Musculoskeletal syndromes associated with malignancy (excluding hypertrophic osteoarthropathy)

Paraneoplastic systemic lupus erythematosus associated with dysgerminoma: a case report and literature review

Rheumatic paraneoplastic syndromes are rare and generally occur no longer than two years before diagnosis of the associated malignancy. Therefore, it can be an essential clue to occult malignancy. A healthy 18-year-old female with no underlying diseases was referred to the rheumatology clinic due to morning stiffness in her hands and a new rash on her fingers. Her labs showed a positive ANA, anti-double strand DNA antibody, anti-RNP, and anti-ribosomal P. Nine months after the diagnosis with SLE, the patient presented with elevated levels of lactate dehydrogenase. A total-body computed tomography scan revealed a solid mass in the pelvis. The pathological findings corresponded to a dysgerminoma tumor. Following surgical tumor removal and chemotherapy, the patient went into remission with both SLE and her oncology conditions, with no relapse of her lupus symptoms in a one-year follow-up. This case underscores the importance of considering malignancy in unexplained lupus symptoms, a crucial point for all physicians to be aware of. We identified 13 cases of paraneoplastic SLE in a literature review. In most cases, SLE is resolved after the tumor has been treated.

Cancer incidence in Familial Mediterranean Fever: A retrospective analysis

OBJECTIVES

Familial Mediterranean Fever (FMF) is the most common hereditary monogenic fever syndrome that is characterized by recurrent attacks of fever and polyserositis. Anti-inflammatory drugs, with colchicine being the first-line therapy, have been used in the management of FMF. This study aims to evaluate the risk of cancer in Turkish FMF patients.

METHODS

We retrospectively screened the cancer-related outcomes of our study group which consisted of Turkish FMF patients registered at our division. Cancer estimates of the Turkish population were published by the Turkish Ministry of Health in the Turkey Cancer Statistics Report 2018. Standardized incidence rates (SIR) were calculated to compare the cancer incidence observed in our study group with the expected cancer incidence of the Turkish population. Subgroup analyses were conducted on the subgroups, based on gender and usage of biological agents.

RESULTS

Our study included 1734 FMF patients, 1054 (60.8 %) of whom were females. The total follow-up was 68,784 person-years. Cancer was observed in 35 (2 %) of these patients. Turkish FMF patients had a significantly lower incidence of cancer, compared with the overall Turkish population [SIR 0.64 (95 % CI 0.46-0.89), p < 0.01]. No significant association was found between cancer and biological agent therapies in FMF patients.

CONCLUSIONS

Findings from our study indicate that the risk of cancer was decreased by 36 % in Turkish patients with FMF, compared with the outcomes of the overall Turkish population. Life-long exposure to anti-inflammatory drugs, primarily colchicine, may be the underlying reason for this outcome. Further studies are needed for the confirmation and explanation of this association.

Increased risk of malignancy in patients with Takayasu's arteritis: a population-based cohort study in Korea

This study aimed to evaluate the relative risk of malignancy in patients with Takayasu's arteritis compared to that in the general population. This retrospective nationwide cohort study used data from the Korean Health Insurance Review and Assessment Service database. All newly diagnosed patients with Takayasu's arteritis were identified between January 2009 and December 2019. They were observed until the diagnosis of malignancy, death, or end of the observational period, December 2020. The standardized incidence ratios (SIRs) of the overall and site-specific malignancies were estimated and compared with the incidence of cancer in the general population retrieved from the National Cancer Registry. We identified 1449 newly diagnosed patients with Takayasu's arteritis during the observational period (9196 person-years). A total of 74, 66, and 8 patients had overall, solid, and hematologic malignancies, respectively. The risks of overall [SIR, 1.62; 95% confidence interval (CI) 1.27-2.03], solid (SIR, 1.51; 95% CI 1.17-1.92), and hematologic (SIR, 4.05; 95% CI 1.75-7.98) malignancies were increased compared to those in the general population. In solid malignancies, breast (SIR, 2.07; 95% CI 1.16-3.42) and ovarian (SIR, 4.45; 95% CI 1.21-11.39) cancers had an increased risk. In hematologic malignancies, the risk of myelodysplasia increased (SIR, 18.02; 95% CI 3.72-52.66). Immunosuppressive agent use was not associated with malignancy. There was no specific period when cancer more frequently occurred. An increased risk of malignancy was observed in patients with Takayasu's arteritis compared to that in the general population in this large-scale nationwide population study of Korean health insurance data.

