Rheumatic syndromes associated with malignancy

Polymyalgia Rheumatica: a Common Disease in Seniors

PURPOSE OF THE REVIEW

Polymyalgia rheumatica (PMR) is one of the most common inflammatory rheumatologic condition occurring in older adults. It is characterized by proximal pain and stiffness in the shoulders, neck, and/or pelvic girdle in individuals over 50 years of age along with evidence of an intense systemic inflammatory response. Although the above clinical symptoms are very characteristic for the condition, it can be mimicked by other autoimmune, infectious, malignant, and endocrine disorders chief among which are giant cell arteritis (GCA) and elderly-onset rheumatoid arthritis (EORA). Recently, PMR was reported in relation to treatment with immune checkpoint inhibitors. Current treatment of PMR consists of low-to-medium doses of glucocorticosteroids (GC) with variable response rates and disease recurrence estimated to occur in 50% of patients while tapering down GC doses. In addition, GC-based regimens cause much of the morbidity associated with PMR in older adults, requiring close monitoring for GC-induced toxicity during therapy and highlighting the need for novel therapeutic strategies. Here, we review the latest findings in the field regarding specific etiologic factors, genetic associations, diagnostic methods, and advancements in treatment strategies and disease monitoring indices.

RECENT FINDINGS

Recent discoveries involving novel therapeutic targets in GCA have accelerated the study of PMR pathophysiology and have advanced treatment strategies in PMR management leading to current trials in IL-6 blocking agents. PMR remains an enigmatic inflammatory condition affecting older adults, with current treatment approach causing much morbidity in this patient population. Advancements in our understanding of novel immunopathologic targets can serve as a solid foundation for future treatment strategies in the field.

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.

Extrahepatic malignancies in primary biliary cirrhosis: a comparative study at two European centers

Limited information and divergent results are available on the prevalence/incidence, survival, and risk factors for developing extrahepatic malignancies (EMs) in primary biliary cirrhosis (PBC). The aim of the study was to analyze the epidemiology and survival rates for EM in PBC patients. The study was conducted on two series of patients followed up at two European centers (361 in Padova, Italy, and 397 in Barcelona, Spain) for a mean 7.7 ± 7 and 12.2 ± 7 years, respectively. The cancer incidence was compared with the standardized incidence ratios (SIRs) calculated using the Cancer Registry of the Veneto Region (Italy) and the Cancer Registry of Tarragona (Spain). Seventy-two patients developed EM. The prevalence of cases was similar in Padova (9.7 %) and Barcelona (9.4 %). The overall cancer incidence was similar to the expected incidence for the general population in the same geographical area (SIR = 1.2), and so was the crude EM rate (855.01 vs 652.86 per 100,000 patient-years, respectively, RR = 1.3). Logistic regression analysis showed that advanced histological stage and extrahepatic autoimmune diseases were significantly associated with the onset of EM. Survival was similar for PBC patients with and without EM (p = n.s.), and actual survival was similar to the one predicted by the Mayo model. The incidence of EM in PBC patients was found similar in Italy and Spain and no different from that of the general population. Advanced histological stage and extrahepatic autoimmune disease were risk factors significantly associated with EM developing in PBC. The onset of cancer in PBC patients does not influence the natural history of their liver disease.

Polyangiitis with granulomatosis as a paraneoplastic syndrome of B-cell lymphoma of the lacrimal gland

Introduction. The clinical course of an autoimmune paraneoplastic syndrome parallels the natural history of the primary malignancy. In most cases, such paraneoplastic are syndromes hardly distinguishable from idiopathic autoimmune diseases. A case of polyangiitis with granulomatosis as a paraneoplastic syndrome in a patient with B-cell Lymphoma of the lacrimal gland has not yet been reported. Case Presentation. We present the case of a male patient with a B-cell Lymphoma of the lacrimal gland, who debuted with symptoms similar to rheumatoid arthritis and acute renal failure, secondary to polyangiitis with granulomatosis. The current pathophysiological hypotheses explaining the relationship between a lymphoproliferative disease and an autoimmune paraneoplastic disorder are discussed. Conclusion. Tumor-associated segmental necrotizing glomerulopathy is a very rare manifestation of glomerular diseases. Some atypical clinical features should increase the suspicion of an underlying tumor, in which case it is essential to treat the primary neoplasia, in order to control the autoimmune manifestations.

