Systemic lupus erythematosus and lymphoma

Bioinformatics-based analysis of the roles of basement membrane-related gene AGRN in systemic lupus erythematosus and pan-cancer development

Introduction

Systemic lupus erythematosus (SLE) is an autoimmune disease involving many systems and organs, and individuals with SLE exhibit unique cancer risk characteristics. The significance of the basement membrane (BM) in the occurrence and progression of human autoimmune diseases and tumors has been established through research. However, the roles of BM-related genes and their protein expression mechanisms in the pathogenesis of SLE and pan-cancer development has not been elucidated.

Methods

In this study, we applied bioinformatics methods to perform differential expression analysis of BM-related genes in datasets from SLE patients. We utilized LASSO logistic regression, SVM-RFE, and RandomForest to screen for feature genes and construct a diagnosis model for SLE. In order to attain a comprehensive comprehension of the biological functionalities of the feature genes, we conducted GSEA analysis, ROC analysis, and computed levels of immune cell infiltration. Finally, we sourced pan-cancer expression profiles from the TCGA and GTEx databases and performed pan-cancer analysis.

Results

We screened six feature genes (AGRN, PHF13, SPOCK2, TGFBI, COL4A3, and COLQ) to construct an SLE diagnostic model. Immune infiltration analysis showed a significant correlation between AGRN and immune cell functions such as parainflammation and type I IFN response. After further gene expression validation, we finally selected AGRN for pan-cancer analysis. The results showed that AGRN's expression level varied according to distinct tumor types and was closely correlated with some tumor patients' prognosis, immune cell infiltration, and other indicators.

Discussion

In conclusion, BM-related genes play a pivotal role in the pathogenesis of SLE, and AGRN shows immense promise as a target in SLE and the progression of multiple tumors.

Cancer and Systemic Lupus Erythematosus

Systemic lupus erythematosus is associated with a small overall increased cancer risk compared with the general population. This risk includes a 4-fold increased risk of non-Hodgkin lymphoma, but a decreased risk of other cancers (such as breast cancer). The pathophysiology underlying the increased risk of hematologic cancer is not fully understood, but many potential mechanisms have been proposed, including dysfunction of the tumor necrosis factor and other pathways. A decreased risk of breast, ovarian, and endometrial cancer might be driven by hormonal factors or lupus-related antibodies, but these links have not been proved.

Malignant Lymphoma in Patients with Systemic Rheumatic Disease (Rheumatoid Arthritis, Systemic Lupus Erythematosus, Systemic Sclerosis, and Dermatomyositis): A Clinicopathologic Study of 24 Japanese Cases

We conducted clinicopathologic and immunohistochemical analyses of the prevalence of Epstein-Barr virus (EBV) among 24 patients with malignant lymphoma complicating systemic rheumatic diseases. (SRD) These 24 patients included 17 with rheumatoid arthritis (RA), 3 with systemic lupus erythematosus (SLE), 2 with systemic sclerosis (SS), and 2 with dermatomyositis (DM). There were 2 men and 22 women ranging in age from 30 to 86 years (mean: 64 years). The interval between the onset of rheumatic disease and that of malignant lymphomas ranged from 3 months to 35 years (mean: 142 months). The use of immunosuppressive drugs before the onset of malignant lymphoma was recorded in 15 patients. Among them, 5 patients received methotrexate (MTX) therapy. Malignant lymphomas were found at extranodal sites in 9 patients, and the disease was in the advanced stage in 17 patients. Histologic and immunohistochemical studies demonstrated that 18 cases (75%) were B-cell lymphoma (RA=12, SLE=2, SS=2, DM=2), 3 (12.5%) were peripheral T-cell lymphoma (RA=3), and 3 (12.5%) were classical Hodgkin lymphoma (RA=2, SLE=1). As in previous reports, there was an increased frequency of diffuse large B-cell lymphoma (50%) in the present series. Moreover, a majority of the diffuse large B-cell lymphomas exhibited activated B-cell phenotype. EBV-encoded small RNAs (Epstein-Barr early region [EBER]-) and/or LMP-1+tumor cells were identified in only 3 cases of classical Hodgkin lymphomas. Our findings suggested EBV-associated lymphoma comprised only a small fraction of all non-Hodgkin's lymphomas in the general SRD patient population.

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.

Clinical and laboratory observation systemic lupus erythematosus and acute lymphocytic leukemia: An unusual case

The association of systemic lupus erythematosus (SLE) and myeloproliferative and lymphoproliferative malignancies is widely reported. There is scarce information available with regards to the association of SLE and malignancy in children. Usually, SLE precedes the onset of lymphoproliferative disease, but the neoplasia can occur earlier or even simultaneously. There are only five pediatric cases of SLE and associated acute lymphoblastic leukemia (ALL) reported in literature. All of these except one satisfied the revised American College of Rheumatology Criteria for SLE. Three of these cases developed SLE several years after successful treatment of ALL. While two cases reported had simultaneous onset of SLE and ALL, one of the cases in this two-patient series, did not fulfill ≥4 criteria for diagnosis of SLE. We present a case of a 3-year-old boy with SLE and coexistent ALL. To the best of our knowledge, only two such cases of simultaneous presentation of both these diseases are present in literature.

