Neoplastic Associations of Rheumatic Diseases and Rheumatic Manifestations of Cancer

Does bevacizumab increase joint pain in patients with cancer? Results of the prospective observational BEVARTHRALGIA study

PURPOSE

The occurrence of arthralgia and myalgia during treatment with bevacizumab (Bev) has been described but not spontaneously reported. We aimed to evaluate the frequency of arthralgia in patients treated with Bev and identify the risk factors.

METHODS

In this observational prospective study, a self-administered questionnaire was distributed to patients at the initiation of Bev and at 3 and 6 months of treatment. Bev (5-15 mg/kg) was administered every 2 or 3 weeks, with or without chemotherapy.

RESULTS

A total of 71 patients (42 with colorectal cancer, 22 with ovarian cancer, and 7 with lung cancer) were enrolled from January to November 2018. All patients completed the questionnaire at initiation, while only 56 (78.9%) and 36 (50.7%) patients completed the questionnaire at 3 and 6 months, respectively. The frequency of joint pain was 29.6% before Bev treatment and increased to 41.8% and 50% at 3 and 6 months, respectively, without reaching significance. The evolution of pain was significant according to the Common Terminology Criteria for Adverse Events grades (P = 0.032). No significant increase in the impact of pain on instrumental or elementary activities was observed over time. The frequency of arthralgia significantly increased at 3 months in patients with ovarian cancer versus those with colorectal cancer (odds ratio: 19.50; 95% confidence interval 4.53-83.98; P < 0.001).

CONCLUSIONS

Bev‑including regimens tend to be associated with a significant increase in the frequency of arthralgia in women treated for ovarian cancer. Physicians should be aware of this side effect.

CLINICAL TRIAL NUMBER

NCT03455907, date of registration: March 7, 2018.

Ontology-based systematic representation and analysis of traditional Chinese drugs against rheumatism

Background

Rheumatism represents any disease condition marked with inflammation and pain in the joints, muscles, or connective tissues. Many traditional Chinese drugs have been used for a long time to treat rheumatism. However, a comprehensive information source for these drugs is still missing, and their anti-rheumatism mechanisms remain unclear. An ontology for anti-rheumatism traditional Chinese drugs would strongly support the representation, analysis, and understanding of these drugs.

Results

In this study, we first systematically collected reported information about 26 traditional Chinese decoction pieces drugs, including their chemical ingredients and adverse events (AEs). By mostly reusing terms from existing ontologies (e.g., TCMDPO for traditional Chinese medicines, NCBITaxon for taxonomy, ChEBI for chemical elements, and OAE for adverse events) and making semantic axioms linking different entities, we developed the Ontology of Chinese Medicine for Rheumatism (OCMR) that includes over 3000 class terms. Our OCMR analysis found that these 26 traditional Chinese decoction pieces are made from anatomic entities (e.g., root and stem) from 3 Bilateria animals and 23 Mesangiospermae plants. Anti-inflammatory and antineoplastic roles are important for anti-rheumatism drugs. Using the total of 555 unique ChEBI chemical entities identified from these drugs, our ChEBI-based classification analysis identified 18 anti-inflammatory, 33 antineoplastic chemicals, and 9 chemicals (including 3 diterpenoids and 3 triterpenoids) having both anti-inflammatory and antineoplastic roles. Furthermore, our study detected 22 diterpenoids and 23 triterpenoids, including 16 pentacyclic triterpenoids that are likely bioactive against rheumatism. Six drugs were found to be associated with 184 unique AEs, including three AEs (i.e., dizziness, nausea and vomiting, and anorexia) each associated with 5 drugs. Several chemical entities are classified as neurotoxins (e.g., diethyl phthalate) and allergens (e.g., eugenol), which may explain the formation of some TCD AEs. The OCMR could be efficiently queried for useful information using SPARQL scripts.

Conclusions

The OCMR ontology was developed to systematically represent 26 traditional anti-rheumatism Chinese drugs and their related information. The OCMR analysis identified possible anti-rheumatism and AE mechanisms of these drugs. Our novel ontology-based approach can also be applied to systematic representation and analysis of other traditional Chinese drugs.

Electronic supplementary material

The online version of this article (10.1186/s12918-017-0510-5) contains supplementary material, which is available to authorized users.

Prevalence of paraneoplastic rheumatic syndromes and their antibody profile among patients with solid tumours

The aims of this study were to assess the prevalence of paraneoplastic rheumatic syndromes in a cohort of patients with newly diagnosed solid tumours and to describe their autoimmune profile, comparing it to the controls. Screening questionnaires (3,770) were distributed, and during a three-step study, 94 patients were confirmed to have both paraneoplastic syndrome and oncology diagnoses. Three control groups-patients with undifferentiated arthritis, Raynaud's phenomenon for non-malignant causes and solid tumours only-were designed to compare with the paraneoplastic cases and their immunology profile. The prevalence of paraneoplastic rheumatic syndromes was 2.65% (95% CI 0.21-3.20). The group of patients with arthritis and the group of patients with Raynaud's syndrome were found to prevail among other clinical presentations of paraneoplastic rheumatic syndromes. Both paraneoplastic syndromes were linked to malignancies of the urogenital system. Antinuclear antibodies were found to be similarly frequent in the paraneoplastic arthritis, paraneoplastic Raynaud's phenomenon and the solid tumour groups. No differences were observed when comparing paraneoplastic arthritis and undifferentiated arthritis, except that the patients with paraneoplastic arthritis were older. Comparing paraneoplastic Raynaud's to Raynaud's phenomenon, male preponderance in the paraneoplastic Raynaud's phenomenon group was observed, and the patients were obviously older. Paraneoplastic rheumatic syndromes are rare and more often occur in older patients. Among them, paraneoplastic arthritis and Raynaud's syndrome were the most frequent. The immunology profile does not help in discriminating between arthritis and paraneoplastic arthritis patients and is of limited use in Raynaud's differential diagnosis.