Post-chemotherapy arthralgia and arthritis in lung cancer

OBJECTIVE

Evaluate the characteristics of arthritis, arthralgia and musculoskeletal pain after chemotherapy in patients with lung cancer.

MATERIALS AND METHODS

In this study, we evaluate the characteristics of 17 patients with joint symptoms following receiving chemotherapy for lung cancer. Demographic information of patients including sex, age, time of rheumatologic findings after starting of chemotherapy, time of improvement after starting of medication, and relevant laboratory findings for each patient.

RESULTS

A total of seventeen patients (six women with mean age 41.2 ± 5.2 years and 11 men with mean age 42.5 ± 8.2) that received standard chemotherapy for lung cancer according to stage of disease. Joint symptoms usually began about seven months after the first session of chemotherapy. Patients had an average of two tender joints and 1 hr of morning stiffness. Four patients were positive for anti-nuclear antibody, and none of patient was positive for rheumatoid factor. Non-steroidal anti-inflammatory drugs, disease modifying anti-rheumatic drugs (DMARD), corticosteroids, and venlafaxine were prescribed. Four patients did not show an improvement. Follow-up was available for all patients. 11 patients showed favorable responses, characterized by a significant decrease (more than 50%) in morning stiffness, pain, and tender joint counts after a mean of three months' treatment. Two patients had complete resolution of symptoms and did not required further medications for arthritis, arthralgia or musculoskeletal pain.

CONCLUSION

Chemotherapy-related arthropathy in lung cancer is not uncommon. Early treatment with NSAID, DMARD, and corticosteroids is effective in the majority of patients.

The presenting manifestations of subcutaneous panniculitis-like T-cell lymphoma and T-cell lymphoma and cutaneous γδ T-cell lymphoma may mimic those of rheumatic diseases: a report of 11 cases

This study aims to investigate the association between subcutaneous panniculitis-like T-cell lymphoma (SPTCL) or cutaneous gamma/delta T-cell lymphoma (CGDTCL) and a variety of manifestations that mimic autoimmune disorders. A retrospective chart review was made for 11 patients who were initially diagnosed as autoimmune diseases but finally turned out to be SPTCL or CGDTCL. Eleven patients were initially diagnosed with erythema nodosum, nodular panniculitis, lupus erythematosus profundus, systemic vasculitis, dermatomyositis, or pyoderma gangrenosum. The interval between presenting symptoms and the diagnosis of lymphoma was 17.5 (range, 3-84)  months on average. Nearly all cases had multiple subcutaneous nodules or plaques that were most commonly distributed on the extremities and trunk. Fever was the primary accompanying sign (9/10), followed by lymphadenopathy (6/11), splenomegaly (5/11), and hepatomegaly (3/11). Two patients developed hemophagocytic syndrome. A total of 26 biopsies involving multiple anatomic locations were performed. Antirheumatic therapy including steroids and immunosuppressive agents administered before the identification of T-cell lymphoma revealed unsustainable therapeutic effect. In contrast, seven cases gained partial response after chemotherapy, while the remaining four cases died with disease progression and disease-associated severe infections. SPTCL and CGDTCL are rare and heterogeneous which may resemble those rheumatologic diseases that are characterized by inflammation involving the skin or subcutaneous fat tissue. The diagnosis relies on the constellation of disease-specific pathologic, immunophenotypic, and T-cell receptor gene rearrangement tests. In the context of an ambiguous clinical picture demonstrating inconsistency with the initial diagnosis of benign autoimmune diseases, repeated excisional biopsies of the subcutaneous lesions may be required to uncover the underlying lymphoma.