Cancer risk in a cohort of patients with systemic lupus erythematosus (SLE) in California

OBJECTIVE

We conducted a retrospective cohort study to examine cancer risk in a large cohort of systemic lupus erythematosus (SLE) patients in California.

METHODS

The cohort consisted of individuals with SLE derived from statewide patient discharge data during the period 1991-2002. SLE patients were followed using cancer registry data to examine patterns of cancer development. Standardized incidence ratios (SIRs) and 95% CI were calculated to compare the observed to expected numbers of cancers based on age-, race-, and sex-specific incidence rates in the California population.

RESULTS

The 30,478 SLE patients were observed for 157,969 person-years. A total of 1,273 cancers occurred within the observation interval. Overall cancer risk was significantly elevated (SIR = 1.14, 95% CI = 1.07-1.20). SLE patients had higher risks of vagina/vulva (SIR = 3.27, 95% CI = 2.41-4.31) and liver cancers (SIR = 2.70, 95% CI = 1.54-4.24). Elevated risks of lung, kidney, and thyroid cancers and several hematopoietic malignancies were also observed. Individuals had significantly lower risks of several screenable cancers, including breast, cervix, and prostate.

CONCLUSIONS

These data suggest that risks of several cancer types are elevated among SLE patients. Detailed studies of endogenous and exogenous factors that drive these associations are needed.

Systemic lupus Erythematosus and IgA multiple myeloma: a rare association?

The coexistence of systemic lupus Erythematosus (SLE) and multiple myeloma (MM) is uncommon and the pathogenetic mechanisms underlying this association remain unclear. We report the case of a woman who was diagnosed with SLE in 1993 aged 57, then developing IgA lambda type MM in the IIB clinical stage 7 years later. The SLE was treated successfully with methylprednisolone and chloroquine, and low dose maintenance steroid was continued with bisphosphonate protection until December 1994 when she suffered multiple vertebral fractures. She continued to receive 4 mg alternate day methylprednisolone and calcitonin until she decided to discontinue her own treatment 2 years later. In 2000, while still in stable SLE remission, she was diagnosed with MM. Protein electrophoresis revealed the IgA lambda paraprotein (40.5 g/l) and she had a Bence Jones (BJ) proteinuria of the lambda light chain type. Bone marrow trephine biopsy revealed a massive patchy infiltrate of abnormal plasmocytes (70%), while an extensive x-ray skeletal survey did not show any new fractures or osteolysis. The patient was treated according to the VMCP protocol without attaining a plateau phase. There was a similar poor clinical response to second and third line treatments (VAD, Thalidomide, Melphalan, and high dose dexamethasone). After 4 years of refractory disease the patient died from severe bilateral pneumonia. This case is discussed with reference to the literature.

Lacrimal gland extranodal marginal zone B-cell lymphoma of MALT-type

PURPOSE

To evaluate the clinical features and outcome of extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue type (MALT lymphoma) in the lacrimal gland.

DESIGN

Retrospective, noncomparative, observational case series in an academic referral setting.

METHODS

A consecutive series of 13 histologically verified MALT lymphoma in the lacrimal gland at presentation was studied. Clinical characteristics, treatment, and prognosis were analyzed.

RESULTS

Eight males and five females with a median age of 64 years and a median follow-up time of 48 months were included. All patients had no prior lymphoma and initially presented as MALT lymphoma in the lacrimal gland. Extraorbital involvement at diagnosis was noted in six patients (46.2%). Two patients had autoimmune disease, and both had Stage IV disease at presentation. Treatment consisted of surgical resection in one patient, radiotherapy in four, chemotherapy in four, and combined radiotherapy and chemotherapy in four. Complete remissions were obtained in eight patients (61.5%). Patients with bilateral disease (61.5%) had a higher rate of advanced-stage disease and a poor outcome. Recurrence was noted in two patients. At the last follow-up, eight patients were free of disease, three were alive with disease, one died of sepsis as a complication of chemotherapy, and one died of lymphoma.

CONCLUSIONS

MALT lymphoma in the lacrimal gland has a high rate of extraorbital involvement and synchronous bilateral lacrimal gland involvement at presentation. The prognosis is relatively poor, especially in patients with advanced disease and bilateral involvement. Extensive staging and long-term follow-up are warranted for these patients.

Multiple myeloma in a patient with systemic lupus erythematosus, myasthenia gravis and non-familial diffuse palmoplantar keratoderma

The coexistence of autoimmune diseases and malignancies including lymphoproliferative diseases is often reported in the literature. Here we report an unusual case with two autoimmune diseases--myasthenia gravis (MG) and systemic lupus erythematosus (SLE) associated with unique palmoplantar keratoderma (PK) which preceded the development of multiple myeloma (MM) for twenty and seven years respectively. MG associated with non-malignant thymoma developed in 1981 and was successfully treated with thymectomy and physostigmine. Thirteen years later SLE was diagnosed and until now it is also accompanied by skin lesions corresponding to non-familial, diffuse palmoplantar keratoderma which is resistant to treatment. In 2001 the patient revealed inguinal and abdominal lymphadenopathy first diagnosed as extramedullary plasmacytoma and then as multiple myeloma on the basis of bone marrow infiltration and monoclonal gammopathy. Therapy with VAD regimen achieved complete remission of the MM and significant improvement of the skin changes lasting for six months. We failed to collect sufficient numbers of CD 34+ cells for peripheral blood stem cell transplantation. Now the malignancy is in partial remission after CHOP therapy and the skin lesions have returned to their initial status. To our knowledge, this is the first case to be reported with coexistence of these four diseases.