Paraneoplastic syndrome due to angiomatoid fibrous histiocytoma: a known presentation of an uncommon diagnosis in a rare site and age

A woman in her 70s presented with a small subcutaneous retrosacrococcygeal mass and a history of elevated erythrocyte sedimentation rate present for several years. It was misdiagnosed as an inflammatory process of unclear origin. She underwent further investigation with the appearance of weight loss and weakness. A sacrococcygeal mass was noted on CT scan. A core needle biopsy was inconclusive for chordoma versus myoepithelioma. Wide surgical resection of the tumour including the coccygeal bone was performed. Following surgery, all the systemic symptoms resolved with normalisation of inflammatory markers. The pathological examination showed a relatively circumscribed multinodular myxoid tumour with lymphatic tissue cuff. Pan-sarcoma fusion analysis detected an EWSR1 (Exon7)-CREB1 (Exon7) fusion gene. The lesion was diagnosed as angiomatoid fibrous histiocytoma with paraneoplastic syndrome presentation of several years' duration.

Association of advanced age and cancer history with autoimmune disease in melanoma patients: a cross-sectional study

Background

Immune-related adverse events (irAEs) are a major toxicity of immune checkpoint inhibitors. Studies have reported that pre-existing autoimmunity increases the risk of irAEs, but it remains unknown which clinical factors are linked to auto-immune disorders in cancer patients. This study aimed to evaluate if the prevalence of autoimmune diseases varied by specific cancer history and advanced age.

Methods

Our cross-sectional medical record review consisted of 291,333 patients (age, ≥18 years) treated between 2000 and 2018. Patients were classified into four study groups (melanoma only, non-cutaneous solid cancer only, melanoma and non-cutaneous cancer, and no cancer history). Dependent variable was the presence of ≥1 autoimmune disorders based on 98 conditions using 317 ICD codes.

Results

Non-cutaneous cancer, in the absence or presence of melanoma, was associated with a higher prevalence of autoimmunity (16.5, 95% CI 16.1–16.9; 20.0, 95% CI 18.3–21.7, respectively) compared to the rates in patients with melanoma only and those without cancer history (9.3, 95% CI 8.6–10.0; 6.2, 95% CI 6.1–6.3, respectively). Among patients with metastases at initial presentation, those in the melanoma and non-cutaneous cancer group had a prevalence of 24.0% (95% CI 20.1–27.9) compared to 19.1% (95% CI 17.2–21.0) in those without metastases. Multiple logistic regression demonstrated that patients > 75 years exhibited the highest odds of autoimmunity relative to other age groups, with age 18–34 as the referent (OR, 1.78, 95% CI 1.67–1.89).

Conclusions

Among patients with melanoma, the greatest prevalence of autoimmunity occurred with advanced age and a history of non-cutaneous cancer.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-09001-1.

Rheumatological Findings in Patients with Breast Cancer

Objective

Breast Cancer (BC) is the most frequently diagnosed malignancy worldwide. Not only may BC be associated with rheumatic symptoms and diseases, but also the drugs used in the treatment of this disease, including aromatase inhibitors (AIs), may lead to musculoskeletal system symptoms. In this study, we aimed to investigate the spectrum of rheumatic symptoms and diseases developing in patients with BC having no previous diagnosis of any inflammatory rheumatic disease.

Materials and Methods

Patients with a history of BC referring to Rheumatology Outpatient Clinics with complaints of musculoskeletal system symptoms at two centers between 2008 and 2018 were screened retrospectively. Patients with a previous diagnosis of any inflammatory rheumatic diseases before the occurrence of BC were excluded. Demographic data, onset and duration of BC, as well as onset and duration of rheumatic symptoms/diseases were recorded. Relevant laboratory tests, including autoantibodies, available imaging findings and the treatments received were also registered.