Cutting edge issues in polymyositis

Skeletal muscle is the target tissue of immunoflogistic processes in patients affected with idiopathic inflammatory myopathies (IIM). IIM are classified into three major forms: polymyositis (PM), dermatomyositis (DM), and inclusion body myositis. Recent data suggest that, in the major subsets of myositis, antigens in muscles drive a B-cell antigen-specific immune response. Moreover, some non-immunological mechanisms have been advocated. In this regard, an increased expression of Jo-1 and Mi-2 in muscle biopsies from PM and DM patients compared to normal muscle has been demonstrated; these candidate autoantigens in myositis are expressed at high levels in regenerating muscle cells rather than in mature myotubes. Myositis autoantigen upregulation has also been observed in neoplastic tissues, thus representing a potential link between cancer and autoimmunity in myositis. Myositis-specific autoantibodies (MSA) are disease markers and target intracellular proteins involved in key processes such as translocation and nuclear transcription. Myositis target antigens encompass aminoacyl-tRNA synthetases, the Mi-2 helicase/histone deacetylase protein complex, the signal recognition particle ribonucleoprotein, together with novel target antigens including p155/140, CADM-140, and SAE. Despite their high specificity for autoimmune myositis, MSA target non-muscle restricted proteins ubiquitary to all cell types, making the specific muscle involvement difficult to explain. Non-immunological mechanisms also seem to contribute to the pathogenesis of IIM; activation of endoplasmic reticulum stress response due to muscle regeneration and inflammation but independent to MHC-1 up-regulation has been recently reported in patients with myositis.

[Gastrointestinal tumors. Clinical manifestations of paraneoplastic rheumatic symptoms]

Paraneoplastic syndromes, as syndromes associated with malignancy, can present unrelated to tumor invasion or metastases. They can occur with varying clinical appearance and are often indistinguishable from idiopathic rheumatic symptoms. Some musculoskeletal disorders are more associated with malignancies. The therapy of rheumatic syndromes can itself have an effect on the tumorigenic process. The clinical severity of paraneoplastic rheumatic symptoms can in many cases aid in the assessment of tumor activity and the response to therapy. While generally an extensive search for occult malignancies in every older rheumatoid patient in cases with no indications of malignancy is not advisable, knowledge of rheumatic symptoms associated with malignancies aids in the important early detection of tumors, while avoiding unnecessary examinations.

Chronic monoarthritis and foot-drop as a paraneoplastic syndrome in prostate cancer

Paraneoplastic rheumatic symptoms, caused by a malignancy, but not directly related to invasion by the tumor or its metastases are the result of a wide variety of tumor-derived biologic mediators. Recognition of paraneoplastic rheumatic syndromes is important, as it may lead to an early diagnosis of cancer. We report a 71-year-old patient with prostate cancer, presented with chronic monoarthritis of the left ankle and foot-drop. Monoarthritis and foot-drop was resistant to non-steroidal anti-inflammatory drugs and corticosteroids. After tumor resection, synovitis resolved and foot-drop disappeared almost totally.

Sacroiliitis as an initial presentation of acute lymphoblastic leukaemia

A 17-year-old male was admitted to the hospital because of fever, low back pain and knee pain which had started a couple of months ago. Pelvic CT-scan confirmed left sacroiliitis. Complete blood count revealed pancytopenia.A bone marrow biopsy and aspiration was performed under local anaesthesia. The pathologist reported Acute Lymphoblastic Leukaemia. The reported patient is the first case of acute lymphoblastic leukaemia, accompanied by sacroiliitis.

Polymyositis, dermatomyositis and malignancy: a further intriguing link

The association between malignancy and autoimmune myositis has been largely described and confirmed by numerous epidemiological studies. The temporal relationship between the two pathologic conditions can vary: malignancy may occur before, at the same time or following the diagnosis of myositis. Beside these observations, the molecular mechanisms underlying this association are still unknown, even though it has been demonstrated a possible antigenic similarity between regenerating myoblasts and some cancer cell populations. To better identify peculiar histopathologic features common to cancer and myositis, we screened muscle biopsies from patients affected with polymyositis, dermatomyositis, myositis in association to cancer, and from patients affected with newly diagnosed cancer, but without myositis. Similarly to the histopatologic features that were observed in the muscle from myositis patients, especially in those with cancer associated myositis, in patients affected with malignancy at the clinical onset of disease we observed early sign of myopathy, characterized by internally nucleated and regenerating myofibers, most of them expressing the neural cell adhesion molecule. The hypothesis that in a particular subset of individuals genetically predisposed to autoimmunity, an initial subclinical tumor-induced myopathy may result in an autoimmune myositis, represents a further intriguing link behind the association of these two conditions.