Non-Hodgkin's lymphoma in patients with systemic lupus erythematosus

Two cases of non-Hodgkin's lymphoma (NHL) associated with systemic lupus erythematosus (SLE) are described. Patient-1 was a 65-year-old woman in whom SLE and diffuse large B-cell lymphoma were concurrently diagnosed. The patient presented with low-grade fever, butterfly rash, arthritis and generalized lymphadenopathy without splenomegaly or bone marrow involvement. Complete remission of NHL and SLE was achieved with cyclophosphamide, adriamycin, vincristine and prednisone. Patient-2 was a 56-year-old woman in whom SLE had been diagnosed 14 years earlier. The patient presented with low-grade fever, bulky splenomegaly without lymphadenopathy, IgMA paraproteinemia, and expansion of a monoclonal CD19+/CD22+ lambda-type B-cell population in both bone marrow and peripheral blood. Diagnosis of a lympho-plasmacytoid lymphoma was established histologically after splenectomy. A partial remission of the neoplasm was achieved with cyclophosphamide, vincristine and prednisone. We suggest that the development of NHLs in patients with SLE may not be coincidental and we recommend the search for NHL in cases of SLE with prominent lymphadenopathy, massive splenomegaly or expansion of a monoclonal CD19+/CD22+ B-cell population.

Systemic lupus erythematosus and cancer: associated or not?

The frequency of cancer in patients with SLE is between 2.5 and 13.8%. A literature review has identified nine full-length studies that estimated the overall risk of cancer in SLE patients compared with the general population. Five of them have not noted an increased risk for the development of overall cancers among SLE patients compared with the general population. One study identified a 30% increased risk (SIR or 1.3) for occurrence of cancer among 1585 SLE patients followed over 10,807 patient-years. Taken together, it is controversial whether the risk of all cancers is increased in SLE patients compared with the general population. Increased risk of lymphatic malignancies has been shown in multiple large series of SLE patients, but SLE is not associated with an increased risk for the development of most of the solid tumors. Pathogenic mechanisms involved with the development of lymphoproliferative malignancies in association with SLE include a common etiologic agent for both diseases, environmental factors as the use of cytotoxic or immunosuppressive agents, genetic variables, and immunologic factors as immunoregulatory disturbances of the immune system.

Systemic lupus erythematosus and B-cell hematologic neoplasm

The association of systemic lupus erythematosus (SLE) and B-cell malignancy is widely reported in the literature. Here we report nine cases of concurrent of SLE or discoid lupus erythematosus (DLE) and lymphoma or plasma cell disorder. A MEDLINE search was done using the keywords, 'SLE' and 'lymphoma' and the characteristics of all identified cases were summarized and analyzed, along with data from our own cases. Numerous variants of B-cell malignancies were encountered in these patients. B-cell malignancy occurs after the diagnosis and treatment of SLE in most reported cases, although it may precede SLE, or occur synchronously with it. The age at onset of the B-cell neoplasm in SLE patients is similar to that in the general population. Mortality in patients with both diseases is associated with progressive B-cell neoplasm, sepsis secondary to either disease, or both. B-cell malignancy and SLE seem to run independent clinical courses rather than being affected by each other. The use of immunosuppressive drugs is common in patients with SLE diagnosed prior to B-cell lymphoma, arguing that the effect of immunosuppression on the pathogenesis of lymphoma can not be excluded. Three areas worthy of study regarding the probable mechanisms for the occurrence of SLE and B-cell malignancies are discussed. A tumor suppressor gene PTEN may link the two disorders via a defective apoptosis pathway to eliminate hyperactive B and T cells in SLE. The accumulation of clonally expanded hyperactive B-cells that recognize self-antigens in the lymph nodes of SLE may predispose these B-cells to DNA breaks, facilitating tumorigenesis. Lastly, EBV infection, found to have a high prevalence in SLE patients, may serve as a common etiological factor in both disorders.

Can morbidity and mortality of SLE be improved?

Systemic lupus erythematosus (SLE) is the second most common autoimmune disorder (after thyroid disease) in women of childbearing age. Lupus is increasingly being recognized throughout the world's population. The incidence and prevalence of SLE varies among racial and ethnic groups. Lupus patient survival has significantly improved over the past five decades, but a three- to fivefold increased risk of death remains compared with the general population. As lupus patients survive longer, these individuals face a range of complications from the disease itself or consequent to its treatment. Emerging data from epidemiological studies underscore the importance of incorporating race and ethnicity in understanding the risk factors leading to the significant burden of mortality and morbidity associated with this disease. This chapter describes the epidemiology of lupus with a focus on racial and ethnic differences, reviews the mortality associated with the disease, discusses selected complications associated with morbidity related to the disease and highlights areas where we can improve mortality and morbidity.