Results

Mean age of 128 BC patients at the time of admission was found to be 54.76±8.21 years. Mean durations of disease for BC and rheumatic disorders were 85.705±15.507 and 60.84±19.20 months, respectively. Out of 128 BC patients, nearly one third (n: 41; 32.03%), developed an inflammatory rheumatic disease, and rheumatoid arthritis was the most frequent pathology. Nonspecific arthralgia and myalgia were more frequent in patients receiving AIs than those receiving tamoxifen, despite lack of significant difference (p=0.421, p=0.411).

Conclusion

Given that nearly one third of the patients developed an inflammatory rheumatic disease, it should be remembered that locomotor symptoms in patients with BC may be caused not only by bone metastasis or paraneoplastic effects, but they may also suggest the presence of associated rheumatic diseases.

The Prevalence of Systemic Rheumatic Diseases Among Breast Cancer Patients and Its Relationship With Survival

Objectives

This study aims to investigate the prevalence of systemic rheumatic diseases (SRDs) among patients with breast cancer (BC) and to identify the clinicopathological characteristics of these patients.

Patients and methods

A total of 3,744 female patients with BC (mean age 49±11.7 years; range, 18 to 92 years) followed in Hacettepe University Faculty of Medicine, Medical Oncology Department between January 2006 and December 2015 were retrospectively assessed. Patients with or without SRD were compared in terms of clinicopathological features including age, menopausal state, smoking status, Body Mass Index (BMI), age of menarche, age at first labor, and number of children. The groups were also evaluated regarding tumor grade, stage, estrogen receptor and progesterone receptor expression, human epidermal growth factor receptor 2 overexpression, and survival.

Results

Of the patients analyzed, 68 (1.81%) had concomitant SRD. Among these patients, 33 (48.6%) had rheumatoid arthritis, eight (11.8%) had familial Mediterranean fever, eight (11.8%) had Behçet's disease, four (5.8%) had Sjögren's syndrome, four (5.8%) had systemic lupus erythematosus, six (8.8%) had ankylosing spondylitis, three (4.4%) had systemic sclerosis, one (1.4%) had polymyositis, and one (1.4%) had temporal arteritis. The groups with or without SRDs were similar in terms of age, smoking status, BMI, menopausal state, breast feeding duration, age at menarche and first birth. Stage 1 and 2 BC was more prevalent in SRD patients (74.6% vs. 64.5%, p=0.018). The rate to receive chemotherapy was significantly lower in patients with SRD. However, there was no significant difference in five-year overall survival rates between patients with or without SRD.

Conclusion

Among patients with BC, 1.81% had concomitant SRD. These patients were diagnosed at early stages and given chemotherapy less frequently. However, they had similar survival rates compared to those without SRDs.

Myasthenia Gravis Complicated with Peripheral T-cell Lymphoma, Not Otherwise Specified (PTCL-NOS), Following Thymectomy and Longstanding Tacrolimus Therapy

Myasthenia gravis (MG), a neuromuscular junction autoimmune disease, sometimes complicates second malignancies; however, T-cell lymphoproliferative disorders have rarely been reported. A 55-year-old man, who received oral tacrolimus and prednisolone for MG for 16 years after thymectomy, presented with left abdominal pain, lymphadenopathy, and splenomegaly. A lymph node biopsy revealed peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS). This is the first report of oral tacrolimus leading to a T-cell lymphoproliferative disorder in patient without a history of transplantation. Physicians should be aware of the possibility of rare T-cell lymphoproliferative disorders, such as PTCL-NOS, occurring as complications in MG patients on immunosuppressive regimens after thymectomy.