Systemic Sclerosis and Cancer

To review recent advances and current controversies on the association between systemic sclerosis (SSc) and cancer, PUBMED was searched from 1966 to the present using the terms: systemic sclerosis, cancer, morphoea, sclerotic diseases. Malignancies, mainly in lung and breast, coexist with idiopathic SSc or with SSc-like disorders, but not with localized forms of scleroderma (morphoea), with the exception of squamous cell carcinoma in patients with pansclerotic morphoea and skin ulcers. The mechanisms connecting SSc and malignancies are unknown. The occurrence of different cancer types with SSc or SSc-like disorders suggest different underlying mechanisms, including altered immune response, common genetic and environmental links, disease-dependent factors, tumor-derived biologic substances and therapies. The process of sclerosis itself may favour cancer in certain sites, and a reaction between T cells and neoantigens formed during irradiation has been suggested to explain the frequent development of morphoea after breast irradiation. Radiotherapy, especially when used for breast cancer, may trigger idiopathic SSc or morphoea and influence the severity of preexisting SSc, with the consequence that SSc is considered a relative contraindication to breast radiotherapy. In conclusion, cancer and SSc may be associated, but it is still controversial as to whether there is a causal relationship. Continuing interest in these associations, in particular in the different modalities of associations, may help to understand the underlying biological mechanisms and to identify patients at risk.

Rheumatic disorders as paraneoplastic syndromes

The long-established observation that some rheumatologic disorders (RDs) are associated with--or precede--the clinical manifestations of a variety of solid and hematological tumors represents an important clue for the early diagnosis and effective treatment of the cancers. Inflammatory myopathies, seronegative rheumatoid arthritis and some atypical vasculitides are the most frequently reported paraneoplastic RDs, although paraneoplastic scleroderma- and lupus-like syndromes, erythema nodosum, and Raynaud's syndrome have also been observed. Generally, the clinical course of a paraneoplastic RD parallels that of the cancer, and surgical removal of the tumor or its medical treatment usually results in a marked regression of the clinical manifestations of the RD. Most paraneoplastic RDs are difficultly distinguishable from idiopathic RDs. Even so, some atypical features of the clinical presentation raise the suspicion of an underlying tumor. This review summarizes current hypotheses for the pathogenesis that leads a tumor to present as an RD and discusses the clinical features that help distinguish paraneoplastic from idiopathic RDs.

Prospective characterization of musculoskeletal symptoms in early stage breast cancer patients treated with aromatase inhibitors

PURPOSE

Aromatase inhibitors (AIs) are increasingly used as adjuvant treatment of postmenopausal women with hormone receptor-positive breast cancer. AIs are commonly associated with musculoskeletal symptoms. The primary objective of this study was to describe the musculoskeletal symptoms that developed in the first 100 subjects enrolled who had at least 6 months follow-up.

METHODS

Women with early stage hormone receptor-positive breast cancer were recruited into a multicenter randomized clinical trial to study the pharmacogenomics of two AIs, exemestane, and letrozole. Patients completed the Health Assessment Questionnaire (HAQ) and Visual Analog Scale (VAS) at baseline, 1, 3, 6, and 12 months to assess changes in function and pain, respectively. Patients were referred for evaluation by a rheumatologist if their HAQ and/or VAS scores exceeded a predefined threshold.

RESULTS

Forty-four of 97 eligible patients (45.4%) met criteria for rheumatologic referral. Three patients were ineligible because of elevated baseline HAQ (2) and failure to initiate AI therapy (1). No baseline characteristics were significantly associated with referral. Median time to onset of symptoms was 1.6 months (range 0.4-10 months). Clinical and laboratory evaluation of patients evaluated by rheumatology suggested that the majority developed either non-inflammatory musculoskeletal symptoms or inflammation localized to tenosynovial structures. Thirteen patients discontinued AI therapy because of musculoskeletal toxicity after a median 6.1 months (range 2.2-13 months).

CONCLUSIONS

Musculoskeletal side effects were common in AI-treated patients, resulting in therapy discontinuation in more than 10% of patients. There are no identifiable pre-therapy indicators of risk, and the etiology remains elusive.

Rituximab for the treatment of the skin manifestations of dermatomyositis: A report of 3 cases

Three patients suffering from classic dermatomyositis (juvenile and adult-onset) with prominent recalcitrant skin manifestations are described. All patients demonstrated good control of muscle symptoms on immunosuppressive medications, but their cutaneous disease persisted despite treatment with at least 4 different systemic treatments and topical agents. They were given rituximab, a monoclonal anti-CD20 antibody, achieving a response with minimal side effects. We document our experience with this medication for the cutaneous lesions of dermatomyositis.