Systemic lupus erythematosus and the risk of malignancy

The objective of this study was to determine the relative risks of malignancy and of site-specific malignancies in patients with systemic lupus erythematosus (SLE). A cohort of 297 patients (91% Caucasian) with SLE were seen between 1975 and 1994 and followed for a mean of 12 years at the University of Saskatchewan Rheumatic Disease Unit. Expected cancer incidence rates were determined based on Province of Saskatchewan population statistics matched to each study patient for age, sex and calendar year of follow-up. Standardized incidence ratios (SIRs) of observed to expected cancers and 95% confidence intervals (95% CI) were calculated. A total of 27 cases of cancer were observed, whereas only 16.9 were expected (SIR 1.59 (95% CI 1.05-2.32)). For site-specific malignancies, an excess of cancer of the cervix (SIR 8.15 (95% CI 1.63-23.81)) as well as hemopoietic malignancy (SIR 4.9 (95% CI 1.57-11.43)) was found. The hemopoietic cancers were predominantly non-Hodgkin's lymphoma (SIR 7.01 (95% CI 1.88-17.96)). We did not find an association of malignancy with known risk factors, including use of cytotoxic agents. Increased risk of malignancy, notably non-Hodgkin's lymphoma and perhaps cervical cancer, should be regarded as a complication of SLE.

Low-grade non-Hodgkin's lymphoma in a patient with systemic lupus erythematosus

Coexistence of systemic lupus erythematosus (SLE) with low-grade non-Hodgkin's lymphoma (LGNHL) has been described occasionally in the literature with the potential pathogenetic role of monoclonal B CD5+/CD19+ cells. We report a case of LGNHL which developed 18 months after diagnosis of SLE. The monoclonal population of lymphocytes in the peripheral blood and bone marrow was CD5/CD19 negative but CD19/CD22 positive. The SLE responded well to treatment with prednisone and the course of the LGNHL was stable and cytotoxic treatment was not required.

Genetic aspects of inherent B-cell abnormalities associated with SLE and B-cell malignancy: lessons from New Zealand mouse models

Genes that predispose to SLE are closely related to key events in pathogenesis of this disease. As much of the pathology can be attributed to high affinity autoantibodies and/or their immune complexes, some of the genes may exert effects in the process of emergence, escape from tolerance mechanisms, activation, clonal expansion, differentiation, class switching and affinity maturation of self-reactive B cells. A number of growth and differentiation factors and signaling molecules, including positive and negative regulators, are involved in this process. Genetic variations associated with functional deficits in some of such molecules can be involved in the susceptibility for SLE. As is the case with SLE, hereditary factors play significant roles in the pathogenesis of B cell chronic lymphocytic leukemia (B-CLL). Patients with B-CLL or their family members frequently have immunological abnormalities, including those associated with SLE. It is suggested that certain genetically determined regulatory abnormalities of B cells may be a crossroad between B-CLL and SLE. A thorough understanding of the genetic pathways in B cell abnormalities leading to either SLE or B-CLL is expected to shed light on their association. New Zealand mouse strains are pertinent laboratory models for these studies. Chromosomal locations of several major genetic loci for abnormal proliferation, differentiation and maturation of B cells and relevant candidate genes, located in close proximity to these intervals and potentially related to the SLE pathogenesis, have been identified in these mice. Further studies make for a wider knowledge and understanding of the pathogenesis of SLE and related B-cell malignancy.

Susceptibility Alleles for Aberrant B-1 Cell Proliferation Involved in Spontaneously Occurring B-Cell Chronic Lymphocytic Leukemia in a Model of New Zealand White Mice

B-cell chronic lymphocytic leukemia (B-CLL) and autoimmune disease are a related event, and genetic factors are linked to both diseases. As B-CLL is mainly of B-1 cell type that participates in autoantibody production, genetically-determined regulatory abnormalities in proliferation and/or differentiation of B-1 cells may determine their fate. We earlier found that, in H-2–congenic (NZB × NZW) F1 mice, while H-2d/z heterozygosity predisposes to autoimmune disease, H-2z/z homozygosity predisposes to B-CLL. Studies also suggested the involvement of non–H-2-linked NZW allele(s) in leukemogenesis. Using H-2–congenic NZW and B10 mouse strains, their F1 and backcross progeny, we have now identified three major NZW susceptibility loci for abnormal proliferation of B-1 cells, which form the basis of leukemogenesis; one H-2–linked locus on chromosome 17 and the other two non–H-2-linked loci, each on chromosome 13 and chromosome 17. Each susceptibility allele functioned independently, in an incomplete dominant fashion, the sum of effects determining the extent of aberrant B-1 cell frequencies. The development of leukemia was associated with age-related increase in B-1 cell frequencies in the blood. Thus, these alleles probably predispose B-1 cells to accumulate genetic alterations, giving rise to B-CLL. Potentially important candidate genes and correlation of the findings with autoimmune disease are discussed.