Migratory polyarthritis as a paraneoplastic syndrome

Carcinomatous polyarthritis (CP) is a rare paraneoplastic disorder that has been associated with a variety of solid tumors. It presents in a similar manner to other polyarticular disorders and often precedes detection of the underlying malignancy, making recognition critical. CP responds to the treatment of the neoplastic process. We present a patient who initially presented with asymmetric inflammatory polyarthritis who was later diagnosed with bronchogenic carcinoma. Following the case report we present our learning objectives, which include the differential diagnosis of inflammatory polyarthritis, diagnostic approach to CP, and features that distinguish it from other more common causes of polyarthritis. We conclude with a brief discussion of the pathophysiology and management of CP.

Risk of malignancy in scleroderma: a population-based cohort study

OBJECTIVE

To determine the incidence of cancer in patients with scleroderma (systemic sclerosis) and to compare those rates with cancer rates in the local population.

METHODS

Cancer risk in scleroderma patients in the Detroit metropolitan area was assessed by linking patient identification codes of the Michigan Scleroderma Registry to the Metropolitan Detroit Cancer Surveillance System database. Patients were screened between the years 1973 and 2002, with additional followup to 2004. Standardized incidence ratios (SIRs) were calculated for selected malignancies (lung, liver, colon, breast, cervical, and prostate cancers, and non-Hodgkin's lymphomas), with stratification by sex and race.

RESULTS

Of 934 patients in the Scleroderma Registry, 538 were included in the study based on tri-county residency (436 females and 102 males). Of these, 45 first malignancies were noted (37 females and 8 males). Lung cancer (10 cases) was found to be the most common cancer in scleroderma patients. However, its incidence was not significantly different from that in the general population of metropolitan Detroit (SIR 1.23). Other types of cancer were examined, and no significant differences were found as compared with the rates in the local population, with 1 exception: black females with scleroderma had significantly higher rates of liver cancer (SIR 45.8).

CONCLUSION

Contrary to previous studies, this study did not find statistical evidence of an increased incidence of cancer in scleroderma patients, except for liver cancer. One possible reason is the high background rates of certain cancers in the metropolitan Detroit area. It may be necessary to consider local cancer rates when comparing different scleroderma cohorts.

Sjögren's syndrome: current therapies remain inadequate for a common disease

Sjögren's syndrome (SS) is a systematic autoimmune disease characterised by dysfunction of the lacrimal and salivary glands. This dryness leads to the symptoms of dry eyes and keratoconjunctivitis sicca, which is painful and may predispose patients to ocular infections. Also, SS patients develop dry mouth, which is uncomfortable and associated with progressive dental disease. SS is divided into secondary SS (where the dryness symptoms are associated with another well defined autoimmune disorder such as rheumatoid arthritis, systemic lupus erythematosus, or scleroderma) and primary SS (where the patients do not fulfil criteria for another well defined associated autoimmune disease). Primary SS has extra glandular organ involvement including lung (interstitial pneumonitis), renal (interstitial nephritis), peripheral and central nervous system manifestations, vasculitis of skin and other organs and increased frequency of lymphoma. This review will concentrate on primary SS. Therapies are divided into agents for topical replacement of deficient secretions (artificial tears, artificial salivas), stimulation of muscarinic M3 receptors (pilocarpine, cevimeline) to increase aqueous secretions, reduction of topical inflammation (topical cyclosporin or corticosteroids for the eye and fluorides or antibacterial varnishes for the mouth) and modification of the immune response in a manner similar to treatment of systemic lupus (antimalarial drugs, methotrexate, cyclophosphamide and perhaps newer agents such as leflunomide or TNF inhibitors).

Seropositive, symmetric polyarthritis in a patient with poorly differentiated lung carcinoma: carcinomatous polyarthritis, hypertrophic osteoarthropathy, or rheumatoid arthritis?

Polyarthritis resembling rheumatoid arthritis (RA) may be the presenting manifestation of occult malignancy. Hypertrophic osteoarthropathy (HOA) may also develop in association with pulmonary neoplasia and consists of clubbing, periostitis, and arthropathy. We describe a patient who presented with a seropositive, symmetric, inflammatory polyarthritis only 4 weeks before a lung tumor became clinically and radiographically apparent. After initiation of chemotherapy, she developed features characteristic of HOA. It appears that the patient had both RA and HOA. We discuss the differential diagnosis and review the relationship of RA, HOA, carcinomatous polyarthritis, and malignancy.

Biphasic synovial sarcoma in the small intestinal mesentery

BACKGROUND

A 46-year-old man presented with recurrent anemia and polyarthralgia. Investigations revealed a mass in the ileal mesentery, which was resected. Results of routine histologic examination suggested a diagnosis of synovial sarcoma, a rare malignancy usually not reported at this site.

METHODS

Tissue was examined immunohistochemically, ultrastructurally, and by fluorescent in situ hybridization to confirm the diagnosis.

RESULTS

Immunohistochemical studies revealed widespread labeling for cytokeratins and focal labeling for desmin and vimentin in the epithelial component, with labeling for epithelial membrane antigen in the epithelial and spindle-cell components. Fluorescent in situ hybridization analysis showed the characteristic t(X;18) translocation of synovial sarcoma.

CONCLUSIONS

This is a unique case of synovial sarcoma in the small intestinal mesentery. Immunohistochemical labeling confirmed the diagnosis, although, to the authors' knowledge, the pattern of desmin labeling has not been described previously. The clinical association with polyarthralgia, which resolved after removal of the neoplasm, also has not been described previously.