[Rheumatoid symptoms in patients with hematologic neoplasms]

Paraneoplastic syndromes in lymphatic or myeloid neoplasms can present with musculoskeletal symptoms, vasculitis-like or febrile symptoms. Hematologic diseases are also associated with rheumatic diseases whereas inflammatory rheumatic diseases are often associated with an increased risk for lymphoproliferative disease. Atypical disease characteristics, lack of disease-specific antibodies or therapeutic response are red flags for diagnosing paraneoplastic or coexistent malignant diseases. New onset of systemic symptoms, worsening of general condition, night sweats or weight loss need to be considered during follow-up and differential diagnostics. This article focuses on musculoskeletal, vasculitis-like and systemic signs of lymphatic or myeloid neoplasms either because of coexistency, tumor association or paraneoplastic disease.

SAPHO Syndrome Masquerading as Metastatic Breast Cancer

SAPHO syndrome is a rare clinical entity composed of synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO). We describe a case of SAPHO syndrome masquerading as metastatic breast cancer in a patient with localized breast cancer who presented with cord compression. There was no pathologic evidence of metastatic cancer; however, a bone scan indicated osseous involvement. After multidisciplinary review of images and with additional findings of pustulosis and acne, a clinical diagnosis of SAPHO was made.

Angioimmunoblastic T-Cell Lymphoma with Polyarthritis Resembling Rheumatoid Arthritis

Angioimmunoblastic T-cell lymphoma (AITL) is a rare subtype of peripheral T-cell lymphoma (PTCL). AITL typically presents with lymphadenopathy, fever, rash, hepatosplenomegaly, and rarely polyarthritis. We report the case of a 50-year-old female who presented with lymphadenopathy, rash, and symmetric polyarthritis. She was later diagnosed with AITL and was treated with chemotherapy with resolution of arthritis. AITL should be suspected in paitents presenting with rheumatoid-like arthritis and diffuse lymphadenopathy.

Urologische Malignome und rheumatoide Arthritis

Urologische Malignome sind relativ häufig und nehmen mit zunehmendem Lebensalter zu. Der demografische Wandel führt dazu, dass bei immer mehr Patienten mit entzündlich-rheumatischen Erkrankungen urogenitale Tumoren koinzident sind oder unter antirheumatischer Therapie auftreten. Die Basistherapie rheumatischer Erkrankungen muss in dieses Fällen individuell sorgfältig abgewogen werden, obwohl die begrenzte Evidenz für die meisten Situationen gegen eine massive Risikoerhöhung durch konventionelle und/oder biologische Basistherapeutika spricht. Paraneoplastische Phänomene auch im Bewegungsapparat können durch urogenitale Malignome ausgelöst werden. Mit den sich abzeichnenden Umwälzungen der medikamentösen Tumortherapie durch die Immunonkologie ergeben sich darüber hinaus neue Herausforderungen für die interdisziplinäre Kooperation von Uroonkologen und Rheumatologen. In dieser Übersichtsarbeit werden unter Berücksichtigung der aktuellen deutschen und europäischen Leitlinien die Diagnostik, Standardbehandlung und Nachsorge urologischer Malignome skizziert. Wir beschreiben Kernaspekte, die von Urologen und Rheumatologen beachtet werden sollten. Durch persönliche Absprache, regelmäßigen Erfahrungsaustausch und Einbeziehung von Rheumatologen in interdisziplinäre Tumorboards sollte zukünftig eine bessere Behandlung unserer gemeinsamen Patienten möglich werden.

Comparison of cancer incidence among patients with rheumatic disease: a retrospective cohort study

Introduction

Rheumatic diseases (RDs) are associated with different cancers; however, it is unclear whether particular cancers are more prevalent in certain RDs. In the present study, we examined the relative incidence of several cancers in a single homogeneous cohort of patients with different RDs.

Methods

Patients (N = 3,586) diagnosed with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), systemic sclerosis (SSc), dermatomyositis (DM) or polymyositis were included. Cancer diagnosis was based on histopathology. The 2008 Korean National Cancer Registry served as the reference for calculating standardized incidence ratios (SIRs).

