The Relationship Between Rheumatologic Disorders and Malignancies

Absence of Long-Lasting Morning Stiffness at the Time of Diagnosis as Paraneoplastic Warning in Patients with Polymyalgia Rheumatica (PMR): Data from Italian Single-Center Study

BACKGROUND

There is little literature on the paraneoplastic value of the absence of long-lasting morning stiffness (MS) at the time of diagnosis of polymyalgia rheumatica (PMR). We investigated whether and to what extent this finding was related to the probability of diagnosing a neoplasia.

PATIENTS AND METHODS

This was an observational, retrospective, single-center cohort study. We enrolled all patients consecutively referred to our rheumatologic outpatient clinic between January 2015 and December 2020, who could be classified as PMR according to 2012 EULAR/ACR criteria. In particular, we assessed all patients scoring a minimum of five points with a combination of clinical and ultrasound (US) criteria. The exclusion criteria were as follows: (a) follow-up duration

RESULTS

143 patients (108 women; median age: 71.5 years) were enrolled, and 35 of them did not have long-standing MS at the time of PMR diagnosis. In 10 patients (6.9%), a neoplasia was diagnosed in the first 6 months of follow-ups; among these, 7 did not have long-lasting MS. Among the remaining 133 PMR patients without subsequent malignancy, 28 did not have long-lasting MS. The odds of cancer were 0.114 (C.I. 95% 0.028, 0.471). Long-lasting MS was inversely associated with the development of neoplasias. In all eight PMR patients diagnosed with solid cancers during follow-ups, the removal of the neoplastic mass led to a fast disappearance of clinical, ultrasound and laboratory findings, thus supporting the diagnosis of paraneoplastic PMR. Finally, a positive response to glucocorticoids (GCs) was present in 100% of the 28 PMR patients without long-lasting MS at the time of diagnosis and without neoplasia during their follow-ups. On the contrary, a positive response to GCs was present in 71% of PMR patients without long-lasting MS and neoplasias during follow-up. Among the variables we assessed, a positive response to GCs was the only one that was statistically significant (p < 0.0001). These data suggested that an inadequate response to GCs in PMR patients without long-lasting MS at the time of diagnosis should strengthen investigations to rule out neoplasias.

CONCLUSIONS

The absence of long-standing MS at the time of diagnosis can be a paraneoplastic warning in patients classified as PMR. A thorough investigation is therefore needed in this subset of patients to rule out neoplasia, before diagnosing an idiopathic PMR and starting treatment with GCs.

Collapse

Key Words

• morning stiffness
• observational study
• paraneoplastic syndrome
• polymyalgia rheumatica
• single-center cohort study

Collapse

MESH Headings Collapse

Grants Collapse

Affiliation(s)

Ciro Manzo Internal and Geriatric Medicine Department, Rheumatologic Outpatient Clinic, Azienda Sanitaria Locale Napoli 3 Sud, Health District No. 59, Sant’Agnello, 80065 Naples, Italy
Alberto Castagna Primary Care Department, Azienda Sanitaria Provinciale Catanzaro, 88068 Soverato, Italy;
Marco Isetta Library and Knowledge Services, Central and North West London NHS Foundation Trust, London NW1 3AX, UK;

Collapse

Paraneoplastic musculoskeletal disorders: review and update for radiologists

Rheumatic paraneoplastic syndromes are rare syndromes that occur at distant sites from the underlying tumor and may involve the bones, joints, fasciae, muscles, or vessels. In the absence of a known tumor, early recognition of a rheumatic syndrome as paraneoplastic permits dedicated work-up for, and potentially early treatment of an occult malignancy. Although there is a continuously growing list of paraneoplastic rheumatic disorders, not all of these disorders have a well-established association with a neoplastic process. The goals of this article are to review the clinical characteristics, diagnostic work-up, and imaging findings of well-documented rheumatic paraneoplastic disorders.

Gastric Adenocarcinoma Presenting as a Rheumatoid Factor and Anti-cyclic Citrullinated Protein Antibody-Positive Polyarthritis: A Case Report and Review of Literature

A 64-year-old male presented with a 6-month history of symmetric polyarthritis involving proximal interphalangeal joints and metacarpophalangeal joints of the hands, wrists, and ankles. Associated symptoms included vomiting, progressive fatigue, and weight loss. Laboratory results showed microcytic anemia, leukocytosis, thrombocytosis, elevated C-reactive protein and erythrocyte sedimentation rate, and rheumatoid factor (RF) and anti-cyclic citrullinated protein (ACPA) antibody positivity. Joints radiographs were normal, without erosions. Upper endoscopy and gastric endoscopic ultrasonography showed a gastric adenocarcinoma with lymphatic involvement. Intraoperatively, peritoneal carcinomatosis was documented, and the patient started palliative chemotherapy. A paraneoplastic seropositive arthritis was assumed, and treatment with low-dose prednisolone and hydroxychloroquine was started. Arthritis remission was achieved and sustained up to 18 months of follow-up, although gastric cancer progression was documented. We describe a unique phenotype of paraneoplastic arthritis (PA) presenting as a seropositive (RF and ACPA positivity) rheumatoid arthritis (RA) with a good response to both low dose corticosteroids and hydroxychloroquine therapy. We also review the literature of PA, mostly the RA-like pattern, and the association between PA and ACPA positivity. This case highlights the importance of considering underlying cancer in elderly male patients, presenting with polyarthritis and systemic symptoms, even in those with ACPA-positive RA-like arthritis.