Susceptibility Alleles for Aberrant B-1 Cell Proliferation Involved in Spontaneously Occurring B-Cell Chronic Lymphocytic Leukemia in a Model of New Zealand White Mice

B-cell chronic lymphocytic leukemia (B-CLL) and autoimmune disease are a related event, and genetic factors are linked to both diseases. As B-CLL is mainly of B-1 cell type that participates in autoantibody production, genetically-determined regulatory abnormalities in proliferation and/or differentiation of B-1 cells may determine their fate. We earlier found that, in H-2–congenic (NZB × NZW) F1 mice, while H-2d/z heterozygosity predisposes to autoimmune disease, H-2z/z homozygosity predisposes to B-CLL. Studies also suggested the involvement of non–H-2-linked NZW allele(s) in leukemogenesis. Using H-2–congenic NZW and B10 mouse strains, their F1 and backcross progeny, we have now identified three major NZW susceptibility loci for abnormal proliferation of B-1 cells, which form the basis of leukemogenesis; one H-2–linked locus on chromosome 17 and the other two non–H-2-linked loci, each on chromosome 13 and chromosome 17. Each susceptibility allele functioned independently, in an incomplete dominant fashion, the sum of effects determining the extent of aberrant B-1 cell frequencies. The development of leukemia was associated with age-related increase in B-1 cell frequencies in the blood. Thus, these alleles probably predispose B-1 cells to accumulate genetic alterations, giving rise to B-CLL. Potentially important candidate genes and correlation of the findings with autoimmune disease are discussed.

Systemic lupus erythematosus and multiple myeloma: a rare association

OBJECTIVE

The association of systemic lupus erythematosus (SLE) and multiple myeloma (MM) is an uncommon event. We report the relapse of SLE in a patient with a previous history of MM, treated with chemotherapy and, subsequently, with alpha-2b interferon (alpha-2b IFN) as a maintenance therapy. The case is discussed in light of past relevant literature.

METHODS

The history and clinical, laboratory and radiographic findings of the patient, as well as the subsequent therapeutic approach are discussed. In our review of the literature, journal articles are identified by Medline search.

RESULTS

We describe the case of a woman who developed a multiple myeloma 14 years after a diagnosis of SLE. A careful literature review confirms that the association of these two diseases has been reported only in a few cases. When the plasma cell neoplasia occurred, SLE had been quiescent for several years; the patient was treated with prednisone-melphalan and, subsequently, with alpha-2b IFN as a maintenance therapy. On admission to our department, SLE was in a relapse phase, probably because of IFN treatment. The disease was poorly responsive to steroid therapy and required the use of cytotoxic drugs.

CONCLUSIONS

The coexistence of SLE and MM is very rare and the possible pathogenetic mechanisms underlying this association remain unclear. The use of interferon in a patient with an autoimmune disease always invites caution.

Non-Hodgkin's lymphoma and other cancers among a cohort of patients with systemic lupus erythematosus

OBJECTIVE

To investigate whether systemic lupus erythematosus (SLE) is associated with non-Hodgkin's lymphoma or other malignant neoplasms.

METHODS

Data on a cohort of 1,585 patients with SLE from the nationwide Danish Hospital Discharge Register were linked to information in the Danish Cancer Registry to determine the occurrence of cancer during up to 15 years of followup. The expected number of cancers was calculated from accumulated person-years and national cancer incidence rates.

RESULTS

There was a significant excess of non-Hodgkin's lymphoma among the SLE patients, based on 8 cases observed against 1.5 expected (relative risk [RR] 5.2, 95% confidence interval 2.2-10.3). In addition, a significantly increased RR was found for cancer of the lung (RR 1.9; n = 15), the liver (RR 8.0; n = 5), and the vagina/vulva (RR 5.7; n = 3).

CONCLUSION

There seemed to be a positive association between SLE and non-Hodgkin's lymphoma. Other cancers with a possible virus-related etiology, such as liver and vaginal/vulva cancer, were also observed in excess. In addition, there was an indication of an increased risk of lung cancer among patients who were hospitalized for SLE.

Malignancy in systemic lupus erythematosus: a report of five cases in a series of 96 patients

The association of systemic lupus erythematosus (SLE) and malignancy has been reported previously and suggests an increased risk of cancer in this disease. Lymphomas are the most frequent neoplasias reported in these patients and carcinoma of the cervix and breast are also seen. Several factors probably play a role in the aetiology of malignancies associated with SLE including intrinsic disturbances of immunity and concomitant immunosuppressive therapy. We report five solid tumors (one breast carcinoma, one squamous cell carcinoma of the anus, one adenocarcinoma of the rectum, one carcinoma of the cervix and one carcinoma of the gallbladder) among 96 patients with SLE. The most striking finding in this study was the absence of haematological malignancies. The incidence of malignancy in the series, the age of diagnosis of SLE and neoplasia and the time delay between SLE and malignancy diagnosis was similar to other series. We did not find any clinical or immunological feature that predicted the development of neoplasia. In conclusion, patients with SLE may have the same malignancies as the general population after adjustment for age and sex. There are no predictive indicators for malignancy and immunosuppressive therapy may be a contributing factor.