Results

During the follow-up period of 31,064 person-years, 187 patients developed cancer. RA and SLE patients showed an increased risk of non-Hodgkin’s lymphoma (SIR for RA patients = 3.387, 95% confidence interval (CI) = 1.462 to 6.673; SIR for SLE patients = 7.408, 95% CI = 2.405 to 17.287). SLE patients also had a higher risk of cervical cancer (SIR = 4.282, 95% CI = 1.722 to 8.824). SSc patients showed a higher risk of lung cancer (SIR = 4.917, 95% CI = 1.977 to 10.131). Endometrial cancer was increased only in patients with DM (SIR = 30.529, 95% CI = 3.697 to 110.283). RA patients had a lower risk for gastric cancer (SIR = 0.663, 95% CI = 0.327 to 0.998). The mean time between the RD and cancer diagnoses ranged from 0.1 to 16.6 years, with the shortest time observed in patients with DM (2.0 ± 2.1 years).

Conclusions

Different RDs are associated with particular cancers. Thus, cancer surveillance tailored to specific RDs might be beneficial.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-014-0428-x) contains supplementary material, which is available to authorized users.

Paraneoplastic syndromes in rheumatology

For patients that present with musculoskeletal symptoms, diagnostic procedures carried out by physicians and rheumatologists are primarily aimed at confirming or excluding the occurrence of primary rheumatic diseases. Another important trigger for musculoskeletal disease, however, is the presence of a tumour. Careful clinical investigation and knowledge of the gestalt of musculoskeletal syndromes related to respective tumour entities is of utmost importance for the diagnosis of paraneoplastic rheumatic diseases such as hypertrophic osteoarthropathy, paraneoplastic polyarthritis, RS3PE syndrome, palmar fasciitis and polyarthritis, cancer-associated myositis and tumour-induced osteomalacia. This places great responsibility on rheumatologists in diagnosing malignancies and referring the patient for effective treatment. The selective influence of tumours on musculoskeletal tissue is surprising and indicates that tumours alter tissues such as the periosteum, synovial membrane, subcutaneous connective tissue, fascia, muscles and bones by specific molecular processes. Some of the underlying mechanisms have been unravelled, providing valuable information on the physiologic and pathophysiologic roles of mediators such as vascular endothelial growth factor and fibroblast growth factor 23.

Work-relatedness of low back pain in nursing personnel: a systematic review

BACKGROUND

Although non-specific low back pain (LBP) is known to be multifactorial, studies from across the globe have documented their higher prevalence in nurses. This systematic review was conducted to ascertain whether this much-documented association constitutes a causal relationship, and whether there is a discernible threshold of exposures associated with this elevated risk.

METHODS

PRISMA guidelines were followed and standard critical appraisal tools were applied. The outcome of interest was non-specific LBP or back injury; exposure was "performing nursing duties." Applicable studies, published in English during 1980-2012, were identified through database searches, screened against preset inclusion/exclusion criteria. Ergonomic assessments of nursing tasks were included along with epidemiological studies. Bradford Hill considerations for causation were utilized as a framework for discussing findings.

FINDINGS

Of 987 studies identified, 89 qualified for inclusion, comprising 21 longitudinal, 36 cross-sectional analytic, 23 descriptive biomechanical/ergonomic, and 9 review studies. Overall studies showed that nursing activities conferred increased risk for, and were associated with back disorders regardless of nursing technique, personal characteristics, and non-work-related factors. Patient handling appears to confer the highest risk, but other nursing duties are also associated with elevated risk, and confound dose-response assessments related to patient handling alone. Associations were strong, consistent, temporally possible, plausible, coherent, and analogous to other exposure-outcomes, with risk estimates ranging from 1·2 to 5·5 depending on definitions. A threshold of nursing activities below which the risk of back disorders is not elevated has not been established.

INTERPRETATION

Notwithstanding the bio-psycho-social nature of LBP, and complexities of studying this area, sufficient evidence exists of a causal relationship between nursing tasks and back disorders to warrant new policies.

