METHODS

A retrospective cohort study was conducted nationwide with newly diagnosed SLE female patients during the period of 1997 to 2001 using the database acquired from the Taiwan National Health Research Institute. Each patient in the study was randomly frequency matched with five SLE-free people based on age. The subsequent developments of haematologic malignancies were observed until the date haematologic cancer was diagnosed or December 2008. The age-adjusted standardized incidence ratios (SIRs), the incidence per 1000 person-years, the follow-up duration to the diagnosis of haematologic malignancies and the cumulative hazard rates of haematologic malignancies between SLE and controls were analysed.

RESULTS

A total of 35 lymphoid and 14 myeloid malignancies were observed among 9349 female SLE patients. Further, significantly higher incidences of both lymphoid and myeloid malignancies were found in SLE patients (SIR: 3.30, 95% confidence interval (CI) = 2.20-4.93 and SIR: 2.86, 95% CI = 1.49-5.09). Also, two peaks of risk ratios for lymphoid malignancies were found in patients aged 21-30 years and 41-50 years. It was observed that the follow-up duration for haematologic malignancies was significantly shorter in SLE patients than in controls (73.21 vs. 105.25 months, respectively). In addition, higher cumulative hazard rates in both lymphoid and myeloid malignancies were found in SLE patients (p < 0.0001).

CONCLUSION

Female SLE patients have a higher incidence of haematologic malignancy in different age groups, and with shorter incubating time than SLE-free people.

Role of autophagy in immunity and autoimmunity, with a special focus on systemic lupus erythematosus

Autophagy is a lysosome-mediated catabolic process that allows cells to degrade unwanted cytoplasmic constituents and to recycle nutrients. Autophagy is also involved in innate and adaptive immune responses, playing a key role in interactions against microbes, in antigen processing for major histocompatibility complex (MHC) presentation, and in lymphocyte development, survival, and proliferation. Over recent years, perturbations in autophagy have been implicated in a number of diseases, including autoimmunity. Systemic lupus erythematosus (SLE) is a multifactorial disease characterized by autoimmune responses against self-antigens generated by dying cells. Genome-wide association studies have linked several single-nucleotide polymorphisms (SNPs) in the autophagy-related gene Atg5 to SLE susceptibility. Loss of Atg5-dependent effects, including clearance of dying cells and cell antigen presentation, might contribute to the autoimmunity and inflammation associated with SLE. Moreover, activation of the mammalian target of rapamycin (mTOR), a key player in the autophagy regulation, has recently been demonstrated in SLE, confirming an altered autophagy pathway in this disease. In the present review, we summarize the autophagy mechanisms, their molecular regulation, and their relevance in immunity and autoimmunity. The potential of targeting autophagy pathway in SLE, by developing innovative therapeutic approaches, has finally been discussed.

Susceptibility of patients with rheumatic diseases to B-cell non-Hodgkin lymphoma

Autoimmune rheumatic diseases (ARD), such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and Sjögren's syndrome (SS), have consistently been associated with the development of B-cell non-Hodgkin lymphoma (BCNHL). In this Review, we focus on reports published since 2006 and summarize the data regarding the BCNHL subtypes and clinical findings associated with this increased risk. Patients with these ARD, particularly those with detectable autoantibodies and systemic involvement, are at increased risk of developing BCNHL, especially diffuse large B-cell lymphoma and marginal zone lymphoma. SS shows the strongest association with BCNHL. Male sex, advanced age, prolonged disease course and increased disease severity, but not family history of autoimmune conditions, seem to be associated with an increased risk of non-Hodgkin lymphoma. Chronic immune stimulation, genetic and environmental factors and some immunosuppressive drugs might be involved in lymphomagenesis in these patients. The reason why some ARD are associated with BCNHL and other autoimmune diseases are not remains unclear. These associations are important as they provide information about the mechanisms of lymphomagenesis, and might help identify new therapeutic targets.

MALT lymphoma: many roads lead to nuclear factor-κb activation

Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT) lymphoma is characterized genetically by several recurrent, but mutually exclusive, chromosome translocations. To date, it has been shown that at least the oncogenic products of t(1;14)(p22;q32)/BCL10-IGH, t(14;18)(q32;21)/IGH-MALT1 and t(11;18)(q21;q21)/API2-MALT1 activate the nuclear factor (NF)-κB activation pathway. Recently, A20, an essential global NF-κB inhibitor, was found to be inactivated by somatic deletion and/or mutation in translocation-negative MALT lymphomas. However, these genetic abnormalities alone are not sufficient for malignant transformation and thus need to cooperate with other factors in MALT lymphomagenesis. Recent studies have shown steady, exciting progresses in our understanding of the biological functions of BCL10, MALT1 and A20 in the regulation of the NF-κB activation pathways and the biology of lymphocytes. This review discusses the implication of these recent advances in the molecular pathogenesis of MALT lymphoma, and explores how the above genetic abnormalities cooperate with immunological stimulation in the development of lymphoma.

The Clinical Usefulness of (18)F-FDG PET/CT in Patients with Systemic Autoimmune Disease

PURPOSE

Individuals with systemic autoimmune disease have an increased susceptibility to both inflammation and malignancy. The aim of this study was to evaluate the clinical usefulness of (18)F-FDG PET/CT in patients with systemic autoimmune disease.

METHODS

Forty patients diagnosed with systemic autoimmune disease were enrolled. Diagnostic accuracy of FDG PET/CT for detecting malignancy was assessed. FDG PET/CT findings, including maximum standardized uptake (SUVmax) of lymphadenopathy (LAP), liver, bone marrow, spleen, joint and muscles, were considered for the characterization of LAPs.

RESULTS

FDG PET/CT could detect metabolically activated lesions in 36 out of 40 patients (90%) including inflammatory lesions in 28 out of 32 patients (88%). The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of FDG PET/CT for the detection of malignancy were 100, 67, 70, 25, and 100%, respectively. Multiple LAPs were found in 25 of 40 patients (63%), and comprised three malignancies, four cases of tuberculosis, and 18 reactive changes. A SUVmax ratio of bone marrow to liver below 0.78 could distinguish malignancy from tuberculosis + reactive change (AUC = 1.000, sensitivity: 100%, specificity: 100%). The SUVmax ratio of spleen to liver in the reactive group was also significantly higher than that in the malignancy group (P = 0.014). SUVmax of LAP in the TB group was significantly higher than that in the reactive group (P = 0.040).

CONCLUSIONS

PET/CT is useful in detecting and differentiating inflammation and malignancy in patients with systemic autoimmune disease. Frequent false-positive interpretations can be minimized by consideration of FDG uptake in bone marrow and spleen.