H-2z homozygous New Zealand mice as a model for B-cell chronic lymphocytic leukemia: elevated bcl-2 expression in CD5 B cells at premalignant and malignant stages

In New Zealand mice, the major histocompatibility complex (MHC) controls the development of both autoimmune disease and B cell chronic lymphocytic leukemia (B-CLL). While H-2d/H-2z heterozygosity acts as one major predisposing genetic element for autoimmune disease, H-2z/H-2z homozygosity acts as an element for B-CLL. In the H-2z/H-2z homozygotes, there was an age-dependent increase in frequencies of CD5 B cells in the blood and spleen, and such CD5 B cells showed oligoclonal to monoclonal expansion, giving rise to B-CLL. B-CLL cells from these mice had surface phenotypes typical of CD5 B lineage cells, and expressed high levels of proto-oncogene bcl-2. Elevated bcl-2 expression was also observed in premalignant B cells in the aged mice, thereby suggesting that apoptosis-resistant, long-surviving CD5 B cells with a self-renewal capacity form the basis of malignant transformation. This model not only provides clues for analyzing multiple steps of genetic alterations involved in the generation of B-CLL, but also sheds light on the correlation between B-CLL and autoimmune disease.

Progressive systemic sclerosis preceded by malignant lymphoma

We report a patient who suffered from progressive systemic sclerosis (PSS) two years after she showed evidence of malignant lymphoma of the jejunum. Surgical resection of the tumor mass and VEMP regimen were successful; the patient was in remission but died of acute respiratory failure five years later. Although several reports have reported malignant lymphoma associated with PSS, lymphoma antecedent to PSS is rarely seen. Immune abnormalities including a high titer of antinuclear factor and positive anti-RNP antibodies were suspected to be associated with the development of PSS in our case.

Autopsy case of hepatocellular carcinoma associated with lupoid hepatitis and complicated by malignant lymphoma

An 81-year-old woman in whom liver dysfunction had been pointed out 3 years previously was diagnosed as having liver cirrhosis due to lupoid hepatitis. Considering the poor prognosis of cirrhosis and her age, immunosuppressive therapy was not adopted. Nine months later, a small liver tumor was found by ultrasonography and was diagnosed as hepatocellular carcinoma (HCC). The tumor was treated with transcatheter arterial embolization, but grew continuously. She also developed gingival lymphoma that was successfully treated. Three years after initial diagnosis of lupoid hepatitis, she died of hepatic failure. An autopsy was performed and confirmed the clinical diagnosis, liver cirrhosis with HCC. HCC is regarded as a rare complication of lupoid hepatitis, but cases of HCC complicating lupoid hepatitis may increase with progress in treatment methods and elongation of survival. The present case suggests that any malignancy can be developed in long-term surviving patients with lupoid hepatitis.

Systemic lupus erythematosus and chronic lymphocytic leukemia: rare coexistence in three patients, with comments on pathogenesis

We describe three patients with coexistent chronic lymphatic leukemia (CLL) and systemic lupus erythematosus (SLE). In two patients, the CLL was present before or coexistent with the SLE when the SLE was diagnosed, while in the third, the CLL developed 5 years after the diagnosis of SLE was first made. Although the association of autoimmune diseases and lymphoproliferative disorders is well established, only a few patients with coexistent CLL and concomitant SLE have been reported. The possible pathogenesis of this rare association is discussed.

Genetic regulation of CD5+ B cells in autoimmune disease and in chronic lymphocytic leukemia

CD5+ B cells have attracted much attention, because of their involvement in both autoimmunity and B cell-type chronic lymphocytic leukemia (B-CLL). B-CLL is a type of leukemia most often occurring among close relatives and is partly associated with the major histocompatibility complex (MHC), a finding relevant to autoimmune disease. We established MHC (H-2)-congenic NZB x NZW (NZB/W) F1 mice (H-2d/z, H-2z/z, and H-2d/d), in that only H-2d/z heterozygotes developed severe SLE, associated with IgG anti-DNA antibodies, as the animals aged. Such age-associated changes occurred in parallel with the decrease in the splenic, but not peritoneal, CD5+ B cells. By contrast, H-2z/z homozygotes did not develop SLE but, in turn, a marked clonal proliferation of CD5+ B cells resembling B-CLL did occur. H-2d/d homozygotes also did not develop the typical SLE, and a moderate CD5+ B frequency persisted. Despite the finding that all the three H-2-congenic NZB/W F1 strains produced IgM anti-DNA antibodies, only the H-2d/z heterozygotes produced IgG antibodies. Whereas the surface phenotype of major IgM producers was CD5+ sIgM+, that of IgG producers was CD5-sIgM-. Genetic and cellular analyses supported our thesis that in the heterozygotes IgM to IgG isotype switching probably emerges in CD5+ B cells and that this event is associated with the loss of CD5 molecules. Because of the lack of genetic elements required for differentiation, only signals for proliferation would be functioning in CD5+ B cells in the H-2z/z homozygotes. These observations infer that certain different, but related, MHC haplotypes may predispose either to B-CLL or to autoimmune disease in close relatives.