Malignancies and soluble tumor antigens in rheumatic diseases

Paraneoplastic symptoms, caused by a malignancy, but not directly related to invasion by the tumor or its metastases are the result of a wide variety of tumor-derived biologic mediators like hormones, peptides, antibodies, cytotoxic lymphocytes, autocrine and paracrine mediators. Recognition of paraneoplastic syndromes is important, as it may lead to an early diagnosis of cancer. There is some evidence that systemic inflammatory diseases, such as rheumatoid arthritis (RA), lupus, scleroderma or dermatomyositis may increase the risk for the development of malignancies, predominantly lymphoproliferative disorders. However, reports are somewhat controversial. Immunosuppressive and cytotoxic drugs used in antirheumatic therapy, such as methotrexate, cyclophosphamide, azathioprine or anti-TNF biologicals may also lead to the development of such tumors. Tumor-associated antigens may be produced by inflammatory cells and their production may be increased in RA and other autoimmune diseases.

Malignancies in Korean patients with inflammatory myopathy

The aim of this study was to assess the prevalence and the common type of malignancies in Korean patients with polymyositis (PM) and dermatomyositis (DM) and to evaluate the differences of clinical and laboratory findings between patients with malignancy and those without malignancy. Forty-one Korean patients, who were diagnosed as PM or DM, were enrolled in this study. They fulfilled the Bohan and Peter's criteria for a definite diagnosis of PM and DM. Patients with PM were 25 and those with DM were 16. Eleven out of 41 patients (26.8%) had malignancies. The malignancy was diagnosed simultaneously or later in 81.8% of patients with inflammatory myopathy (IM). The breast cancer was the most common malignancy. In this study, forty three years old as a screening age for malignancy had 88.9% sensitivity and 50.2% specificity. The serum levels of creatine kinase (CK) were significantly lower in patients with malignancy than those without malignancy.

Polymyalgia rheumatica and colon malignacy: case report

Polymyalgia rheumatica (PMR) is a relatively common disorder in the elderly. Whereas the relationship between polymyalgia rheumatica and giant cell arteritis (GCA) is well recognized, there is still controversy about PMR and malignancy. We are presenting a patient with PMR and adenocarcinoma of the sygmoid colon and hypothesize a paraneoplastic relationship.

Paraneoplastic rheumatic syndromes

Paraneoplastic symptoms caused by a malignancy but not directly related to tumour invasion are the result of a wide variety of tumour-derived biologic mediators, such as hormones, peptides, antibodies, cytotoxic lymphocytes, autocrine and paracrine mediators. Recognition of paraneoplastic syndromes is important, as it may lead to an early diagnosis of cancer. On the other hand, the clinical severity of the symptoms can be used as a guide to the extent of response to underlying tumour therapy. The quality of life of the patient is affected, therefore the palliative treatment of paraneoplasia is very important.

Skin involvement in dermatomyositis

PURPOSE OF REVIEW

Dermatomyositis (DM) is a rare multisystem autoimmune disorder of adults and children that primarily affects skin and skeletal muscle. Classification systems of dermatomyositis, polymyositis, and the other idiopathic inflammatory myopathies focus primarily on features of muscle involvement. However, cutaneous disease does not always parallel muscle disease in its onset, activity, or response to therapy. This review will describe the distinct cutaneous clinical and histopathologic presentation of DM and the relation between these cutaneous findings, pathogenesis of DM, and serological subsets of DM.

RECENT FINDINGS

This review discusses recent findings that have begun to elucidate the pathogenesis of DM, including polymorphism of tumor necrosis factor-alpha 308A allele and maternal fetal microchimerism. The recent description of other systemic diseases and drugs causing DM-like eruptions and the recognition that DM can resemble other common dermatoses highlights the need for a cutaneous biopsy to diagnose and distinguish the cutaneous features of DM. Once diagnosed, a number of noninvasive imaging modalities and new cutaneous assessment instruments can be used to follow and evaluate patients with DM.

SUMMARY

Recognition of cutaneous and histopathologic findings in DM is essential for prompt and accurate diagnosis and treatment of DM.