[Hemato-oncological diseases. Associated rheumatic symptoms]

Paraneoplastic syndromes are observed in up to 8% of tumor patients. These disorders arise from tumor secretion of hormones, peptides, growth factors or cytokines or from immune cross-reactivity between malignant and normal tissues. Among many others paraneoplastic syndromes may also affect the rheumatologic system resulting in various musculoskeletal symptoms and/or syndromes. On the other hand, mainly hematological or lymphoproliferative diseases may also cause rheumatic symptoms by cell invasion or when affecting cellular elements of blood or the coagulation system. The aim of this article is to provide an overview of the various associations between rheumatic symptoms and hemato-oncological diseases which might be of importance in clinical practice.

[Tibial pain and unilateral knee arthritis: Precursors of paraneoplastic arthropathy]

Various rheumatic symptoms can occur in association with malignancies and are termed the so-called paraneoplastic arthropathy. The clinical picture is often similar to primary inflammatory rheumatic diseases. At present there exist no epidemiological data on this disease entity. The case of a patient with tibial pain and unilateral knee arthritis as precursors of a paraneoplastic syndrome is presented. The patient presented with the clinical manifestation of small cell lung cancer 2 years after the first presentation in the rheumatology clinic.

Report of anti-CCP antibody positive paraneoplastic polyarthritis and review of the literature

A 45-year-old female presented to the rheumatology clinic with complaint of pain and swelling of multiple small joints of the hands and feet. She also complained of cough and shortness of breath onset around the same time. Since her cyclic citrullinated peptide antibody (anti-CCP) and rheumatoid factor tests were positive, rheumatoid arthritis (RA) was diagnosed and she was started on prednisone with plans for additional disease modifying therapy. Chest X-ray showed a small right pleural effusion. While additional pulmonary evaluation was being planned, a few weeks later she presented with dyspnea, fever and tachycardia. Spiral CT showed pulmonary emboli and increased pleural effusion and patient was started on anticoagulation. A chest tube was placed and exudative pleural effusion was drained. Cytology sample from bronchoscopy raised concerns for adenocarcinoma. Open lung biopsy confirmed moderately differentiated adenocarcinoma. The patient died of lung cancer in the hospital 8 weeks from her diagnosis of RA. We describe a case of paraneoplastic polyarthritis with positive anti-CCP antibody test which has not been reported before. We also review the literature on paraneoplastic arthritis which has been described in association with various other malignancies besides lung cancer.

[Myopathies and malignancy]

There is a greater risk of developing cancer among patients with inflammatory myositis, specifically dermatomyositis. This relationship was first described in 1916 by Sterz and has been corroborated in population based studies. This chapter describes clinical and serological characteristics of patients with myositis and cancer, as well as the most common malignancies and diagnostic and prognostic considerations in this group of patients.

[Elderly-onset rheumatoid arthritis distinguished from polymyalgia rheumatica with malignancy]

The differential diagnosis between polymyalgia rheumatica and elderly-onset rheumatoid arthritis is difficult because these diseases share similar clinical findings, especially at onset. We report a case of elderly-onset rheumatoid arthritis that was distinguished from polymyalgia rheumatica with malignancy. A 77-year-old woman was admitted to our hospital because of pain and bilateral stiffness in her shoulders and her hips. Tests for rheumatoid factor and anti-cyclic citrullinated peptide antibody were negative. Bone erosions and joint space narrowing were not detected radiographically, and polymyalgia rheumatica was suspected. Her arthralgia disappeared with a few days after treatment with prednisolone (10 mg per day) was started, and ESR and CRP were normalized. Computed tomographic scanning of the chest showed a nodular lesion in the right lower lobe, and biopsy revealed lung cancer. Positron-emission tomography with 18F-fluorodeoxyglucose (FDG) performed before lung surgery showed increased uptake of FDG in the bilateral shoulder joints and wrist joints. Enhanced MRI showed synovitis and bone erosions in the right acromioclavicular joint and bilateral carpal bones and also radiographically bone erosions were seen in the carpometacarpal joint of the right thumb. Therefore, a diagnosis of elderly-onset rheumatoid arthritis was made. In patients with polymyalgia rheumatica, the detection of rheumatoid synovitis should be routinely evaluated.