Increased risk of cancer in patients with systemic lupus erythematosus

To evaluate the risk of cancer in patients with systemic lupus erythematosus (SLE) a series of 205 consecutive patients (182 women and 23 men) were followed up for cancer through the files of the Finnish Cancer Registry. The follow up consisted of a total of 2340 person years. Fifteen cancers were diagnosed against 5.7 expected (relative risk (RR) 2.6, 95% confidence interval (CI) 1.5 to 4.4). Among the women there were four non-Hodgkin's lymphomas against 0.09 expected (RR 44, CI 11.9 to 111) and two soft tissue sarcomas against 0.04 expected (RR 49, CI 6.0 to 177). When evaluated by a case control study previous treatment with cytostatic drugs showed no influence on the occurrence of cancer in this series of patients with SLE.

Major histocompatibility complex controls clonal proliferation of CD5+ B cells in H-2-congenic New Zealand mice: a model for B cell chronic lymphocytic leukemia and autoimmune disease

By employing H-2-congenic NZB, NZW and (NZB x NZW)F1 mice with either the homozygous H-2d/H-2d, H-2z/H-2z or heterozygous H-2d/H-2z haplotype, we found that in the spleen of all the congenic strains homozygous for H-2z, there were extremely high frequencies of CD5+ B cells. These cells eventually proliferated in an oligoclonal or even monoclonal fashion, and B cell-chronic lymphocytic leukemia (B-CLL) developed in some cases. Because this feature was not observed in H-2d/H-2d homozygotes or H-2d/H-2z heterozygotes, the high CD5+ B cell frequencies are apparently controlled by the homozygosity of a locus or cluster of loci closely linked to H-2z complex of NZW strain. As the CD5+ B cell frequencies in the peritoneal cavity did not differ among the H-2-congenic strains, the frequencies of these cells in the peritoneal cavity and in the spleen appear to be at least in part under separate control. Flow cytometry and Southern blot analyses using an immunoglobulin gene JH probe revealed that the H-2z/H-2z homozygotes, there was a propagation of distinct clonal populations between the spleen and the peritoneal cavity, a finding which suggested that in the major histocompatibility complex (MHC)-related microenvironments for CD5+ B cell propagation differ between the two compartments. All our findings taken together imply that certain different but related MHC haplotypes may predispose either to B-CLL or to autoimmune disease, in close relatives.

OPD4-positive T-cell lymphoma of the liver in systemic lupus erythematosus

Primary malignant lymphoma of the liver occupying the right lobe, 14 x 9 x 7 cm in size, developed in a 30-year-old man with a 4-year history of autoimmune hemolytic anemia. The diagnosis of systemic lupus erythematosus (SLE) accompanying thrombocytopenia had been made clinically 10 months earlier. The liver biopsy specimen revealed diffuse proliferation of large lymphoma cells expressing the activated helper/inducer T-cell phenotype (LCA+, UCHL1+, OPD4+, LN3+, MT1-, L26-, MB1-, Leu M1-, Ki-1-, KP1-). The lymphoma was successfully treated by chemotherapy and irradiation. Intractable thrombocytopenia provoked fatal esophageal hemorrhage. At autopsy, no lymphomatous lesion was identified, and the hepatic right lobe contained an encapsulated necrotic lesion without any viable tumor cells. The bone marrow revealed marked hyperplasia of erythroid and megakaryocytic series. Extramedullary hematopoiesis was demonstrated in the liver, spleen and lymph nodes. This is the second case of primary hepatic T-cell lymphoma associated with SLE.

Cutaneous diseases preceding diagnoses of lymphoreticular malignancies

Dermatology visits during a 5-year period before the diagnosis of lymphoreticular malignancy in 258 subjects were reviewed and compared with visits made by 258 randomly selected, age- and sex-matched control subjects in the same period. Six of the 96 patients with leukemia and none of their matched controls (p less than 0.05) had cutaneous malignancies 20 to 60 months before the diagnosis of leukemia. There was no increase in cutaneous malignancies preceding lymphoma. A common factor predisposing to both cutaneous malignancy and leukemia, such as a defect in immunosurveillance, is suggested.

Sjögren's syndrome and fibrosing alveolitis complicated by pulmonary lymphoma

The case of a middle aged woman who presented with fibrosing alveolitis, in her mid-forties, followed by a sicca syndrome and who subsequently developed a pulmonary lymphoma (B cell) while receiving azathioprine therapy is recorded. Of interest was the absence of polyclonal B cell activation, e.g., production of rheumatoid factor, hypergammaglobulinaemia, high titre antinuclear antibodies or antibodies to extractable nuclear antigens (ENA) during most of her illness. Persistently raised IgM levels and low IgA levels were demonstrated. The relevance of azathioprine to development of the lymphoma is discussed.

Systemic lupus erythematosus and primary cerebral lymphoma

A woman with a 21 year old history of systemic lupus erythematosus (SLE) is presented. During a period of low connective tissue disease activity she developed sudden difficulty in walking and after much investigation was found to have a primary lymphoma of the brain. She died 6 months after this diagnosis from meningeal spread, despite radiotherapy to the tumour. The association between SLE and lymphoma is discussed.

Increased proto-oncogene expression in peripheral blood lymphocytes from patients with systemic lupus erythematosus and other autoimmune diseases

Using RNA hybridization techniques, we examined the expression of proto-oncogenes associated with lymphocyte activation in vitro in patients with systemic lupus erythematosus and other autoimmune diseases. T and B lymphocytes from these patients were found to have significantly increased expression of c-myc, c-myb, and c-raf RNA when compared with those of normal individuals. Among the mononuclear cell subpopulations, B lymphocytes expressed higher levels of RNA for these proto-oncogenes compared with the T lymphocytes. Since prompt expression of these and other proto-oncogenes occurs in fibroblasts and lymphocytes following mitogenic stimulation, we propose that the present findings reflect the pathologically activated state of various lymphocytic subpopulations which is observed in systemic lupus erythematosus and in other autoimmune diseases. Endogenous and exogenous factors which lead to the expression of autoimmunity might share the induction of proto-oncogene expression as a common pathogenetic step.

Interleukin-2 restores the depressed allogeneic cell-mediated lympholysis and natural killer cell activity in patients with systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is characterized by a variety of profound T-cell abnormalities among which are decreased cytotoxic capacity measured by allogeneic cell-mediated lympholysis (CML), natural killer cell (NK) activity, and decreased lymphokine production. In a group of 13 patients with active SLE, allogeneic CML, tested by a 4-hr 51Cr-release assay, was 18.2 +/- 2.7% while in the group of normal individuals CML was 41.2 +/- 2.7%. If optimal doses of affinity-purified interleukin-2 (IL-2) were present during the mixed lymphocyte culture, the CML of SLE patients was increased to normal levels (40.4 +/- 4.0%). In contrast, interferon-alpha (IFN-alpha) increased (but not significantly) the levels of CML. Mixed lymphocyte reaction, tested by tritiated thymidine incorporation, was also decreased in the group of patients (14,820 +/- 815 cpm vs 28,972 +/- 5880 cpm in normals) and it was increased to normal levels if IL-2, but not IFN-alpha was added to the cultures. NK activity was decreased in the group of patients tested by 51Cr-release assay, harvested at 6 and 18 hr. IL-2 increased the NK activity up to normal levels, while IFN-alpha was only partially efficacious. These results demonstrate that IL-2, but not IFN-alpha, can potentiate or even fully restore the deficient cytotoxic effector function of peripheral mononuclear cells in patients with SLE.

Neoplasms of the immune system in rheumatoid arthritis

Two studies are reported of patients with rheumatoid arthritis. The first was a retrospective-prospective-prospective study and comprised a cohort of 489 patients with rheumatoid arthritis followed for a mean of 12.2 years. Lymphoproliferative malignancies developed in 10 patients (2.2 percent) after a mean interval of 11.8 years. The second was a study of 30 patients, from various centers in England, with rheumatoid arthritis and lymphoproliferative malignancies. The effects of chronicity of rheumatoid arthritis, drug therapy, and possible predisposing factors in the etiology of the lymphoproliferative malignancies were examined. Cytotoxic drugs could not be implicated in the pathogenesis of the lymphoproliferative malignancies, but phenylbutazone and D-penicillamine may have played a role in some cases. Current evidence supports the hypothesis that chronic synovitis in rheumatoid arthritis is associated with persistent activation of lymphocytes in lymph nodes and eventual malignant transformation in some cases.

Cancer morbidity in rheumatoid arthritis

A consecutive series of 489 patients with rheumatoid arthritis seen at the centre was studied to determine their cancer morbidity. Overall the 36 cancers diagnosed in the series between 1964 and 1981 were not significantly in excess of the expected number, but there was a highly significant excess of tumours of the reticuloendothelial system. The excess was mainly due to 6 observed cases of lymphoma. We conclude that there is a highly significant association between rheumatoid arthritis and the subsequent development of lymphoproliferative malignancy in this series.

Lymphoproliferative malignancy in rheumatoid arthritis: a study of 20 cases

A series of 20 patients with definite or classical rheumatoid arthritis who subsequently developed a lymphoproliferative malignancy are described. The mean time between the onset of the 2 diseases was 13.2 years. A wide range of types of non-Hodgkin's lymphoma and Hodgkin's disease were found; there were no unusual histological features in the lymphomas. Although many of the patients had had gold, penicillamine, and other second-line drugs, none of them had received cytotoxic drugs, and there was no evidence that therapy was a cause of their malignancies. The likely cause of the association is a predisposition to both diseases.

Hodgkin's lymphoma in an adolescent with systemic lupus erythematosus

An adolescent female with systemic lupus erythematosus (SLE) with diffuse proliferative lupus nephritis subsequently contracted Hodgkin's lymphoma, mixed cellularity type. Prior to the diagnosis of Hodgkin's lymphoma, hypogammaglobulinemia developed with IgG deficiency. The nephritis, which improved on steroid therapy, remitted entirely after nitrogen mustard, vincristine, procarbazine, and prednisone (MOPP) therapy. The hypogammaglobulinemia also remitted after chemotherapy for Hodgkin's lymphoma. The literature concerning the association of SLE and Hodgkin's lymphoma is reviewed. The significance of this concurrence is discussed in regard to the possible pathophysiology and the clinical management.